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Diabetic Ketoacidosis



Diabetic Ketoacidosis It is an acute metabolic complication of diabetes mellitus that may present with a decreased level of consciousness

Risk Factors

Signs and symptoms

• Nausea/vomiting
• Shortness of breath
• Obtundation/drowsiness
• Thirst/polyuria
• Fruity smelling breath
• Confusion
• Abdominal pain
• Fever
• Altered mental fuction
• Dehydartion
• Lethargy
• Coma

Diagnostic criteria

• Blood glucose > 11.0mmol/L or known diabetes mellitus
• Ketonuria ++ or more on Ketostix
• Glasgow Coma Scale less than 12, systolic BP below 90mmHg and pulse over 100 or below 60bpm each indicates severe status.


• Check blood glucose
• Urine for ketones
• Arterial blood gases
• Urea, creatinine and electrolyte


  • Non-pharmacological

    • Admit for intensive care
    • Insert nasogastric tube for gastric decompression
    • Use DKA chart to guide treatment and monitor the patient
  • Pharmacological

    Fluid and electrolytes replacement

    If systolic BP < 90mmHg give:

    • 0.9% sodium chloride solution (500ml) over 10–15 minutes. If SBP remains below 90mmHg this may be repeated once.

    Most patients require between 500 to 1000ml given rapidly.

    • If systolic BP remains <90mmHg consider other causes (septic shock, heart failure)
    • Do NOT use plasma expanders

    If the systolic BP is > 90mmHg

    • Normal Saline(NS) 1 litre + Potassium chloride (KCl) 2g when available 2 hourly for 1st 4hours, then 4 hourly
    • Ringer’s Solution 1 litre 2hourly for 1st 4hours, then 4 hourly

    • When blood glucose falls to 14 mmol/L or below, start 5% Dextrose 500mls 4hourly
    • Isotonic dextrose saline may be used in place of dextrose 5%
    • If a patient is still dehydrated continue Normal saline or Ringer’s solution as well.
    • More cautious fluid replacement should be considered in young people aged 18–25 years, elderly, pregnant, heart or renal failure, mild DKA, other serious co-morbidities

    Soluble insulin 8 IU (0.1 IU/kg) IM and 8 IU IV at begining. Then give 8 IU (0.1 IU/kg) IM soluble insulin bolus hourly

    • Check blood glucose 2hourly if using IM route or 4 hourly if sc route
    • Expect a fall in capillary blood glucose of 3.0mmol/L/hour: increase the insulin rate by 1.0 IU/hour increments hourly until glucose falls at this rate.
    • If blood glucose is fluctuating widely, then use the guide in Table 2:
    • When blood glucose falls to 14 mmol/L or bellow give soluble insulin 4 IU SC 4 hourly OR IM 2 hourly and continue until the patient is able to eat again then change to twice or thrice daily insulin as follows:

    o Give insulin 0.5–0.75 IU/kg/day (the higher doses for the more insulin resistant i.e. teens, obese)
    o Give 50% of total dose with the evening meal in the form of long-acting insulin and divide remaining dose equally between pre-breakfast, pre-lunch and pre-evening meal. OR
    o Use pre-mixed insulin: give two thirds of the total daily dose at breakfast, with the remaining third given with the evening meal.

    Refers to Picture 1. Treatment of diabetic ketoacidosis in case of blood glucose fluctuations

    Other important notes and measures

    • Assess Cardial Vascular System (CVS) for volume overload (Input output chart, oedema (lungs, peripheral)
    • Maintain an accurate fluid balance chart, the minimum urine output should be no less than 0.5ml/kg/hour
    • Consider urinary catheter if no urine passed after 2 hours or if incontinent
    • Consider nasogastric tube and aspiration if the patient does not respond to commands
    • Screen for infection and give antibiotics if clinical evidence of infection.
    • Only with severe acidosis Sodium bicarbonate (NaHCO3) 50mmol may be given under doctor’s instruction.


Updated on,

23 Novemba 2020 12:29:25


1. STG

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