Clinical Practice Guidelines: Management of

Type 2 Diabetes Mellitus (5th Edition) 2015

Topic 12

Management of diabetic emergencies:

Diabetes ketoacidosis

Diabetic Ketoacidosis

• Most serious acute complications.

• High mortality rate if unrecognised. The overall mortality is

<1%, mortality rate >5% in the elderly.

• Precipitating factors: infection, missed therapy, acute

coronary syndrome, CVA, surgery etc.

• Diagnostic criteria: (All three must be met)

• Capillary blood glucose >11 mmol/L

• Capillary ketones >3 mmol/L or urine ketones ≥2+

• Venous pH <7.3 and/or bicarbonate <15 mmol/L

High Dependency Unit Care

• High-dependency unit (HDU)admission and insertion of

central line in the following circumstances:

• Elderly

• Pregnant ladies

• Heart or kidney failure

• Other serious comorbidities

• Severe DKA

Criteria For Severe Ketoacidosis

• Venous bicarbonate <5 mmol/L

• Blood ketones >6 mmol/L

• Venous pH <7.1

• Hypokalaemia on admission (<3.5 mmol/L)

• Glasgow Coma Scale (GCS)<12

• Oxygen saturation <92% on air (arterial blood gases

required)

• Systolic BP <90 mmHg

• Pulse >100 or< 60 beats/minute

Principles Of Management – 1st Hour

Modified from Management of DKA in Adults, NHS Trafford Diabetes, January 2012

Fluid And Potassium Replacement

2-6th Hour

6-12th Hour

12-24 Hours

Resolution Of DKA

What is the next step of management?

Expectation: Patient should be eating and drinking and

back on normal insulin

• If DKA is not resolved identify and treat the reasons for

failure to respond

• Convert to subcutaneous regime when biochemically stable

(blood ketones <0.3 mmol/L, pH >7.3) and the patient is

ready and able to eat.

Do not discontinue intravenous insulin infusion until 30

minutes after subcutaneous short acting insulin has been

given.

What is the next step of management?

Calculating subcutaneous insulin dose in insulin-naïve

patients; Calculating a Basal Bolus (QID) Regimen.

• Estimate Total Daily Dose (TDD) of Insulin. The TDD can be

calculated by multiplying the patient’s weight (in kg) by 0.5 to

0.75 units.

• Use 0.75 units/kg for those thought to be more insulin

resistant e.g. obese, acanthosis nigricans

Example

An 80-kg person would require approximately 80 x 0.5

units or 40 units in 24 hours.

Give 50% of total dose at bedtime in the form of long

acting insulin and divide remaining dose equally between

pre-breakfast, pre-lunch and pre-evening meal.

E.g. Short-acting insulin 7u tid & 20 units bedtime