chapter
Clinical Viva
Pages 16

DKA consists of the biochemical triad of ketonaemia, hyperglycaemia, and acidaemia. Therefore, management is directed at correcting these key issues. • Full clinical history and examination • Rapid ABC assessment including a full set of observations and Glasgow

coma score • Large-bore IV access (or central access if this is not possible) • Consider precipitating causes and treat appropriately • All patients with DKA need specialist diabetic team input within 24 hours

of admission

Initial investigations • Blood: blood glucose, urea and electrolytes, full blood count, blood

cultures, blood gas • ECG to look for arrhythmias due to associated electrolyte abnormalities • Chest radiograph if clinically indicated • Urinalysis and culture to rule out infection

Specific Treatment • Drugs

° Establish usual medication for diabetes ° Commence a fixed rate insulin infusion (FRII), if weight not available

from patient estimate weight in kg (in pregnancy you should use patients current weight)

sodium chloride if systolic blood pressure is < 90 mmHg (may need more depending on response and may need to consider use of vasopressors to maintain BP)

° The suggested regime in a previously healthy 70 kg adult would be: - 1L 0.9% sodium chloride over first hour - 1L 0.9% sodium chloride with potassium chloride over next 2 hours - 1L 0.9% sodium chloride with potassium chloride over next 2 hours - 1L 0.9% sodium chloride with potassium chloride over next 4 hours - 1L 0.9% sodium chloride with potassium chloride over next 4 hours - 1L 0.9% sodium chloride with potassium chloride over next 6 hours - Mandatory reassessment of cardiovascular status at 12 hours

° Once blood glucose is less than 14 mmol/L, then 10% dextrose should be commenced at 125 mL/hr and ran with the normal saline

• Electrolyte replacement ° If potassium is > 5.5 mmol/L, no potassium replacement is given in

fluid infusions ° If 3.5-5.5 mmol/L, 40 mmol per litre of saline should be given ° Below 3.5 mmol/L requires senior ITU input as more potassium will

need to be given with extra monitoring

• Goals ° Aim is to reduce blood ketones and suppress ketogenesis ° Achieve a fall of ketones of at least 0.5 mmol/L/hr ° Get resolution within 12-24 hours

• The precipitating cause needs to be treated (in this case, the infected hand)

How do you make a sliding scale insulin or Variable Rate Intravenous Insulin Infusion (VRIII)?