Diabetic Ketoacidosis (DKA)

Persons at extra risk: newly diagnosed T1DM, onset of pregnancy in T1DM, T1DM diabetics with poor compliance, inter-current infection, failure to administer insulin when ill and not eating.
Investigate immediately blood sugar, urine dipstick for glucose and ketones, electrolytes and urea, venous blood gas if possible.
Check malaria as well FBC +/- Blood culture if suspecting infection.
Hypoglycemia, subdural hematoma (elderly), stroke, malaria, meningitis, sepsis may also precipitate DKA.
If blood sugar levels cannot be obtained, it may be difficult to distinguish clinically between hypoglycemic and hyperglycemic coma, in that case
- give 50 ml 50% Dextrose stat: in case of hypoglycemia, it will wake the patient up; in case of hyperglycemia, it will do no harm.

TREATMENT

Fluid Management
- Fluid deficit 4-6 litres
- Give 0.9 % normal saline, 1 litre stat, 1 litre over 1 hour, 1 litre over 2 hours, 1 litre over 4 hours and 1 litre 6hrly
- Use 5 % dextrose if blood glucose <15 mmol/L within 24 hrs of admission
  - Be cautious with fluid management in patients with heart failure
Potassium Replacement (added to normal saline litre)
- withhold potassium in first litre and do not give > 20mmol/L of Potassium over 1 hour

Potassium level(mmol/L)	Potassium replacement (mmol/L)
<3	40
3-4	30
4.1-5	20
5.1-6	10
>6	Do not give

NB: Monitor Potassium 4 hourly

Insulin
Via an infusion pump:
- mix 50 IU of Soluble Insulin (0.5 ml) with 50mls of normal saline in a 50cc syringe
- start insulin infusion at 0.1 IU/kg/hr. (e.g., 70 kg patient give 7 IU/hr.)
- with hourly glucose monitoring switch to Variable Rate Intravenous Insulin Infusion (VRIII) as follows (VRIII was formerly referred to as Sliding Scale)

Blood glucose(mg/dl)	No infections Insulin required (IU)	With infections Insulin required (IU)
0-72	0	0
72-143	1	2
144-215	2	3
216-288	3	5
289 – 360	4	6
361 – 432	6	8
>432	8	10

If no pump available

Load with 10 IU soluble insulin IV then 4-6 units q2h until glucose is < 14 mmol/L

NB: When to switch to scheduled insulin

Patient is out of DKA evidenced by; no ketones in urine (or serum) and normal acid base balance (pH and bicarbonate). In our context when there is 2++ or less ketones in the urine and patient is well and eating.
Before discontinuation of the IV-Insulin infusion, administer a fast acting/soluble insulin subcutaneous dose an hour before the iv is stopped to allow an overlap.
Use the rule of 2/3 and 1/3 and titrate according to insulin requirements as described in the diabetes mellitus section.

Note: Patient should continue with their NPH/protaphane insulin as before whilst still on the IV-Insulin infusion