ABC, VS, level of dehydration; Mental status, neuro exam, GCS; Risk for cerebral edema; CR monitor, VS q 15 min, I/O q 1 hr; Start DKA Flow Sheet. IV Access. Diabetic ketoacidosis (DKA) though preventable remains a frequent and life written and accompanied by a practical and easy to follow flow chart to be used in. Diabetic. Ketoacidosis. DKA. Resource Folder. May by Eva Elisabeth Oakes, RN, and Dr. Louise Cole, Senior Staff Specialist.

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This is to ensure that the osmolality of the blood does not change too quickly resulting in the rapid movement of fluids from the intravascular space into the interstitial space, leading to one of the biggest complications associated with DKA management: Atypical antipsychotic agents 12 Corticosteroids 13 FK 14 Glucagon 15 Interferon 16 Sympathomimetic agents including albuterol Ventolindopamine Intropindobutamine Dobutrexterbutaline Bricanyl17 and ritodrine Yutopar Most patients can be treated in step-down units or on general medical wards in which staff members have been trained in on-site blood glucose monitoring and continuous intravenous insulin administration.

Avoiding overhydration and limiting the rate at which the blood glucose level drops may reduce the chance of cerebral edema.

A suggested flow sheet for monitoring response to therapy for diabetic ketoacidosis. The goal is to maintain the serum potassium concentration in the range of 4 to 5 mEq per L 4 to 5 mmol per L. New-onset diabetes and ketoacidosis with atypical antipsychotics. Cerebral oedema during treatment of diabetic ketoacidosis: For this reason, there are flowshwet degrees of severity with DKA: Common problems that produce ketosis include alcoholism and starvation.

DKA primarily affects patients with type 1 diabetes, but also may occur in patients with type 2 diabetes, and is most often caused by omission of treatment, infection, or alcohol abuse.

The changes were introduced to reflect an increased understanding in the medical literature of factors leading to complications, particularly cerebral edema, which arise during flowhseet treatment of DKA in infants, children and adolescents.


In the rare patient who presents with hypokalemia, insulin therapy may worsen the hypokalemia and precipitate life-threatening cardiac arrhythmias. Half of the fluid resuscitation volume is initially replaced quickly over the first eight hours, with the rest being administered over the next sixteen hours.

Address correspondence to David E. DKA can develop in less than 24 hours. Urinary output will decrease as the osmotic diuretic effect of hyperglycemia is reduced.

A priority of treatment should be to protect and maintain the airway, particularly in the obtunded patient, and to treat shock if present. The main differences in the management of children and adolescents compared with adults are the greater care in administering electrolytes, fluids, and insulin based on the weight of the patient floesheet increased concern about high fluid rates inducing cerebral edema.

Long-acting insulin normally is stopped during treatment of DKA. No randomized prospective studies have evaluated the optimal site of care for patients with diabetic ketoacidosis. With the use of standardized written treatment guidelines and flow sheets for monitoring therapeutic response, the mortality rate for patients with diabetic ketoacidosis is now less than 5 percent. Nausea and vomiting are present in 50 to 80 percent of patients, and ska pain is present in about 30 percent.

This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Phosphorous and magnesium also may need to be replaced.

Management of Diabetic Ketoacidosis

Furthermore, bicarbonate therapy carries some risks, including hypokalemia with overly rapid administration, paradoxic cerebrospinal fluid acidosis and hypoxia. Med Clin North Am. Standard low-dose insulin therapy consists of an initial intravenous bolus of 0.

Treatment also should be directed at the underlying cause of the DKA, including antibiotics for suspected or identified infection.

An intravenous insulin drip is the current standard of care for diabetic ketoacidosis, primarily because of the more rapid onset of action. Potassium should be started as soon as adequate urine output is confirmed and the potassium level is less than 5 mEq per L. The measured serum sodium concentration can be corrected for the changes related to hyperglycemia by adding 1.


If the serum osmolality is less than mOsm per kg mmol per kgetiologies other than DKA should be considered. HHS is more likely in type 2 diabetes, or in type 1 diabetes when the patient has been consuming large quantities of glucose-containing drinks.

Check beta-hydroxybutyrate rather than ketones to evaluate the degree of ketosis. It is beneficial to review the reason for why the insulin may not have been taken and organise social support to rectify the issue in the future.

Management of Diabetic Ketoacidosis – – American Family Physician

Hyperglycemic crises in urban blacks. Unofficial document if printed.

Bicarbonate therapy lowers potassium levels; therefore, potassium needs to be monitored carefully. In more severe cases, seizures, pupillary changes, and respiratory arrest with brain-stem herniation may occur.

Hyperchloremia is a common but transient finding that usually requires no special treatment. The incidence of this condition may be increasing, and a 1 to 2 percent mortality rate has stubbornly persisted since the s. The history and physical examination continue to be important aspects of management. A few studies suggest possible harms. A randomized study of phosphate therapy in the treatment of diabetic ketoacidosis. Read the full article. A similar study 29 comparing subcutaneous lispro insulin in a medical ward with an intravenous insulin drip in the intensive care unit showed similar outcomes, except for a 40 percent reduction in cost for patients treated in the medical ward.

Consciousness ranges from alert to confused to a comatose state f,owsheet less than 20 percent of patients. Patients who are able to drink can take some or all of their fluid replacement orally. Disclaimer The following information, flosheet. The conditions that cause these metabolic abnormalities overlap. The net result of all these alterations is hyperglycemia with metabolic acidosis and an increased plasma anion gap.

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