2008 Clinical Practice Guidelines - Canadian Diabetes Association

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<strong>2008</strong> CLINICAL PRACTICE GUIDELINES S66 Figure 1. Management of DKA in adults Diagnose DKA glucose, anion gap* + serum/urine ketones and/or serum beta-OHB, pH or bicarbonate ➝ ➝ ➝ ➝ ➝ ➝ Monitor Plasma electrolytes, anion gap, glucose, creatinine, plasma osmolality, fluid balance, level of consciousness every 2–4 h Precipitating factors (Table 1) Complications (Table 1) Manage Acidosis IV fluids Serum [K + ] ECFV ➝ 3.3 mmol/L but
MANAGEMENT Objectives of management include restoration of normal ECFV and tissue perfusion; resolution of ketoacidosis; correction of electrolyte imbalances and hyperglycemia; and the diagnosis and treatment of coexistent illness. The issues that must be addressed in the patient presenting with DKA or HHS are outlined in Table 1. A summary of fluid therapy is outlined in Table 2, and a management algorithm and formulas for calculating key measurements are provided in Figure 1. Table 1. Priorities* to be addressed in the management of patients presenting with hyperglycemic emergencies Metabolic Precipitating cause of DKA/HHS •ECFV contraction •Potassium deficit and abnormal concentration •Metabolic acidosis •Hyperosmolality (water deficit leading to increased corrected sodium concentration plus hyperglycemia) •New diagnosis of diabetes •Insulin omission •Infection •Myocardial infarction •Drugs *Severity of issue will dictate priority of action DKA = diabetic ketoacidosis ECFV = extracellular fluid volume HHS = hyperosmolar hyperglycemic state Other complications of DKA/HHS •Hyper/hypokalemia •ECFV overexpansion •Cerebral edema •Hypoglycemia •Pulmonary emboli •Aspiration •Hypocalcemia (if phosphate used) •Stroke •Acute renal failure •Deep vein thrombosis Table 2. Summary of fluid therapy for DKA and HHS in adults 1. Administer IV normal saline initially. If the patient is in shock, give 1 to 2 L/hour initially to correct shock; otherwise, give 500 mL/hour for 4 hours, then 250 mL/hour for 4 hours. 2. Add potassium immediately if patient is normo- or hypokalemic. Otherwise, if initially hyperkalemic, only add potassium once serum potassium falls to
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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