3. Diagnosis ?
• A 13-year-old girl with a past medical history of
anxiety is brought to the emergency room for nausea,
vomiting, & abdominal pain. She also reports of ↑ed
• On physical exam, she is lethargic & markedly
dehydrated with dry mucous membranes & sunken
eyes. Her abdominal exam is normal.
• Laboratory results - ↑ed serum glucose 400 mg/dL &
K+ 4.9mEq/L. Urinalysis- +ve for ketones.
• IV fluids given, admitted to the ICU for close
monitoring & administration of an insulin drip.
DKA is a serious acute complications of
Significant risk of death and/or morbidity
especially with delayed treatment.
The prognosis of DKA is worse in the extremes
of age, with a mortality rates of 5-10%.
With the new advances of therapy, DKA
mortality ↓ed to < 2%.
Before discovery & use of Insulin (1922) the
mortality was 100%.
• HHS and DKA are not mutually exclusive but
rather 2 conditions that both result from some
degree of insulin deficiency.
• They can and often do occur simultaneously. In
fact, 1/3rd of patients admitted for
hyperglyceamia exhibit characteristics of both
HHS & DKA.
• DKA is defined as the presence of all 3 of the
(i) Hyperglycemia (glucose >250 mg/dL)
(iii) Acidemia (pH <7.3).
8. Role of Insulin
• Required for transport of glucose into:
• Inhibits lipolysis
• Effects of absence of insulin:
Glucose accumulates in the blood.
Uses amino acids for gluconeogenesis
Converts fatty acids into ketone bodies : Acetone, Acetoacetate, β-
13. Treatment of DKA
• Replace fluid and
• IV Insulin therapy
• Watch for complications
• Treat causes
• Continue insulin therapy
• Prevent recurrence
14. FLUID REPLACEMENT
Administer NS as indicated to maintain hemodynamic status, then
follow general guidelines:
NS for first 4 hrs.
Consider 0.45% NS thereafter.
Change to D5 & 0.45% NS when blood glucose ≤250 mg/dL.
16. INSULIN MANAGEMENT
Regular insulin 10 U IV stat (for adults) / 0.15 U/kg IV stat.
Start regular insulin infusion 0.1 U/kg/h / 5 U/h.
↑e insulin by 1 U /h every 1–2 hr if <10% ↓e in glucose/no improvement in
↓e insulin by 1–2 U/h (0.05–0.1U/kg/h) when glucose ≤250 mg/dL &/or
progressive improvement in clinical status with ↓e in glucose of >75 mg/dl/h.
Don’t ↓e insulin infusion to <1U/h.
17. INSULIN MANAGEMENT
Maintain glucose b/w 140 & 180 mg/dL.
If BSL ↓es to <80 mg/dl, stop insulin infusion for no >1 hr & restart infusion.
If BSL consistently <100 mg/dl, change IV fluids to D10 to maintain BSL b/w 140 & 180
Once patient is able to eat, consider change to S/C insulin:
Overlap short-acting insulin S/C & continue IV infusion for 1–2 hr.
For pts. with previous insulin dose: return to prior dose of insulin.
For pts. with newly diagnosed diabetes: full-dose S/C insulin based on 0.6 U/kg/day.
18. Start S/C insulin:
Anion gap normal
Serum HCO3- ↑es to >15mEq/L
Patient able to eat
Mental status improves
19. Na+ REPLACEMENT
Calculate effective Sr. Na+ = Sr. Na+ + 1.6 (BG -100)/100
0.9% NaCl is infused @ 15–20ml/kg/wt/h or greater during 1st
hour (∼1– 1.5L in avg. adult). Subsequent choice for fluid
replacement depends on the state of hydration, serum
electrolyte levels, & urinary output.
0.45% NaCl infused @ 4–14ml/kg/h is appropriate if the
corrected Sr. Na+ is N/↑ed; 0.9% NaCl at a similar rate is
appropriate if corrected Sr. Na+ is low.
20. K+ REPLACEMENT
• Don’t administer K+ if Sr. K+ >5.5 mEq/L or patient is anuric.
• Use KCl but alternate with KPO4 if there is severe phosphate depletion & patient is
unable to take phosphate by mouth.
• Add IV K+ to each litre of fluid administered unless contraindicated.
Sr. K+ (mEq/L) Additional K required
<3.5 - 4.0 40mEq/L
>5.5 Stop K+ infusion
Hypophasphatemia may develop during ↑ed
If Sr. level <1mg/dl then phosphate
supplementation considered + monitor for
hypocalcemia & hypomagnesemia
No benefit demonstrated in RCT .
Clinical trials don’t support the routine use of HCO3- replacement
HCO3- replacement & rapid reversal of acidosis can impair cardiac function,
reduce tissue oxygenation and promote hypokalemia & hypocalcemia.
In presence of severe acidosis pH<6.9, in hemodynamic instability with pH<7.1
and hyperkalemia with ECG findings, HCO3- therapy considered .
In presence of severe acidosis (arterial pH <6.9), ADA advises HCO3- [50
mmol/L (meq/L) of Na2HCO3- in 200 mL of sterile water with 10 meq/L KCl/h for
2 h until the pH>7.0].
Flow sheet mantained tabulating mental status, vital signs,insulin
dose,fluid and electrolyte administered and urine output
Capillary glucose 1-2hrly,electrolytes especially K+, HCO3- &
phosphate) and anion gap every 4 hrly for first 24 hrs
Monitor BP, pulse, respiration, fluid intake & output every 1-4 h
24. Blood Glucose monitoring
• Check initial blood glucose (BG) q1h. Goal - to ↓e 50-75mg/dL/h
• Once stable ( 3 consecutive values ↓ed in target range), change BG
monitoring to q2h.
• Resume q1h monitoring for each change in insulin infusion rate
• Add dextrose 5% to IV fluids when BG <250mg/dL
• For Goal BG is 150-200 mg/dL until anion gap treated
25. ONCE DKA RESOLVED
• Most patients require 0.5-0.6U/kg/day
• Highly insulin resistant patients: 0.8-
• Give subcutaneous insulin at least 2
hrs prior to weaning insulin infusion.
26. COMPLICATIONS OF DKA
Shock (If not improving with fluids, then consider MI)
• Severe dehydration
• Cerebral vessels - occurs hrs to days after DKA
Pulmonary Edema (Result of aggressive fluid resuscitation)
• First 24 hrs
• Mental status changes
• May require intubation with hyperventilation
27. CLINICAL ERRORS
• Giving insulin without sufficient fluids
• Using hypertonic glucose solutions
Fluid shift & shock
• Premature K+ administration before insulin has begun to act
• Recurrent ketoacidosis
• Premature discontinuation of insulin & fluid when ketones still present
• Failure to administer K+ once levels falling
Hypoglycemia (Insufficient glucose administration)
30. Compare & Constrast
VALUE DKA HHS
Anion gap >12 <12
Mental status Alert, drowsy to stupor and
Sodium (mEq/L) 125-135 135-145
Pottassium (mEq/L) Normal to High Normal
Creatinine (mg/dl) Slight Increase Moderate increase
• A 13yr old girl with a past h/o of anxiety is brought to the emergency
room for nausea, vomiting, and abdominal pain. She also reports ↑ed
urinary frequency. On physical exam, she is lethargic and markedly
dehydrated with dry mucous membranes and sunken eyes. Her
abdominal exam is normal. Laboratory results show ↑ed serum
glucose of 400 mg/dL and Potassium is 4.9mEq/L. A urinalysis is
positive for ketones. She is given fluids and admitted to the ICU for
close monitoring and administration of an insulin drip.