DKA Management Protocol

Cheatsheet Content

Treatment of Diabetic Ketoacidosis (DKA) Airway: Ensure patient is maintaining own airway, sit patient up to prevent acidosis. Breathing: Check $SpO_2$ & correct hypoxia with supplementary $O_2$, watch for Kussmaul breathing, which may be present to compensate for metabolic acidosis. Circulation Maintain 2 Large bore intravenous line (18 or 20 gauge) Vitals Monitor: B.P, pulse rate, Respiratory rate, Temperature, $SpO_2$ x 4 hourly Monitor labs: Blood sugar level x 1 hourly, electrolytes level and ABGs every 4 hourly. Insulin therapy: Pak.*Brands (Humulin-R/Actrapid/Insuget-R) Inj Regular Insulin x 5-10 units x IV (0.14mg/kg) + 5-10 units x Subcutaneous (0.4mg/kg) x stat Regular Insulin Infusion: 60 units (0.1mg/kg/hour) of Regular insulin injection in 100ml 0.9% N/S is prepared in 100ml IV chamber x IV x 10 mic drops/minute, should be start if $K^{++} > 3.5$ Not to start IV Insulin if $K^{++}$ level is $ Continuous IV insulin infusion until the anion gap is normal Once anion Gap is normal then shift the Patient to Subcutaneous (S/C) insulin Fluid replacement therapy: Extracellular fluid loss is replaced by 0.9% N/S (isotonic solution). Intracellular fluid loss is replaced by Dextrose 5% OR 10%. (Fluid of choice is 0.9% N/S or 0.45% N/S) 0.9% Normal saline (N/S) should be infused rapidly to provide 1L/hour over the first 1-2hours. Next 24-48 hours: Adjust Intravenous fluid rate and composition according to CVP, urine output, blood glucose, and corrected sodium levels. Than 1L of 0.9% N/S in 2 hours Than 1L of 0.9% N/S in 4 hours Than 1L of 0.9% N/S in 6 hours Than 1L of 0.9% N/S in 8 hours. Change to 5% dextrose to maintain blood glucose $ This will prevent the development of hypoglycemia and also reduced the chances of cerebral edema. Most Hospital Ward/ER Protocol First 1-2L 0.9% N/S is given fast in 1 hour. Then $3^{rd}$ drip of 1L 0.9% N/S is given at the rate of 125 drops/minute. Add 20ml (20-40mEq/L) of KCL to each Liter of 0.9% of N/S once K is $ Then $4^{th}$ drip of 1L 0.9% N/S + KCL 20ml is given at the rate of 88 drops/minute Then $5^{th}$ drip of 1L 0.9% N/S + KCL 20ml is given at the rate of 33 drops/minute Then $6^{th}$ drip of 1L 0.9% N/S + KCL 20ml is given at the rate of 22 drops/minute If pH=7.0 or $ Acidosis usually resolves with fluids and insulin therapy, the use of bicarbonate is usually not necessary Current study: Sodium Bicarbonate should be avoided $\rightarrow$ Oxford textbook of medicine Start 5% Dextrose if RBS value is $ If RBS value is $> 250$mg/dL changed dextrose into 0.9% N/S Disability & Exposure (Secondary Survey) Consider early HDU/ICU Admission NPO status in patients with high anion gap metabolic acidosis on insulin infusion Pass Nasogastric tube and folly's catheter (Input/output record x 1-4 hourly) Monitor pupillary reflexes and GCS level Inj Calcium gluconate in 100ml 0.9% N/S over 15 minutes if indicated (SOS) Antibiotics for associated infection: Inj. Ceftriaxone 2g (Oxidil, Titan, Rocephin) in 100ml 0.9% Or Inj. Moxifloxacin 400mg/250ml (Moxiget, Avelox) x IV x OD PPIs: Inj Omeprazole 40mg (Risek, Ruling) x IV x OD Give appropriate analgesic if pain and anti-emetic if nausea/vomiting