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Management Protocol for DKA and HHS
Department of Internal Medicine

Ephrem Hagos MD, Mengistu Alemayehu MD, Ahemed Reja MD
© 2002, Department of Internal Medicine.

Definition
Precipitating Factors
Clinical Features
Classification
Assessment
General management
Fluid Treatment
Insulin Treatment
Potassium, Bicarbonate and phosphate treatment
Miscellaneous

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Diabetic Ketoacidosis ( DKA)

Diabetic Ketoacidosis ( DKA ) is a medical emergency that is seen in patients with uncontrolled diabetes. Although DKA is classically associated with type1 diabetes, it may also occur in type 2 diabetes in the face of severe stress. DKA may also be the presenting clinical problem in previously undiagnosed type 1 diabetes.

Precipitating Factors

  • Newly diagnosed type 1 or type 2 diabetes
  • Infections [pulmonary, Urinary tract and sepsis]
  • Other inter-current illnesses: stroke, myocardial infarction, trauma, surgical illnesses and occasionally pregnancy
  • Omission of insulin: deliberate or due to poor education ( missing insulin during inter-current illnesses )
  • Emotional stress
  • Unknown precipitating factor
  • In Ethiopian set up the major precipitating factor is omission of Insulin
  • Poorly controlled diabetes culminating in DKA [ those with high HgA1c level are at high risk]

Clinical Manifestation
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DKA is a combination of hyperglycemia, acidosis and ketosis. All three must be present to make the diagnosis.

Symptoms

  • Worsening polyuria, polydypsia
  • Postural dizziness
  • Anorexia, nausea, vomiting and abdominal pain ( may mimic acute abdomen )
  • Dyspnea
  • Malaise and altered mentation

    Signs

  • Dehydration ( sunken eye balls, dry tongue, loss of skin turgor )
  • Tachycardia and hypotension or frank shock
  • Drowsiness, stupor or coma
  • Deep breathing ( Kussmaul's respiration ) - evidence for acidosis
  • Acetone breath ( fruity odor) - evidence for ketosis

Laboratory findings

  • Hyperglycemia >250 mg/dl, but usually less than 800 mg/dl
  • Hyperketonemia
  • Ketonuria ( >2+)
  • Plasma sodium often low
  • Plasma potassium - normal, low or high
  • Arterial PH low

    • Normal 7.34-7.43
    Mild 7.1-7.2
    Moderate 7.0-7.1
    Severe < 7.0

  • Serum bicarbonate < 15 meq/1
  • Total fluid deficit 5-8 liters
  • High anion gap

Classification of DKA according to severity

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Mild
Moderate
Severe
Plasma Glucose(mg/dl) >250 >250 >250
Arterial PH 7.25-7.30 7.00-7.24 <7.00
Serum Bicarbonate 15-18 10-15 <10
Anion Gap >10 >12 >12
Mental State Alert Drowsy Stupor/Coma

 

Assessment should include
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  • Diagnosis: minimum criteria for the diagnosis include:

1. RBS>250
2. Urinary ketone > +2
3. Clinical sign of Acidosis

  • Severity [based on mental status and degree of dehydration]
  • Degree of fluid loss based on

1. An orthostatic increase in pulse with out change in blood pressure indicates 10% decrease in ECF [2 liters]
2. An orthostatic drop in blood pressure [ >15/10 mmHg] indicates a 15-20% decrease in ECF [3-4 liters]
3. Supine hypotension indicates a decrease of >20% in ECF [>4liter]

  • Precipitating factor/s
  • Concomitant problem or complications
    ARF, initial hyperkalemia, etc.
    Chronic complications if any
    Additional diagnosis like ischemic heart disease, stroke, peripheral vascular diseases etc.

Management
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General management

  • Open an IV line with a cannula and admit to the Medical ICU, and put on continuous ECG and pulse oximetery and Q15 minutes BP for hypotensive and Q30 minutes BP after stabilization for the first 4 hours, then Q1-2 hours for the first 24 hours. Insert CVP line for a shock patient.
  • General care of the Unconscious
  • Prepare flow chart:

    1. RBS every one hour until blood sugar is around 250mg then every two hour
    2. Urine ketone every 3 hnours
    3. Electrolytes and renal function on admission and 24 hours later. If a need be there, it could be done more frequently.
    4. CBC, U/A, CXR, depending on the patients condition, L.P, Cultures(urine, blood, CSF),ABG if possible
    5. Important calculations to make

    Anion gap (AG)
    AG = [ Na+] - [ Cl- + HCO3-]
    Corrected Sodium *
    Corrected Na+ = [ Na + 1.6 x([ glucose in mg/dl] - 100)
    Serum Osmolality
    Plasma osm = 2 x Corrected Na + Glucose/18 + BUN/2.8
    * Serum sodium should be corrected for hyperglycemia

     

Drug Management
The sequence of management should be, FLUID> INSULIN> POTASSIUM

1.Fluid Management

Volume to be infused:

1. For all patients with DKA, 1000 ml 0.9% saline over the first hour
2. For patients with supine hypotension
0.9% saline per hour until SBP is >90mmHg
Target is to replace fluid deficit of 4-6 liters over 48 hours[ positive fluid balance of 4-6 liters including urine out put and insensible loss within 48 hours]
3. For patients with orthostatic hypotension, positive fluid balance of 4 liters over 48 hours
4. For patients with orthostatic increase in pulse rate without change in BP, positive fluid balance of 2 liters in 24 hours.


Rate of Infusion [after stabilization of the BP]

1. 500ml per hour for the first 4 hours
2. 250ml per hour for the subsequent 4 hours
3. Subsequent replacement depends on the urine output, ongoing loss and the fluid balance
4. Once the patient is fully conscious and able to take fluid by mouth, replacement could be combined with oral intake of fluid.

 

2.Insulin Administration

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Intermittent Insulin Administration

  • 10 Units IV & 10 U IM [ in extremes of weight, 0.4U/Kg, ½ IV & ½ IM
  • 6U [ 0.1U/kg] IM hourly until the RBS comes down to about 250mg%, then

1. space insulin injection Q2hours until ketone < +1
2. keep serum glucose between 150-250mg with 5% or 10% dextrose solution
3. If RBS doesn’t drop by at least 50-70mg% during hourly insulin, double the dose

 

Continuous Insulin Administration

  • Make a solution of 1unit regular insulin per 2 ml of normal saline [199ml N/S plus 1ml regular insulin 100U/ml] in an IV bag and attach to the perfuser. NOTE: 2ml of the solution contains 1unit of regular insulin.
  • Initially give IV bolus of 0.15 U/kg or 10 units then, continuous infusion at a rate of 0.1 U/kg/hr (5-7 U/h)
  • If RBS does not drop by at least 10%, the insulin infusion may be doubled every hour
  • When RBS reaches 250 mg/dl, decrease the insulin infusion rate to 0.05-0.1U/kg ( 3-6U/hr), and change NS to 5%or 10% D/W
  • ** In hypovolemic shock, an intravenous route should be used exclusively.

 

Post DKA Insulin Administration

  • Once the patient has recovered from DKA, put him/her on 4hourly sliding scale. Sliding scale should be overlapped by continuous IV insulin infusion for 2 hours following the initial subcutaneous insulin treatment or 6U of IM injection at the 2nd hour following the SC insulin.

Sliding scale regimen

Random Blood Sugar Regular Insulin SubCu
<150
0
150-199
4
200-249
8
250-300
12
>300
16

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3.Potassium replacement

  • Fundamental aspect of DKA treatment.
  • If there is no urine out or initial serum potassium is > 5.5 mEq/1,delay potassium administration.
  • Return of urine to above oliguric levels ( approximating 30cc per hour ) is a useful guide to initiation of potassium replacement.
  • Serial ECG tracing ( showing progression to low T waves, appearance of U waves ) may help in indirectly monitoring the serum potassium.
  • Absence of bowel sounds ( paralytic ileus ) and loss of tendon jerks indicate extreme potassium deficiency.
  • If initial serum potassium is normal ( 3.5 - 5.0 mEq/1), add 20 mEq to each liter of IV fluid
  • If initial serum potassium is low ( <3.5 mEq/1), add 40 mEq to each liter of fluid
  • Goal of replacement: maintain plasma potassium level between 4 and 5 mEq/1
  • Potassium is discontinued once patient resumes eating or drinking

    4.Bicarbonate - routine use not recommended
    Indications:

  • PH < 7.0
  • shock
  • critically ill patient
    dose:
    7.5% or 8.4% NaHCO3 50ml in 250 ml of sterile water or half NS to be infused over 1-2 hrs.
    Add 15 mEq of KCl for each ampoule of bicarbonate administration ( if serum potassium is les then 5.5 mEq/1)

    5.Phosphate therapy - routine phosphate replacements is unnecessary in DKA.

    6.Miscellaneous points


    Infections should be looked for repeatedly during DKA management and, if detected, should be treated promptly according to the nature of the infection. It should be noted that the patient in DKA may not show fever initially but fever becomes apparent as the severity of the DKA diminishes and the patient's condition improves.

    Additional complications that may be present in DKA from the outset or may develop in the course of treatment include acute renal failure, cerebral edema, cerebral thrombosis and myocardial infarction depending on the age of the patient, duration of diabetes and quality of control of the diabetes. Other precipitating factors should also be treated accordingly.

    In severely sick patient where identification of a precipitating factor is difficult, broad spectrum antibiotic treatment could be justified.

    Resolution of DKA

    1. Clinical Criteria: Alert, fully hydrated, absence of acidotic & acetone breath
    2. Biochemical criteria:
    RBS <200 mg/dl
    HCO3 >18meq/L
    Ph > 7.3
    AG < 12

    Post DKA

  • Educate patient on various aspects of diabetes
  • Educate patient not to miss insulin injections during inter-current illnesses
  • Make the insulin regimen simple in newly diagnosed patients.
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