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    Management of Diabetic Ketoacidosis

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    Ajay Dherwani
    Management of diabetic ketoacidosis involves fluids, insulin, and electrolyte replacement. Fluids such as normal saline are given to decrease blood glucose levels. Insulin is administered via IV drip with a bolus and continuous infusion to lower glucose levels and close the anion gap. Electrolytes like potassium and bicarbonate are replaced based on lab results. Close monitoring of glucose and electrolyte levels is important to guide management and determine readiness for transition to subcutaneous insulin and oral intake.

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    Management of Diabetic Ketoacidosis

    Uploaded by

    Ajay Dherwani
    26 views23 pages
    Management of diabetic ketoacidosis involves fluids, insulin, and electrolyte replacement. Fluids such as normal saline are given to decrease blood glucose levels. Insulin is administered via IV drip with a bolus and continuous infusion to lower glucose levels and close the anion gap. Electrolytes like potassium and bicarbonate are replaced based on lab results. Close monitoring of glucose and electrolyte levels is important to guide management and determine readiness for transition to subcutaneous insulin and oral intake.

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    Management of diabetic ketoacidosis involves fluids, insulin, and electrolyte replacement. Fluids such as normal saline are given to decrease blood glucose levels. Insulin is administered via IV drip with a bolus and continuous infusion to lower glucose levels and close the anion gap. Electrolytes like potassium and bicarbonate are replaced based on lab results. Close monitoring of glucose and electrolyte levels is important to guide management and determine readiness for transition to subcutaneous insulin and oral intake.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    26 views23 pages

    Management of Diabetic Ketoacidosis

    Uploaded by

    Ajay Dherwani
    Management of diabetic ketoacidosis involves fluids, insulin, and electrolyte replacement. Fluids such as normal saline are given to decrease blood glucose levels. Insulin is administered via IV drip with a bolus and continuous infusion to lower glucose levels and close the anion gap. Electrolytes like potassium and bicarbonate are replaced based on lab results. Close monitoring of glucose and electrolyte levels is important to guide management and determine readiness for transition to subcutaneous insulin and oral intake.

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    Management of Diabetic Ketoacidosis

    Objectives

    • Management of DKA:
    • 1) Fluids
    • 2) Insulin
    • 3) Electrolyte replacement
    Management: Fluids

    • Give between 4-6 liters, t


    • Fluids help decrease the blood glucose levels
    • Always start with NS
    • Bolus and then steady rate (i.e. 150cc/hr)
    • Switch to 0.45% NS when “corrected” sodium
    within normal limits

    • Switch to D5 1/2NS when glucose between 200-250


    Management: Insulin

    • IV insulin dripbolus approx 10 units (or


    .1unit/kg), then initiate drip at 0.1 unit/kg/hr
    • Avoid bolus if K<3.3
    • Replete K before starting drip
    • Insulin drive s potassium into the cells so
    if potassium starts off very low can make
    hypokalemia life threatening.
    • Switch to SC insulin when anion gap closed
    signifying acidosis cleared.
    Management: Electrolyte Replacement

    • Bicarbonate:
    • If pH<6.9 (controversial) or K>6 with ECG changes
    • Potassium:
    • If potassium <5.3
    • 20-60 meq/L of ½ NS given when K <5.3 with severe acidosis
    • Phosphate:
    • If phos <1, especially if muscle weakness
    • When needed 20-30mEQ/L of potassium phosphate can be added to
    replacement fluids
    Overall Management

    • Be sure to check q1hour glucose checks and q2-4hrs


    bmp to monitor anion gap and acidosis
    CASE
    • A 24 year old female with past medical history of
    diabetes mellitus I is brought to the ER by her mother
    with complaints of fatigue and increased thirst and
    urination. Of note patient states she ran out of her
    insulin last week. She also has had a runny nose and
    cough for the past week. She noticed her glucose
    levels have been running “very high” and got
    concerned.

    • On Exam:
    • BP 101/72; heart rate: 113; respirations: 32; Temperature: 36.8 °C;
    pulse oximetry: 100% on room air.
    • General: No apparent distress, AA and Ox3.
    • HEENT: dry mucous membranes
    • CV: tachycardic, normal s1, s2. No murmurs
    • Lung: CTAB
    • Abdomen: +bs, non distended, slight tenderness to deep palpation,
    no HSM no rebound or guarding
    • Ext: no cyanosis, clubbing or edema
    • What labs do you want to order?
    • Complete blood count with
    differential
    • Urinalysis
    • urine ketones by dipstick
    • Arterial blood gas
    Lab Results:
    • EKG sinus tachycardia
    • BMP:
    • Na: 124
    • K: 5.0
    • Cl: 95
    • CO2: 11
    • BUN: 38
    • Cr: 1.8
    • Glucose 450
    • AST:40
    • ALT:41
    • Alk phos:67
    • Arterial blood gas:
    pH 6.9, CO2 9, bicarb 10
    • WBC 13K, Hb14.4 mg/dL, and Hct 43.5%.
    • 75% neutrophils
    • UA +glucose, +protein, -leuko esterase, -nitrite NO KETONES
    • Serum ketones test ordered is positive for beta-
    hydroxybutyrate
    • What would you do next?
    • Bolus 10 units insulin, then start insulin drip
    • Bolus with normal saline, then start maintence
    • Blood cultures, chest x-ray to rule out other sources of
    infection
    • Empiric antibiotics?
    • Bicarbonate?
    • Q2 hour BMP checks:
    • After 6 hours:
    • Na: 139
    • K: 2.5
    • Cl: 108
    • Co2: 13
    • BUN 28
    • Creatinine 1.4
    • Glucose 280
    • ABG:
    • pH 7.2, CO2 of 18 and a bicarb of 12
    • What do you do next?
    • Switch to 0.45% saline with potassium supplements
    • Repeat BMP in 4 hours:
    • Na: 142
    • K: 4.5
    • Cl: 110
    • Co2: 15
    • BUN 38
    • Creatinine 1.2
    • Glucose 230
    • Start on d5 ½ NS with K supplements
    • Continue insulin drip
    • Repeat BMP in 4 hours:
    • Na: 140
    • K: 4.0
    • Cl: 110
    • Co2: 23
    • BUN 28
    • Creatinine 1.1
    • Glucose 105
    • Continue insulin drip
    • Start patient on home regimen of SQ insulin or calculate
    last 24 hour total dose and give 50% in form of long acting
    (i.e lantus)
    • 2 hours later…
    • Stop drip (after 2 hours of starting the SQ insulin)!!
    • Feed patient!
    • If anion gap remains closed after meal can transfer to
    floor.
    Key Points

    • Close monitoring is crucial with glucose checks and bmps


    as electrolytes respond quickly and management
    depends on these numbers

    • Early fluid resuscitation is important

    • Insulin gtt must overlap SQ insulin for 2 hours prior to


    discontinuation of the drip

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