Things to remember
- Give 0.9%NaCl
- Actrapid “Fixed Rate” 0.1unit/kg/hr
- Basal Insulin (lantus/levemir) give this too – usual time and dose
- Potassium – if below 5.5 will need KCl infusion (see guide)
- BM <14 – Start 10% Dextrose 125ml/hr
- BEWARE SGLT-2 inhibitors chance of Euglycaemic DKA
Criteria:
- Blood ketones ≥ 2 mmol / L or Ketonuria ≥ 2+ on standard blood & urine sticks respectively.
- BM > 11 mmol/L or known Type 1 Diabetes
- BEWARE SGLT-2 inhibitors increased chance of Euglycaemic DKA (Dapagliflozin/Forxiga®, Canagliflozin/Invokana®, Empagliflozin/Jardiance®, Ertugliflozin/Steglatro®)
- Venous bicarbonate ≤ 18 mmol and / or pH < 7.3
Tests:
- Blood: FBC, U&E, LFTs, VBG, plasma glucose, blood cultures (only if septic and febrile)
- ECG
- CXR
- Urinalysis (for infection screen and for ketones)
Fluid:
Adult patients may require significant amounts of fluid
- Bag 1 – 0.9% NaCl 1000ml 1hr
- Bag 2 – 0.9% NaCl 1000ml 2hr
- Bag 3 – 0.9% NaCl 1000ml + 20mmol KCl 4hr
- (further bags see PDF)
Potassium:
Potassium levels will likely drop significantly with insulin therapy so we need to consider KCl infusion. In the initial stages it is safer to use a separate bag through a second cannula (due to fluid flow rates)
- [K] <3.5 – Senior Review
- [K] 3.5 – 5.5 – 0.9%NaCl + 40mmol KCL 4hr
- [K] >5.5 – Nil required
Insulin:
- Add 50unit Actrapid insulin to 49.5ml 0.9%NaCl
- Run @ 0.1unit/kg/hr [i.e 60kg adult – 6ml/hr]
- Levemir or Lantus, continue this at usual dose and times
- Not improving contact Med Reg
BM ≤ 14 mmol/l
- Start 10% dextrose @ 125ml/hr
- Contact Med Reg
HDU/ICU Escalation
Most patients will improve will on this regime, however some will benefit from higher level of care than avalible
After the patient has revived their 2nd bag (approx 3hrs treatment) if ANY of the following referral to HDU/ICU should be considered
- pH <7.0 (OR <7.2 and not improving)
- HCO3 <5
- K < 3.5
- sBP <90
- GCS <12
- Comorbidities : Heart OR Renal Failure
- Pregnant
Onward referral will be managed as outlined in the agreed responsibility document if destination requires altering
(this has been agreed between Medicine, ED and ICU)
