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Management of an adult with diabetic ketoacidosis

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Management of DKA is aimed at optimization of volume status; hyperglycemia and ketoacidosis; electrolyte abnormalities; and potential precipitating factors:

  • fluid administration and deficits
    • is the most important initial therapeutic intervention which is aimed at
      • restoration of circulatory volume
      • clearance of ketones
      • correction of electrolyte imbalance
    • 0.9% sodium chloride is recommended as the initial replacement fluid
    • rate and volume of fluid replacement may need to be modified for patients with kidney or heart failure, the elderly and adolescents.
  • insulin therapy
    • a fixed-rate intravenous insulin infusion (FRIII) calculated on 0.1 units⁄ kg is recommended
    • if the following metabolic targets are not achieved, the FRIII rate should be increased
      • reduction of the blood ketone concentration by 0.5mmol/L/hour
      • increase the venous bicarbonate by 3.0mmol/L/hour
      • reduce capillary blood glucose by 3.0mmol/L/hour
      • maintain potassium between 4.0 and 5.5mmol/L
  • intravenous glucose infusion
    • introduction of 10% glucose is recommended when the blood glucose falls below 14 mmol ⁄ l in order to avoid hypoglycaemia, while continuing the fixed-rate intravenous insulin infusion to suppress ketogenesis.
    • continue 0.9% sodium chloride solution concurrently to correct circulatory volume if the fluid deficit has not been corrected.
    • glucose should not be discontinued until the patient is eating and drinking normally
  • potassium, bicarbonate, and phosphate therapy
    • if serum potassium is
      • <3.3 mEq/L – stop insulin and give potassium intravenously
      • 3.3 and 5.3 mmol/L – small amounts of potassium may be added to the intravenous fluid
      • >5.3 mmol/L. – no replacement is necessary
    • adequate fluid and insulin therapy will resolve the acidosis in diabetic ketoacidosis and the use of bicarbonate is not indicated
    • there is no evidence of benefit of phosphate replacement and the routine measurement or replacement of phosphate is not recommended.
  • patients should be educated about t the precipitating cause and early warning symptoms (1,2)

The patient should be converted to an appropriate subcutaneous regime when biochemically stable (blood ketones less than 0.6mmol/L, pH over 7.3) and the patient is ready and able to eat (1).


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