DKA

Question 1

Fluid Management in DKA

Answer 1

IV fluids:

• 1L 0.9% NaCl over 1 hour
• 1L 0.9% NaCl over 2 hours with 20mmol KCl (or 40mmol)
• 1L 0.9% NaCl over 2 hours with 20mmol KCl (or 40mmol)
• 1L 0.9% NaCl over 4 hours with 20mmol KCl (or 40mmol)
• 1L 0.9% NaCl over 4 hours with 20mmol KCl (or 40mmol)
• 1L 0.9% NaCl over 6 hours

Insulin: fixed rate: 0.1 units per kg

Question 2

How to restart patient’s usual insulin?

Answer 2

Administer usual SC dose with meal

Then stop fixed rate insulin infusion within 30-60mins of that dose

Question 3

DKA management within first 1 hour

Including what you would like to monitor

Answer 3

1. ABCDE assessment of the patient + large bore IV access
2. Arrange relevant investigations (they should not delay treatment)
3. 1L 0.9% saline over 1 hour
   Give STAT fluid challenge if systolic BP <90mmHg
4. Fixed rate insulin infusion (0.1 units/kg/hr) AFTER commencing fluid

5. Continue any long acting insulin the patient is already on
Initiate hourly:
Blood/capillary glucose
Blood/capillary ketones
Observations including GCS
Continuous ECG monitoring

Question 4

What do you want to make sure glucose doesn’t fall below?

If it does, what do you do?

Answer 4

Make sure capillary glucose falls below 14mmol/L

If it does start 125ml/hour 10% glucose alongside the saline

Question 5

What do you want the ketones level to do after the first hour?

What do you do if it doesn’t?

Answer 5

Want ketones to fall by 0.5mmol/L/hour

If not then increase fixed rate insulin infusion

Question 6

When do you stop fixed rate insulin infusion?

Answer 6

If:
pH > 7.3
Bicarbonate < 18 mmol/L
Blood ketones <0.3mmol/L

Question 7

What do you do about the insulin infusion in the 12th - 24th hour?

Answer 7

If not eating: start sliding scale infusion

If eating: restart subcutaneous insulin regimen, which may result in some crossover with IV insulin