Management of diabetic ketoacidosis in adults
Management of diabetic ketoacidosis (DKA) should be started as soon as possible. Adults with early mild ketosis (capillary [finger-prick] blood ketone concentration 0.6 to 1.5 mmol/L) should follow their sick-day management plan, if they have one. Early intervention can help stabilise the patient sooner and possibly avoid hospitalisation.
Approaches to managing DKA vary; institutions should have local management protocols. If a local protocol is not available, one example is the Queensland Health diabetic ketoacidosis protocol (Management of diabetic ketoacidosis in adults [age 16 years and over]) at the Queensland Government website.
When managing DKA, involve the local multidisciplinary diabetes service, or phone the nearest tertiary hospital or major healthcare service for specialist endocrinology advice. If phoning for advice regarding initial management, see Information to assist initial management of diabetic ketoacidosis or hyperosmolar hyperglycaemia for information that may aid the discussion.
When phoning for specialist endocrinology advice, the following information about the patient can assist in diagnosing and determining severity of diabetic ketoacidosis or hyperosmolar hyperglycaemia. Do not delay phoning for help for an unwell patient—not all of this information needs to be immediately available.
- clinical presentation including possible precipitating factors
- level of consciousness
- venous blood gases including venous pH
- blood concentrations of [NB1]
- electrolytes (and anion gap)
- glucose
- ketones
- serum osmolality
- serum creatinine and estimated glomerular filtration rate
- fluid balance
- weight
- usual total daily insulin dose, if applicable
- history, including comorbidities, if available.
The main aim in managing DKA is to progressively restore the acid–base balance and clear the body of excessive ketones. This involves:
- correction of fluid loss with aggressive intravenous fluid replacement
- correction of hyperglycaemia and suppression of ketone production with insulin (with the addition of a glucose infusion when the blood glucose concentration has fallen)1
- correction of electrolyte disturbances, particularly potassium
- thorough investigation for and management of concurrent infection or other precipitating conditions (eg stroke, myocardial infarction, deep vein thrombosis) or factors (eg adherence to usual insulin regimen).
In cases of DKA associated with severe hypoxia or organ failure, lactic acidosis may occur.
Frequent monitoring is vital to guide management of DKA.
For patients taking a sodium-glucose co-transporter 2 (SGLT2) inhibitor, stop the drug immediately (see information about SGLT2 inhibitors and DKA in Diabetic ketoacidosis associated with sodium-glucose co-transporter 2 inhibitors).
Intravenous infusions may be run in separate lines to allow individual adjustment as required. Consider giving the intravenous insulin and intravenous glucose infusion through a single cannula (piggyback), so that one infusion cannot be stopped without the other.
In the rare event that intravenous insulin cannot be given safely, intramuscular insulin may be used for correction of hyperglycaemia and acidosis—seek specialist advice.
Once the patient is stable, transition from an intravenous insulin infusion back to subcutaneous insulin injections or continuous subcutaneous insulin infusion (CSII) pump. Consider the very short half-life of intravenous insulin when stopping the infusion; subcutaneous basal insulin should be started at least 1 hour before stopping the intravenous infusion. If restarting a patient on a CSII pump, always consider disruption of insulin delivery from the pump as a possible contributor to DKA; monitor blood glucose concentrations hourly for the first 4 hours after restarting the CSII to ensure it is functioning. See Disruption of pump–delivered subcutaneous insulin.