Expansion
Fluid first, then fixed rate insulin, watching the potassium
Expansion
The diagnostic triad
- Ketonaemia 3 mmol/l or more, or significant ketonuria
- Blood glucose above 11 mmol/l, or known diabetes
- Bicarbonate below 15 or venous pH below 7.3
Note that the glucose may be normal: euglycaemic DKA occurs with SGLT2 inhibitors, in pregnancy and with reduced intake, and is easily missed.
Management
- Fluid first: sodium chloride 0.9 per cent, a bolus if systolic under 90, then a replacement regimen
- Fixed rate insulin infusion at 0.1 units/kg/h
- Potassium in the fluid once the level is known and below 5.5, since total body potassium is depleted even when the serum level is high
- Continue long acting insulin; stop short acting
- Add 10 per cent glucose alongside once the glucose falls below 14, so the insulin can continue to clear ketones
Targets: ketones falling by 0.5 mmol/l/h, bicarbonate rising by 3 mmol/l/h, glucose falling by 3 mmol/l/h.
“Treat the ketones, not the glucose.” The insulin is switched off only when the ketosis resolves, not when the glucose normalises.
Cerebral oedema is the feared complication, mainly in children, caused by over rapid fluid or osmolar correction.