DKA – Diabetic Ketoacidosis 💉

JBDS-IP March 2023

DKA first hour

T=0 is the time intravenous fluids are commenced. If intravenous access cannot be obtained, request critical care support immediately.

Open the JBDS PDF now and follow the rest of the pathway as soon as first-hour treatment is underway. Do not wait until 60 minutes have elapsed.

Diagnostic criteria (all three)

• Capillary blood glucose above 11 mmol/L
• Capillary ketones above 3 mmol/L or urine ketones ++ or more
• Venous pH less than 7.3 and/or bicarbonate less than 15 mmol/L

Immediate management: 0 to 60 minutes

• Action 1: Commence 0.9% sodium chloride solution (large bore cannula) via an infusion pump. Use the fluid rates below.
• Action 2: Commence a fixed-rate intravenous insulin infusion (FRIII) 0.1 unit/kg/hour based on estimated weight. 50 units human soluble insulin (Actrapid or Humulin S) made up to 50 ml with 0.9% sodium chloride. If the patient normally takes a long-acting insulin analogue (glargine, detemir, degludec), continue at the usual dose and time.
• Action 3: Assess the patient: respiratory rate, temperature, blood pressure, pulse, oxygen saturation; Glasgow Coma Scale; full clinical examination.
• Action 4: Further investigations: capillary and laboratory glucose; venous blood gas; U&E and FBC; blood cultures; ECG; CXR; MSU.
• Action 5: Monitoring: hourly capillary blood glucose; hourly capillary ketones if available; venous bicarbonate and potassium at 60 minutes, 2 hours, and 2-hourly thereafter; 4-hourly plasma electrolytes; continuous cardiac monitoring if required; continuous pulse oximetry if required.
• Action 6: Consider precipitating causes and treat appropriately.

Initial fluid replacement

Restoration of circulating volume is the priority.

Potassium replacement

• K⁺ above 5.5 mmol/L: Nil
• K⁺ 3.5–5.5 mmol/L: 40 mmol/L of infusion solution
• K⁺ below 3.5 mmol/L: Senior review. Additional potassium required.

Request urgent senior review. HDU / level 2 and/or central line may be required

• Young people aged 18–25 years
• Elderly
• Pregnant
• Heart or kidney failure
• Other serious comorbidities

Severe DKA

• Blood ketones above 6 mmol/L
• Venous bicarbonate below 5 mmol/L
• Venous pH below 7.0
• Hypokalaemia on admission (below 3.5 mmol/L)
• GCS less than 12
• Oxygen saturation below 92% on air (arterial blood gases required)
• Systolic BP below 90 mmHg
• Pulse over 100 or below 60 bpm
• Anion gap above 16. Anion gap = (Na⁺ + K⁺) − (Cl⁻ + HCO₃⁻)