Page 1: Diabetic Ketoacidosis Management

Presentation titleSUB TITLE HERE

A Nimalasuriya MD

Maria Ureña RN, MHA

Diabetic Ketoacidosis Management

Page 2: Diabetic Ketoacidosis Management

Goals of Discussion

Pathophysiology of DKA

Biochemical criteria for DKA

Treatment of DKA

Prevention of DKA

Hyperosmolar Nonketoic Syndrome

Page 3: Diabetic Ketoacidosis Management


Annual incidence in U.S. •5-8 per 1000 diabetic subjects•2.8% of all diabetic admissions are due to DKA•Overall mortality rate ranges from

2-10% Higher is older patients

Page 4: Diabetic Ketoacidosis Management

Diabetic Ketoacidosis

Due to:

Severe insulin deficiency Absolute type 1 Relative type 2 Associated with cocaine use Atypical anti-psychotics

Page 5: Diabetic Ketoacidosis Management

DKAPrecipitating Factors

Failure to take insulin

Psychological Secondary gain Weight concerns

Failure to increase insulin

Illness/Infection Pneumonia MI Stroke Acute stress Trauma Emotional

Page 6: Diabetic Ketoacidosis Management

Diabetic Ketoacidosis

Also…• Excess counterregulatory hormones• Glucagon• Epinephrine• Cortisol• Growth hormone

Page 7: Diabetic Ketoacidosis Management

Role of Insulin

Required for transport of glucose into: Muscle Adipose Liver

Inhibits lipolysisAbsence of insulin

Glucose accumulates in the blood Liver Uses amino acids for gluconeogenesis Converts fatty acids into ketone bodies Acetone, Acetoacetate, β-hydroxybutyrate

Page 8: Diabetic Ketoacidosis Management

Counterregulatory Hormones - DKA

Increases insulin


Activates glycogenolysis and


Activates lipolysis

Inhibits insulin secretion

Epinephrine X X X XGlucagon XCortisol X XGrowth

Hormone X X X

Page 9: Diabetic Ketoacidosis Management

Insulin Deficiency

Glucose uptakeProteolysis


Amino Acids

GlycerolFree Fatty Acids


HyperglycemiaHyperglycemia Ketogenesis

AcidosisAcidosisOsmotic diuresis DehydrationDehydration

Page 10: Diabetic Ketoacidosis Management

Signs and Symptoms of DKA

Polyuria, polydipsia Enuresis

Dehydration Tachycardia Orthostasis

Abdominal pain Nausea Vomiting

Fruity breath Acetone

Kussmaul breathing

Mental status changes Combative Drunk Coma

Page 11: Diabetic Ketoacidosis Management

Signs and Symptoms of DKA (continued)



Acute surgical Emergency



Acute abdomen

Page 12: Diabetic Ketoacidosis Management

Lab Findings

Hyperglycemia blood sugar greater than 250

Anion gap acidosis Bicarbonate <15

mEq/L pH <7.3

Urine ketones and serum ketones


Page 13: Diabetic Ketoacidosis Management

Differential Diagnosis Anion Gap Acidosis

Alcoholic ketoacidosis

Lactic acidosis

Renal failure

Ethylene glycol or methyl alcohol poisoning

Starvation in late pregnancy or lactation (rare)

Page 14: Diabetic Ketoacidosis Management

Treatment of DKA

Initial hospital management Replace fluid and electrolytes IV Insulin therapy Glucose administration Watch for complications Treat causes Disconnect insulin pump

Once resolved Convert to home insulin

regimen Prevent recurrence

Page 15: Diabetic Ketoacidosis Management

Flow sheet

STAT•Arterial ABG•CBC with differential• urinalysis• blood glucose•blood urea nitrogen (BUN)•Electrolytes• chemistry profile• creatinine levels •electrocardiogram chest X-ray and cultures as needed.

Serum Na should be corrected for •hyperglycemia

Follow up labs•plasma glucose• Lytes• BUN/creatinine •venous pH every 2 -4 hr

Page 16: Diabetic Ketoacidosis Management

Treatment of DKAFluids and Electrolytes

Fluid replacement Restores perfusion of the tissues Average fluid deficit 3-5 liters

Initial resuscitation 1-2 liters of normal saline over the first 2 hours Slower rates of 500cc/hr x 4 hrs or 250 cc/hr x 4

hours When fluid overload is a concern

After the first Liter consider ½ NS

Page 17: Diabetic Ketoacidosis Management

Treatment of DKAFluids and Electrolytes

Sodium replacement Calculate effective serum sodium Serum sodium + 1.6 ( blood glucose-100)/100 isotonic saline (0.9% NaCl) is infused at a rate of 15–20

ml · kg−1 body wt · h−1 or greater during the 1st hour ( 1–1.5 l in the average adult). Subsequent choice for ∼fluid replacement depends on the state of hydration, serum electrolyte levels, and urinary output.

In general, 0.45% NaCl infused at 4–14 ml · kg−1 · h−1 is appropriate if the corrected serum sodium is normal or elevated; 0.9% NaCl at a similar rate is appropriate if corrected serum sodium is low.

Page 18: Diabetic Ketoacidosis Management

Treatment of DKAFluids and Electrolytes

Hyperkalemia initially present Resolves quickly with insulin drip Once urine output is present and K<5.5,

add 20-40 meq KCL per liter.

Phosphate deficit May want to use Kphos

Bicarbonate not given unless pH <7

Page 19: Diabetic Ketoacidosis Management

Treatment of DKAInsulin Therapy

IV bolus of 0.15 units/kg (~ 10 units) regular insulinIV infusion 0.1 units/kg /hrIf blood glucose does not drop by 50 mg double the

infusion rateDo not give if K is less than 3.3 mEq/LHydrate firstFollow with hourly regular insulin infusionGlucose levels

Decrease 75-100 mg/dl hour not more than this Minimize rapid fluid shifts

Page 20: Diabetic Ketoacidosis Management

Treatment of DKAGlucose Administration

plasma glucose reaches 250 mg/dl in DKA or 300 mg/dl in HHS,

decrease the insulin infusion rate to 0.05–0.1 unit · kg−1 · h−1 (3–6 units/h),

Add dextrose (5–10%) to the intravenous fluids. maintain the above glucose values until acidosis in

DKA or mental obtundation and hyperosmolarity in HHS are resolved

Page 21: Diabetic Ketoacidosis Management

DKA ResolvedTreatment

Blood sugar less than 200 mg

Bicarbonate greater than 18 mEq/L

Venous pH greater than 7.3

Page 22: Diabetic Ketoacidosis Management

Once DKA ResolvedTreatment

Most patients require 0.5-0.6 units/kg/day

highly insulin resistant patients 0.8-1.0 units/kg/day

Long acting insulin 1/2-2/3 daily requirement NPH or Lantus

Short acting insulin 1/3-1/2 given at meals Regular, Humalog, Novolog

Give insulin at least 2 hours prior to weaning insulin infusion.

Page 23: Diabetic Ketoacidosis Management

Complications of DKA

Infection Precipitates DKA Fever Leukocytosis can be secondary

to acidosisShock

If not improving with fluids r/o MI

Vascular thrombosis Severe dehydration Cerebral vessels Occurs hours to days after DKA

Pulmonary Edema Result of aggressive fluid


Cerebral Edema First 24 hours Mental status changes Tx: Mannitol May require intubation with


Page 24: Diabetic Ketoacidosis Management

Prevention of DKASick Day Rules

Never omit insulin

Cut long acting in halfPrevent dehydration and hypoglycemiaMonitor blood sugars frequentlyMonitor for ketosisProvide supplemental fast acting insulinTreat underlying triggersMaintain contact with medical team

Page 25: Diabetic Ketoacidosis Management

Goals of Discussion

Pathophysiology of DKA

Biochemical criteria for DKA

Treatment of DKA

Prevention of DKA

Hyperosmolar Nonketoic Syndrome

Page 26: Diabetic Ketoacidosis Management

Hyperosmolar Nonketotic Syndrome

Extreme hyperglycemia and dehydration Unable to excrete glucose as quickly as it

enters the extracellular space Maximum hepatic glucose output results in a

plateau of plasma glucose no higher than 300-500 mg/dl

When sum of glucose excretion plus metabolism is less than the rate which glucose enters extracellular space.

Page 27: Diabetic Ketoacidosis Management

Hyperosmolar Nonketotic Syndrome

Extreme hyperglycemia and hyperosmolarityHigh mortality (12-46%)At risk

Older patients with intercurrent illness Impaired ability to ingest fluids

Urine volume falls Decreased glucose excretion

Elevated glucose causes CNS dysfunction and fluid intake impaired

No ketones Some insulin may be present Extreme hyperglycemia inhibits lipolysis

Page 28: Diabetic Ketoacidosis Management

Hyperosmolar Nonketotic Syndrome Presentation

Extreme dehydration

Supine or orthostatic hypotension

Confusion coma

Neurological findings Seizures Transient hemiparesis Hyperreflexia Generalized areflexia

Page 29: Diabetic Ketoacidosis Management

Hyperosmolar Nonketotic Syndrome Presentation

Glucose >600 mg/dl

Sodium Normal, elevated or low

Potassium Normal or elevated

Bicarbonate >15 mEq/L

Osmolality >320 mOsm/L

Page 30: Diabetic Ketoacidosis Management

Hyperosmolar Nonketotic Syndrome Treatment

Fluid repletion NS 2-3 liters rapidly Total deficit = 10 liters

Replete ½ in first 6 hours

Insulin Make sure perfusion is adequate Insulin drip 0.1U/kg/hr

Treat underlying precipitating illness

Page 31: Diabetic Ketoacidosis Management

Clinical Errors

Fluid shift and shock Giving insulin without sufficient fluids Using hypertonic glucose solutions

Hyperkalemia Premature potassium administration before insulin

has begun to act Hypokalemia

Failure to administer potassium once levels fallingRecurrent ketoacidosis

Premature discontinuation of insulin and fluids when ketones still present

Hypoglycemia Insufficient glucose administration

Page 32: Diabetic Ketoacidosis Management

Successful management requires Judicious use of fluids Establish good perfusion Insulin drip

Steady decline Complete resolution of ketosis

Electrolyte replacement Frequent neurological evaluations High suspicion for complications

Determine etiology to avoid recurrent episodes

Successful Management

Page 33: Diabetic Ketoacidosis Management

Time For Questions?