1. DIABETIC KETOACIDOSIS
-Management
 Dr.Abhijeet

2.  Charisma a 11 yr old girl brought to casualty
with c/o drowsiness, abdominal pain, Fast
breathing ,nausea & vomiting with weight
loss 3-4 kg in 2 weeks.
 She had h/o high grade fever 4-5 days back &
treated with Antibiotics in other hospital.
 All blood investigations were done there
except GRBS.

3.  O/E : She was severely dehydrated with
acidotic breathing /tachypnoea & in state of
altered consiousness.

4.  Monitoring and Investigations:
-Moderate-severe DKA- Admit in ICU.
-Hrly HR,RR,BP, Spo2, GCS
-Monitor for warning signs of cerebral edema
: Headache, bradycardia, recurrent vomiting, altered
sensorium, CN palsies, abnormal pupillary response.

5.  LAB TESTS:
-Hrly GRBS, Blood gas Q4H, Sr electrolytes-Q4H,
-Blood urea, creat.-Q12H
On admission:Charisma’s GRBS was 623mg/dl,
ABG: pH-6.3, HcO3-6.7

6.  MANAGEMENT:
1. IV Rehydration:
-Check for level of dehydration
-If shock signs +, give Bolus NS 0.9% 10 ml/kg over 30 min.
-Initial fluid boluses are not required if no signs of shock.
Maintainence Fluid:
<10kg - 100ml/kg/day
10-20kg- 1000ml + 50ml/kg for each kg> 10kg
>20 kg - 1500ml + 25ml/kg for each kg >20 kg

7. Eg : for 35 kg child
Maintainence fluid :
(85ml x 35kg) + 1875 ml– Bolus /23=ml/H
=119 ml/Hr
Max fluid over 24 hr -4L/m2
-Underhydration is safer than overhydration.

8. -Start rehydration with NS over 48 hrs.
-Strict fluid balance charting every few hrs.
2. Acidosis correction & Bicarbonate therapy:
-DKA patients have wide Anion gap metabolic acidosis
d/t excess of Ketones & Lactate
-Use of Bicarb therapy is contravercial as it may cause
Paradoxical CNs acidosis, Hypokalemia, Increased Na
load & sudden rise in Sr osmolality.

9.  Indications of Bicarb Therapy-
-PH<7
-Refractory shock
-Life threatening hyperkalemia
 HCO3 required in mmol = 0.3 X Wt.in KgX
Base deficit
Give half of calculated bicarb. Over 4 Hrs by
slow infusion then reassess Blood gas, cease
when Ph<7

10.  Potassium replacement:
- DKA Patients have profound total body potassium
deficit d/t polyurea . Hypokalemia worsens with
hydration & Insulin.
- K+ Replacement should begin prior to commencing the
insulin infusion, after initial fluid bolus.
- Start K+ at the rate of 5meq/kg/day.
reassess K+ every 2 Hrs for 1st 6 Hrs then every 4 Hrly.

11. -Aim to maintain K+ > 4-4.5 m eq/L.
 Insulin infusion:
- Start after correction of shock.
- Start at 0.05-0.1 units/kg/hr.
- Aim to fall Blood glucose at 100mg/dl/hr.
- Titration of Insulin:
- Adjust insulin infusion rate to keep BSL between 100-
200mg/dl.

12. - Decrease insulin infusion rate by 50% if BSL fall is >
100mg/dl/hr
- Increase insulin rate by 50% if BSL fall is
<100mg/dl/hr
- Change IVF to ½ NS + D5% when BSL falls below
300mg/dl.

13.  Cerebral edema
- It is the sudden unexpected complication of therapy of
DKA which occurs during 1st 24 Hrs of t/t, usually when
metabolic parameters are normalizing.
- Monitor GCS.
- Mannitol 1-1.5 gm/kg by rapid IV infusion aiming to
rise Sr osmolality by 5-10 m osm/kg & decrease
cerebral edema.

14.  Treatment of precipitating infections if present.
-Urine & Blood c/s done to rule out any focus of
infection.
- Start impirical antibiotics if Raised blood Total
counts persisting or active focus of infection
present.

15.  Oral feeds-
- Kept NPO till metabolically stable, i.e(BSL<200, pH>
7.3, HCO3>15mmol/L).
 Stopping of IV Insulin:
- When child is alert & Metabolically stableMost
convinient time to chance to SC insulin is just before
meals.

16.  Suggested Schedule:
- SC insulin 30 min before meal meal + insulin
infusionstop infusion 90 min after SC dose.
- Usual total daily dose is 1 U/Kg/day.
- May require modification as per BSL values.

17. - If the metabolic state is not attained correctly, The
‘SEVENTH’S SCALE insulin regime can be started :
Short acting insulin given Q6H with
2/7th total daily dose given before breakfast,
2/7th before Lunch,
2/7th before evening food &
1/7th without food at midnight

18.  If child;s metabolic state is normal, proceed directly
to ‘Combined insulin regimen’:
- Combination of Long+ Short acting insulin given
BD, 30 min prior to morning & evening meals i.e.
2/3rd of total daily insulin in morning &
1/3rd prior to Dinner.
- BSL may be checked ½ Hr prior & 2 Hrs after each
meals.

19. THANK YOU !