Diabetes Emergencies

Treatment

The clinical features and laboratory investigations support the diagnosis of diabetic ketoacidosis (DKA). This is an acute medical emergency and requires urgent treatment in a medical HDU setting with involvement of senior medical staff.

Top Tip - DKA in children carries a significant risk of cerebral oedema. Remember that there is a specific guideline for management of DKA in patients under 16 years. This Paediatric Management Guideline is available from http://www.bsped.org.uk

Urgent treatment for DKA is commenced with IV fluid administration and insulin infusion as per protocol.

See Scottish DKA Protocol - Emergency Management

and

Scottish DKA Protocol - 4 Hours to Discharge

After four hours the BG has fallen to 13.6mmol/L. Repeat biochemistry is:

Na 136mmol/L, K 4.2mmol/L, Urea 7.3mmol/L, Creat 88mmol/L.
The patient has passed urine.

Which of the following IV fluids / IV insulin prescriptions should be used now?

0.9% saline at 500ml per hour.
0.9% saline with 40mmol per litre potassium at 500ml per hour IV insulin at six units per hour.
0.45% saline with potassium 20mmol per litre at 500ml per hour + 10% dextrose 100ml per hour, IV insulin at three units per hour.
Reduce 0.9% saline to 150ml per hour. Commence 10% glucose with 20mmol potassium chloride at 100ml per hour. Reduce insulin infusion to three units per hour.
0.9% saline + potassium 20mmol per litre + sodium bicarbonate 50mmol per litre at 500ml per hour, IV insulin at three units per hour.

Please answer each row

Well done, correct.

Once the blood glucose falls below 14mmol/l then 10% dextrose should be added. The insulin rate can then be maintained which will enhance the clearance of ketones.