ENDOCRINE UNIT
HOSPITAL UNIVERSITI SAINS MALAYSIA
KOTA BHARU
KELANTAN
STANDARD OPERATING PROCEDURE
Subject: MANAGEMENT OF DIABETIC KETOACIDOSIS (DKA)-ADULT REGIME
Primary responsibilities: Nursing, Pharmacy, and Medical staff
Preamble
1. Resuscitation in patient with cardiorespiratory collapsed according to standard
‘ABC’ protocol
2. It is preferred that patient with DKA are referred to the endocrine unit
(Endocrinologist on-call).
Management is divided into:
A. Fluid therapy
B. Insulin infusion
C. Electrolyte management
D. Treatment of underlying cause
A. FLUID THERAPY
Fluid replacement is priority one in the treatment of DKA
1. Route-intravenous
2. Type of fluid started with 0.9% NaCl (Normal saline)
3. Rate:Rate
1 pint over 30 min for 1 hour
1 pint over 1 hour for 2 hour
1 pint over 2 hour for 4 hour
1 pint over 4hour for 8 hour
Step 1
Step 2
Step 3
Step 4
Action
=> review
=> review
=> review
=> review
Fluid
1 litre
1 litre
1 litre
1 litre
Note:
1. Starting point depend on severity of dehydration. If a patient is not
severely dehydrated, may start with Step 2 or Step 3.
2. After each step, review the patient for adequacy of fluid
replacement and evidence of fluid overload
.
a) Symptom eg. Breathlessness
b) Sign eg. BP,PR, JVP, Lung Examination(for basal
crepitation)
c) Monitoring-Input/output chart (Aim for urine output
~1ml/min)
-CVP (When indicated; aim for CVP reading 810cm H2O)
d) Laboratory values-Hb, Hct, Urea (if available)
3. At review
•
If patient still hemodynamically unstable ie. dehydrated and
hypotensive with no urine output – repeat same step
•
If patient is improving, follow from step 1- step 4, and
continue step 4 as maintenance
•
If patient developed fluid overload, withhold fluid therapy
and manage the fluid overload accordingly. Once stable,
restart fluid therapy at slower rate ie. skip the next step and
go directly the step after that (eg. Step 2 –fluid overloadskip Step 3-go to Step 4)
4. Usual deficit in moderate DKA is 6L (range 4-8L)-aim 50%
replacement in 6 hour, and total replacement within 24-48 hours.
5. In the acute stage, do not order fluid regimen for 24 hour. Always
review after each step of fluid regime.
6. Caution in the elderly, those with heart failure or renal failure,
slow replacement is imperative and frequent review is necessary
to detect sign of fluid overload.
7. Use 0.45% NaCl (half normal saline) if serum Na>160mmol/L.
8. Once blood glucose level ~10mmol/L-change to 5% dextrose.
B. INSULIN INFUSION
Insulin therapy is priority two in the management of DKA
1) Route-Intravenous
2) Type-short acting (regular insulin, Actrapid HM, or Humulin R)
3) Rate
a) Start at 2u/hr
• Irrespective of blood glucose level
• Bolus insulin is not recommended
b) Monitor blood glucose level hourly
I. Aim for blood glucose drop of 2-4mmol/L per hour
o If CBG is dropping at <2mmol/L per hour-increase
insulin dose by 2u/hr. Continue increasing the dose
by 2u/hr until blood glucose fall by 2-4mmol/hr,
OR insulin dose more than 6u/hr
o If CBG is reducing at the rate of 2-4mmol/L per
hour- maintains the current dose
o If CBG is reducing at the rate >4 mmol/L per hour –
reduce insulin infusion by 2u/hr (or if present
insulin dose is ≤2u/hr, half the current dose)
II. Initially, aim for CBG~10mmol/L (range 8-12mmol/L) until
DKA has improved, inform doctor if CBG <8mmol/L OR >
12 mmol/L. Once DKA has resolved (fully conscious,
acidosis normalized) aim for CBG of 4-6mmol/L. Inform the
doctor if CBG <4mmol/L OR >8mmol/L. Consider changing
to s/c insulin if patient is able to take regular meal.
III. Caution:
o Inform endocrinologist on-call if insulin rate is
>6u/hr.
o Withold insulin infusion if serum potassium
<2.5mmol/L with ECG changes of hypokalaemia.
– Correct potassium under continuous cardiac
monitoring. –restart insulin therapy once serum
potassium ≥3.0mmol/L or normalization of ECG
changes.
C. ELECTROLYTE MANAGEMENT
1. Potassium
a) Begin potassium replacement at the second hour of fluid therapy
b) Stat with 0.5 gm KCL per hour over 2 hour (eg. Add 0.5gm KCL in 1 pint
of normal saline and run over 1 hour for 2 hour).
c) Once serum potassium result is available, replace according to the result
(provided urine output is adequate ie. ≥30ml/hr)
Serum potassium (mmol/L)
Replacement
<2.5
**Fast correction
2.5-3.0
1.5gm of KCL/pint (19.5 mmol/pint)
3-4
1.0gm of KCL/pint (13.0 mmol/pint)
4.0-5.5
0.5gm of KCL/pint (6.5mmol/pint)
**Fast correction
• IV: 30mmol (2gm) of KCL in 100 ml normal saline over 1 (one)
hour via central vein (may use fast flowing cubital fossa vein
while waiting for central vein insertion), AND
Oral: Three Slow- K tablets (8mmol of potassium per tablet)
every hour, if tolerated.
• Correction is given under continuous cardiac monitoring
d) Danger
a. Rapid infusion of KCL may cause cardiac arrest
b. KCL must never be administered by IV bolus or IM injection
e) Caution
a. Do not give potassium if urine output is poor ie. ≤30ml/hr (patient
may need to be catheterized for accurate urine output charting)
b. Withold potassium replacement if serum potassium is >5.5mmol/L
c. Withold insulin if serum potassium < 2.5mmol/L
f) Aim-Serum Potassium 4.0-5.0mmol/L
2. Sodium
a) If serum sodium is normal, use 0.9% NaCl(normal saline) in fluid therapy
b) If serum sodium is elevated (>160mmol/L) use 0.45% NaCl (half normal
saline) in fluid therapy
3. Bicarbonate
a) Bicarbonate replacement is not routinely indicated in the management of
DKA
b) Consider giving bicarbonate replacement if pH <7.0 and/or serum
bicarbonate <10mmol/L
• Give 50ml 8.4% NaHCO3 over 1 hour
• Repeat ABG 1 hour after completion of infusion
• Repeat NaHCO3 infusion if pH is still <7.0
c) Caution-HCO3 over correction may cause complication including:
• Hypokalaemia
• Cerebral oedema
• Pulmonary oedema
• Lactic acidosis
4. Phosphate
a) Phosphate replacement is not routinely indicated in the management of
DKA
b) Consider giving phosphate replacement if serum phosphate <0.3mmol/L
or in patient with severe hypoxia
D. TREATMENT OF UNDERLYING CAUSE
1) Underlying cause ie. Infection, cardiac event, or inadequate insulin dose need to
be appropriately addressed.
LIST OF PROCEDURE FOR PATIENT WITH DKA
1) Central Venous Monitoring (CVP) – In patient who are severely dehydrated,
in congested heart failure, or difficulty in assessing hydration status
accurately, or hemodynamically unstable.
2) Continuous Bladder Drainage – For accurate urine output measurement
3) Ryles Tube Insertion – In patient with reduced conscious level to reduce risk
of aspiration
4) Continuous Cardiac Monitoring – In patients who are hemodynamically
unstable, patient with ischemic heart disease, rhythm disturbance, or those
suspected of hypo/hyperkalaemia.
LIST OF INVESTIGATIONS FOR PATIENT WITH DKA.
1) Plasma glucose (by central laboratory)- At presentation in A&E on admission to
the ward or if ward CBG reading recorded as ‘HIGH’
2) Full blood count – (At presentation in A&E) on admission to the ward and as
indicated
3) Blood Urea and Serum Electrolyte – (At presentation in A&E) on admission to
the ward and 2 hourly for the first 6 hour, then 4-hourly until stable then daily
until electrolyte abnormalities resolved.
4) ECG – (For those ≥30 years old) on admission and as indicated. ECG monitoring
is required in patient who hemodynamically unstable, patient with ischemic heart
disease, rhythm disturbance, or those suspected of hypo/hyperkalaemia.
5) CXR-As indicated
6) ABG- At presentation in A&E, on admission to the ward and 4-hourly until
stable, then daily until DKA resolved.
7) Others eg. Cardiac enzymes, blood culture to define precipitating cause and/or
concomitant illness, when indicated.
ESSENTIAL MONITORING FOR PATIENT WITH DKA
A. Clinical assessment by doctor
Hourly (or more frequently) in the acute stage until stable
1. Symptom abdominal pain, vomiting, weakness
2. Sign-mental status, hydration status, vital sign, evidence of fluid overload
3. Review of ward monitoring.
4. Review of ward monitoring
B. Ward monitoring (by nurse)
1. Hourly CBG until stable (Please send blood to central laboratory if meter
reading is ‘HIGH’, ‘LOW’ or ‘ERROR’)
2. *Hourly BP, PR, CVP. Mental status
3. Hourly urine output (CBD may be undicated)
*More frequent monitoring of vital sign eg. Every 15 or 30 minute, may be
indicated in acutely ill patient.
C. Laboratory monitoring
1. Plasma glucose (by central laboratory)- At presentation in A&E, on
admission to the ward, or if ward CBG reading recorded as ‘HIGH’,
‘LOW’ or ‘ERROR’.
2. Blood Urea and serum electrolyte – At presentation in A&E, on admission
to the ward, and 2-hourly for the first 6 hour, then 4-hourly until stable,
then daily until electrolyte abnormalities resolved.
3. ABG- At presentation in A&E, on admission to the ward, and 4 hourly
until stable, then daily until DKA resolved
Prepared by:
NORHAYATI BT. YAHYA
13/1/2009
Reviewed by:
PROF EMERITUS DATO’ MUSTAFFA EMBONG
13/1/2009