DIABETIC KETOACIDOSIS
MILDER CASES
- < 5% dehydration and clinically well- Oral Rehydration+ Subcutaneous Insulin.
- MEDICATIONS- NovoMix 30 or Humalog Mix 25 insulin
- 0.5 units/ kg before breakfast
- 0.25 units/ kg before tea.
SEVERE CASES
- Hyperglycaemia (BG >11 mmol/l)
- pH< 7.3
- Bicarbonate < 15 mmol/l
MANAGEMENT
- Airway
- Breathing
- Circulation
INVESTIGATIONS
- Blood glucose
- Urea and electrolytes
- Blood gases
- Blood ketones
DEHYDRATION
Mild 3% dehydrationModerate 5% dehydrationSevere 8% dehydration |
Do not use more than 8% dehydration in calculations
EXAMINATION
- Cerebral oedema
- Infection
- Ileus
MANAGEMENT
1.FLUIDS:
Requirement = Maintenance + Deficit –fluid already given
Deficit (litres) = % dehydration x body weight (kg)
Use 5% to 8% dehydration to calculate fluids
Hourly rate = (48 hr maintenance + deficit – resuscitation fluid already given) / 48 |
Type of fluid
0.9% sodium chloride with 20 mmol/l KCl in 500ml for at least 12 hours.
Once the blood glucose has fallen to 14 mmol/l add glucose to the fluid
0.9% sodium chloride with 20 mmol/l KCl in 500ml for at least 12 hours.
Once the blood glucose has fallen to 14 mmol/l add glucose to the fluid
POTASSIUM
- U & E’s 4 hourly,
- Cardiac monitor for T wave changes.
INSULIN
- DO NOT start insulin immediately.
- No initial bolus.
- Actrapidat 1 units/kg/hour.
- When Blood glucose < 14 mmol/l, change to 5% glucose
- DO NOT reduce the insulin.
- If the blood glucose < 4 mmol/l, give bolus of 2 ml/kg of 10% dextrose and increase glucose concentration of infusion.
- If pH > 7.3, and glucose < 14mmol/l, and a glucose-containing fluid has been started, reduce the insulin infusion rate, to 0.05 units/kg/hour.
BICARBONATE
If pH< 6.9, Differentials
- Insufficient insulin
- Inadequate resuscitation
- Sepsis
- Hyperchloraemic acidosis
- Poisoning
Change to subcutaneous insulin once blood ketone levels are below 1.0mmol/l,
ALGORITHM FOR DIABETIC KETOACIDOSIS MANAGEMENT
*Reference from Julie Edge, Oxford, 2009