DKA is complicated to manage and needs close monitoring and treatment modifications.
It is possible to manage mild DKA without admission to the intensive care unit (ICU); however, many cases will require ICU care.
After admission to ICU, central venous and arterial lines are usually required. Swan-Ganz catheterisation and continuous percutaneous oximetry are needed in patients with haemodynamic instability. Monitoring of respiratory parameters is also required to ensure adequate oxygenation and airway protection.
1 to 6 hours
Order hourly blood glucose and hourly blood ketones.
Perform a venous blood gas for pH, bicarbonate, and potassium at 60 minutes, 2 hours, and 2 hourly thereafter.
Aim for a reduction in blood ketones of 0.5 mmol/L/hour if blood ketone measurement is available.
Use venous bicarbonate or blood glucose measurement if blood ketone measurement is not available.
Aim for an increase in venous bicarbonate of 3.0 mmol/L/hour or a reduction in blood glucose of 3.0 mmol/L/hour.
If the target rates for blood ketones, blood glucose, and venous bicarbonate are not achieved:
Check the insulin infusion pump is working and connected and that the correct insulin residual volume is present (to check for pump malfunction)
Increase the insulin infusion according to local protocols (if there is no insulin pump malfunction) until the target rates for ketones, glucose, and bicarbonate are achieved.
Maintain the potassium level between 4.0 and 5.0 mmol/L.
Maintain an accurate fluid balance chart.
Aim for a minimum urine output of 0.5 ml/kg/hour.
Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.
Monitor vital signs closely according to local protocols.
Request a chest x ray if oxygen saturations fall as this may be a sign of pulmonary oedema. Consider performing an arterial blood gas.
6 to 12 hours
Seek senior advice if clinical and biochemical markers are not improving.
Check ketones, blood glucose, venous pH, bicarbonate, and potassium at 6 hours.
Assess for resolution of DKA. This is defined as:
Venous pH >7.3 AND
Blood ketone level <0.6 mmol/L
12 to 24 hours
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