DKA SC

5th year this note is NOT enough .. please refer to the book Done by: Ruba Felimban 1

Extra Session with Dr. Abdulmoein Al Agha

Case: patient with high blood glucose level, here we should determine if it is DKA or ONLY

Hyperglycemia because the management of each one is different.

Criteria of DKA:

Hyperglycemia …. > 250 mg/dl.

Ketosis and ketonuria … (keton appears in blood firstly and then in the urine) so some times

the patient comes with ketosis without ketonuria.

Metabolic acidosis … PH < 7.3 & HCo3 < 18.

Dehydration.

Note: as we mentioned the keton appears in blood firstly before the urine and also disappears from

the blood firstly before the urine.

Management of Hyperglycemia:

Oral or IV hydration for 4 hours mainly + extra dose of short acting SC insulin.

11.6 CLINICAL FEATURES OF DKA

Symptoms

Nausea & vomiting.

Abdominal pain.

Weakness.

Polyuria, thirst.

Weight loss.

Blurred vision.

Signs

Dehydration.

Tachycardia, hypotension.

Cold extremities & peripheral cyanosis.

Air hunger (Kussmaul breathing).

Smell of acetone.

Hypothermia.

Confusion, drowsiness & coma.

DKA SC

5th year this note is NOT enough .. please refer to the book Done by: Ruba Felimban 2

Management of DKA:

1. Hydration:

IV fluid bolus 10-20 ml/kg over 1 hour only for the cases of moderate & severe

dehydration.

Type of fluid:

Normal saline.

Ringer lactate.

Maintenance and Deficit Fluid:

Maintenance fluid for 24 hours.

Deficit fluid for 36-48 hours.

No ongoing loss.

We don’t give ORS because the vasoconstriction of the gut vessels can leads to paralytic

ilues if we give ORS.

*E.g. patient with DKA, 36 kg & 7% dehydration.

Maintenance calculation:

10 x 100 = 1000

10 x 50 = 500

16 x 20 = 320

Total 1820/ 24 hours = 75.8/h.

Deficit calculation:

36 x 70 = 2520/ 2 days

½ = 1260/ 1st day ½ = 1260/ 2nd day

½ = 630/ 1st 8 hours ½ = 630/ 2nd 16 hours

78.7/h 39.3/h

So finally we will give the patient:

-78.7 (Deficit) ml + 75.8 (Maintenance) ml in 1st 8 hours.

-39.3 (Deficit) ml + 75.8 (Maintenance) ml in 2nd 16 hours.

*& continoue the rest of Deficit and Maintenance fluid.

DKA SC

5th year this note is NOT enough .. please refer to the book Done by: Ruba Felimban 3

2. IV Insulin.

IV infusion 0.1 unit/kg/h.

When should we shift to use SC insulin?

The main principle in the management of such case is to correct acidosis.

If the Glucose become < 250mg/dl:

We start giving 5% Dextrose N.S.

If the glucose drops to 80 mg/dl … what should we do in such case?

We increase Dextrose to 10% and remember not to try decrease insulin dose.

3. Correction of Electrolytes Disturbance:

Na & Cl They will be corrected during rehydration.

K Give 5-6 mmol/kg/day as we start giving IV insulin because it helps K to be shifted

intracellular (even if K level is normal because it is false normal).

Phosphate Usually there is no need to give KPO3 but if we give that can lead to

hypocalcaemia so we need to add Ca if we decide to give potassium phosphate.

4. Correction of Metabolic Acidosis:

If the patient in Shock or PH < 7:

We need to give HCO3 1-2 mmol/kg/dose.

Otherwise no need to give HCO3 because the acidosis will be corrected during

management.

5. Treatment of Precipitating Factors:

The patient should be educated to control his blood glucose level.

If there is infection that precipitates for DKA, it should be treated.