1. Management of Adult Diabetic Ketoacidosis Adapted from the WHO IMAI District Clinician Manual Vol. 1 Dr. Linda Hawker, June 2014

2. Presentation of DKA  Three Main Features :  1. Hyperglycaemia : blood sugar over 17 mmol/litre (more than 300 mg/dl))  2. Ketones increased in urine and blood  3. Acidosis: Blood pH less than 7.3 due to Ketoacidosis and Lactic acidosis  Slide 1

3. Dehydration  DKA causes significant fluid loss, usually 3 to 6 litres and causes lactic acidosis  Expect to give many litres of fluid during treatment  Rehydration is very important  Slide 2

4. Potassium Loss  With acidosis comes potassium (K+) loss  All patients will require potassium replacement  Slide 3

5. Who can have DKA? Can be child or adult, type 1 or type 2 diabetes (more common in Type 1). Common triggers:  Infection (example: pneumonia, gastroenteritis, urinary tract infection)  Stopped medications  Long duration of disease  Slide 4

6. What does the patient look like?  Usual presentations :  Nausea, vomiting, abdominal pain  Fatigue, muscle cramps  Increased voiding (polyuria), increased drinking (polydipsia)  Lethargy, eventually coma  Deterioration starting with infection  Shortness of breath, deep breaths  Shock (dehydration or sepsis)  Ketotic (sweet smelling) breath Slide 5

7. Important !  The dehydration, acidosis and electrolyte problems are more dangerous than the high blood sugar and must be treated first  Slide 6

8. Investigations  Blood glucose, should be more than 14 mmol/l (252 mg/dl)  Electrolytes, creatinine, bicarbonate  ECG  Urine dipstick for glucose and ketones  Whole blood count, blood culture if fever  Chest X ray if suspect pneumonia  Slide 7

9. Treatment  Step 1: Give IV fluids, start promptly  Step 2: Correct potassium problems  Step 3: Give insulin  Step 4: Treat precipitating cause (eg: infection)  Slide 8

10. Manage Fluids Step 1  Start IV - if in shock (SBP < 90) give 1 litre normal saline (NS) immediately, give as quickly as possible. Do not add K+ to this litre  If no shock, IV NS at 5-10 ml / kg body weight per hour ( about 1 litre per hour in average adult)  Replace fluid more cautiously if pregnant, heart failure, kidney failure, elderly  Slide 9

11. Manage potassium (K+) Step 2  K+ will fall quickly as you give IV fluids, can cause heart arrhythmias  Monitor K+ levels or ECG hourly for 4 hours  Give IV K+ slowly over an hour, never by bolus, can add to IV Normal saline  Keep K+ at 4-5 mEq/litre  If can’t do blood K+, monitor by ECG  Slide 10

12. Manage Potassium (K+)  If lab can do blood potassium level, do not start replacing K+ until less than 3.3 and urine output is at least 50 ml per hour.  If lab can’t do K+, use ECG to see if signs of low or high K+.  If can’t do K+ or ECG, starting with the second hour of IV fluids, add 20mmol K+ to each litre of fluid and slow IV rate once the patient is producing urine.  Slide 11

13. ECG and low or high K+ Low K+ (hypokalemia) Level under 3.3:  Small or absent T waves, large U wave,  Add 40 mmol per litre of fluid and run at one litre per hour until EKG normal High K + (hyperkalemia) Level over 5.3:  Tall, pointed T waves and widened QRS  Don’t add K+ to IV, check again in 1 hour  Slide 12

14. ECG: normal and low K+ levels Slide 13

15. ECG: high K+ levels Slide 14

16. Manage Glucose Step 3  Start short-acting (soluble) insulin subcutaneous (SC),intramuscular (IM) or intravenous(IV) once you have begun fluid replacement, and if K+ is over 3.3  Children under 18 years are at increased risk of cerebral oedema and it is better to wait until fluids have been given for 1-2 hours before starting insulin  Slide 15

17. First Hour: fluids, K+, insulin Insulin : Add 100 units of regular (soluble) insulin to 100 ml of sodium chloride 0.9% (normal saline) to make a standard concentration of 1unit insulin/ml of IV solution Source of table: WHO IMAI District Clinician Manual Volume 1 pages 138, 139 Slide 16

18. After first Hour: fluids, K+, insulin Note: K+ 5.3 Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Slide 17

19. Monitoring DKA  Check pulse, BP, hydration status and level of consciousness every hour and confirm that the fluids are being infused  If possible, check blood glucose every hour until it is less than 14 mmol/l, then switch to dextrose in saline infusion (dextrose 5% +sodium chloride 0.45%)  Check K+ level or ECG on arrival, then every hour x 4 hours, then after 4 hours  Slide 18

20. Monitoring DKA  May stop IV therapy and hourly insulin when patient can eat and drink and there are no signs of acidosis (deep breathing), and if blood glucose is under 12 mmol/l ( 216 MG/DL)  Then patients can receive maintenance insulin shots according to glucose levels and weight  Assess for signs of infection and start antibiotics as soon as possible  Slide 19

21. Giving Insulin after IV  If patient is drinking and eating:  Resume home insulin if glucose controlled  If new to insulin: 0.7 units lente x patent’s weight in kg = total daily dose (usually given at bedtime or split 50% at breakfast and 50% at bedtime)* Eg: 80 kg pt. x 0.7 = 56 units lente (28 U qAM + 28 U qHS) Don’t give insulin if blood glucose under 4 * Based on Interior Health SC Insulin PPO for adult pt. eating Slide 20

22. Key Messages  Start IV fluids early, patients are dehydrated  Monitor K+ by blood or ECG, replace slowly by infusion, never bolus  Monitor blood sugar, give short acting insulin SC or IV (IV infusion requires extremely close monitoring)  Treat infection promptly  Slide 21

23. Core Reference Sources Available on WHO Publications Web site  WHO Integrated Management of Adolescent and Adult Illness (IMAI) District Clinician Manual : Hospital Care for Adolescents and Adults Volume 1  Quick Check in Emergency/OPD: pages 18 – 25 of IMAI Manual – a very useful method of triaging ill patients in OPD. Available as wall poster too.  Slide 22

24. Questions? Zambezi floodplainSlide 23