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 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.
Initially, serum glucose, electrolytes, BUN, creatinine, calcium, magnesium, phosphate, ketones, lactate, creatine phosphokinase, LFTs, urinalysis, ECG, upright chest radiograph, CBC, and ABGs are obtained. Subsequently, glucose and electrolytes are measured at least hourly; calcium, magnesium, and phosphate are checked every 2 hours and BUN, creatinine, and ketones every 2 to 6 hours, depending on the patient's clinical condition and response to therapy.
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.
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