Monitoring
It is possible to manage mild DKA without admission to the intensive care unit (ICU); however, many patients will require ICU care.[1]
After admission to ICU, central venous and arterial lines are usually required. Swan-Ganz catheterization and continuous percutaneous oximetry are needed in patients with hemodynamic instability. Monitoring of respiratory parameters is also required to ensure adequate oxygenation and airway protection.
In all patients, capillary blood glucose testing should be performed during treatment every 1-2 hours using a hospital-calibrated glucose meter. Electrolytes, renal function, venous pH, osmolality, and glucose should be checked every 2-4 hours until stable.[1]
Serial beta hydroxybutyrate (BOHB) measurements may aid monitoring of the response to treatment in DKA. However, measurement of ketone bodies, in the absence of a meter with capacity to measure BOHB, is not recommended. BOHB is converted to acetoacetate, which is detected by the nitroprusside method, during the treatment of DKA. Therefore, the increase in acetoacetate during DKA treatment may mistakenly indicate a worsening of ketonemia.
Monitoring bicarbonate, anion gap, and pH has also been shown to reflect the response to therapy. A flow sheet classifying these findings as well as mental status, vital signs, insulin dose, fluid and electrolytes therapies, and urine output allows easy analysis of response to therapy and resolution of crises.[110][111]
Management and monitoring should continue until resolution of DKA. The criteria for resolution are:[1]
plasma/capillary ketones <0.6 mmol/L AND
venous pH ≥7.3 or bicarbonate ≥18 mEq/L (≥18 mmol/L)
Ideally, plasma glucose should also be <200 mg/dL (<11.1 mmol/L). At this point, insulin dose can be decreased by 50%.[1]
The anion gap should not be used as a criterion, as it may be misleading because of the presence of hyperchloremic metabolic acidosis caused by large volumes of isotonic saline solution.[1] Because BOHB is converted into acetoacetate as the acidosis improves, urinary ketone measurement should also be avoided as a criterion of DKA resolution.[1]
Discharge planning should start early in the admission, and should be structured, individualized and updated as needed.[4] If oral glucose-lowering drugs are held whilst the patient is being treated for DKA but are to be continued following discharge, these should be reinstated 1-2 days before discharge.[4] A follow-up appointment within a month of discharge is advised, with earlier review preferable if changes have been made to drugs or there is suboptimal glycemic management at discharge.[4]
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