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الرحيم
Dr. Fathi El Sewi
Diabetic Ketoacidosis (DKA)
It is a life threatening but reversible complication of
type 1 diabetes due to absolute insulin deficiency.
A-Primary assessment:
-Volume status and degree of dehydration.
-Blood pressure and cardiac condition.
-Degree of consciousness.
-Degree of acidosis.
-Precipitating disease
B-Ongoing monitoring:
1-General measures:
-Airway and O2 inhalation if needed.
-IV line.
-Urinary Foley's catheter (if in shock).
-NGT (Nasogastric Tube): to avoid gastric dilatation
and protection from aspiration .
-Thrombosis prophylaxis: 5000 units of heparin SC/12
hours.
-Empiric use of 3rd generation cephalosporin
antibiotics.
2-Specific measures:
Successful therapy of hyperglycemic crises requires
the administration of:
a-Fluids:
1- Correct volume deficit and hypotension.
2- Improve tissue perfusion.
3-Improve insulin sensitivity (insulin
counterregulatory hormones).
4-Improve glomerular filtration rate:
i-↑ excretion of large amount of glucose in urine.
ii-Clears hyperketonemia.
5- Correct metabolic acidosis.
b-Insulin: Reversal of metabolic abnormalities :
i-Corrects hyperglycemia.
ii-Inhibits ketogenesis.
• Regimen:
Initial bolus: 0.1 U/kg body wt given IV.
Maintenance: 0.1 U/kg/body wt /hour:
a- IV Infusion set: Add 100 units of regular insulin
+500 ml saline i.e. every 5 cc fluid contains 1 unit of
insulin
b-IV infusion set is not available: IM route.
Potassium Therapy
• Initially: Mild to moderate hyperkalemia occur in
patients with DKA.
• Later on: After initiation of:
Insulin therapy
Correction of acidosis lead to hypokalemia.
Volume expansion & hydration
Rational of potassium therapy
• In the 1st 2 liters of fluid add no potassium.
• If urine output confirmed add KCl from 3rd liter on.
If serum potassium:
< 3 mEq/L add 20 – 40 mEq KCl/liter to IV saline.
3-5 mEq/L add 10 – 20 mEq KCl/liter to IV saline.
> 5 mEq/L add no potassium.
• Patient with oliguria or renal insufficiency: K levels must be
frequently monitored with continuous ECG evaluation.
• The infusion continues until the patient can tolerate oral
potassium supplement (15 CC potassium syrup/ 8 hours).
A Guide Protocol
1-Establish the diagnosis.
2-Establish the precipitating disease.
3-Assess the degree of dehydration: (BP, urine output, skin turgor)
4-Calculate total fluid deficit:
• For DKA: about 3-6 liters.
• For NKHH state: about 9 liters.
5-Determine the type of fluid as replacement:
– Use normal isotonic saline 0.9% in:
a-All cases of DKA.
b-Initial (1st 2 liters) in NKHH state.
– Use half strength saline 0.45% if measured sodium > 145 mEq/L.
6-Order the rehydration program as follow (normal
saline):
– First 4 hours : 50% of the calculated total fluid deficit.
– Next time for up to 24h: 50% of the calculated total
fluid deficit.
7-Order and start insulin regimen:
– Type of insulin: Rapid or short acting insulin.
– Initial bolus = 0.1 unit X BW in Kg / direct IV.
– Maintenance = 0.1 unit X BW in Kg / hour.
Infusion set available:
Order: Add 100 units of regular insulin to 500 cc saline
i.e. every 5 cc contains one unit of insulin, calculate the
dose and give by IV drip.
Infusion set is not available IM route