ENDOCRINE UNIT HOSPITAL UNIVERSITI SAINS MALAYSIA KOTA BHARU KELANTAN STANDARD OPERATING PROCEDURE

Subject: MANAGEMENT OF DIABETIC KETOACIDOSIS (DKA)-ADULT REGIME

Primary responsibilities: Nursing, Pharmacy, and Medical staff

Preamble 1. Resuscitation in patient with cardiorespiratory collapsed according to standard ‘ABC’ protocol 2. It is preferred that patient with DKA are referred to the endocrine unit (Endocrinologist on-call). Management is divided into: A. Fluid therapy B. Insulin infusion C. Electrolyte management D. Treatment of underlying cause

A. FLUID THERAPY Fluid replacement is priority one in the treatment of DKA 1. Route-intravenous 2. Type of fluid started with 0.9% NaCl (Normal saline) 3. Rate:Rate 1 pint over 30 min for 1 hour 1 pint over 1 hour for 2 hour 1 pint over 2 hour for 4 hour 1 pint over 4hour for 8 hour

Step 1 Step 2 Step 3 Step 4

Action => review => review => review => review

Fluid 1 litre 1 litre 1 litre 1 litre

Note: 1. Starting point depend on severity of dehydration. If a patient is not severely dehydrated, may start with Step 2 or Step 3. 2. After each step, review the patient for adequacy of fluid replacement and evidence of fluid overload . a) Symptom eg. Breathlessness b) Sign eg. BP,PR, JVP, Lung Examination(for basal crepitation) c) Monitoring-Input/output chart (Aim for urine output ~1ml/min) -CVP (When indicated; aim for CVP reading 810cm H2O) d) Laboratory values-Hb, Hct, Urea (if available) 3. At review •

If patient still hemodynamically unstable ie. dehydrated and hypotensive with no urine output – repeat same step

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If patient is improving, follow from step 1- step 4, and continue step 4 as maintenance

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If patient developed fluid overload, withhold fluid therapy and manage the fluid overload accordingly. Once stable, restart fluid therapy at slower rate ie. skip the next step and go directly the step after that (eg. Step 2 –fluid overloadskip Step 3-go to Step 4)

4. Usual deficit in moderate DKA is 6L (range 4-8L)-aim 50% replacement in 6 hour, and total replacement within 24-48 hours. 5. In the acute stage, do not order fluid regimen for 24 hour. Always review after each step of fluid regime. 6. Caution in the elderly, those with heart failure or renal failure, slow replacement is imperative and frequent review is necessary to detect sign of fluid overload. 7. Use 0.45% NaCl (half normal saline) if serum Na>160mmol/L. 8. Once blood glucose level ~10mmol/L-change to 5% dextrose. B. INSULIN INFUSION Insulin therapy is priority two in the management of DKA 1) Route-Intravenous 2) Type-short acting (regular insulin, Actrapid HM, or Humulin R) 3) Rate a) Start at 2u/hr • Irrespective of blood glucose level • Bolus insulin is not recommended b) Monitor blood glucose level hourly I. Aim for blood glucose drop of 2-4mmol/L per hour o If CBG is dropping at 4 mmol/L per hour – reduce insulin infusion by 2u/hr (or if present insulin dose is ≤2u/hr, half the current dose)

II. Initially, aim for CBG~10mmol/L (range 8-12mmol/L) until DKA has improved, inform doctor if CBG 12 mmol/L. Once DKA has resolved (fully conscious, acidosis normalized) aim for CBG of 4-6mmol/L. Inform the doctor if CBG 8mmol/L. Consider changing to s/c insulin if patient is able to take regular meal. III. Caution: o Inform endocrinologist on-call if insulin rate is >6u/hr. o Withold insulin infusion if serum potassium 160mmol/L) use 0.45% NaCl (half normal saline) in fluid therapy

3. Bicarbonate a) Bicarbonate replacement is not routinely indicated in the management of DKA b) Consider giving bicarbonate replacement if pH