Diabetic ketoacidosis

and hyperglycemic crisis

R1 Paphawee Sukkua 
 Outline 
 Pathophysiology
 Clinical manifestation
Hyperglycemic
 Diagnosis
crisis
 Treatment 
 Complications 
Pathophysiology
  Reduce daily insuline injection 
 Infection
 Pregnancy
Important  Hyperthyroid pheochoocytoma , cushing 's
cause  syndrome
 Medications : steroid used , thaizide 
 CVA , MI , PE , GIB
 Pancreatitis
 Major trauma , Surgery 
  Polyuria
 Polydipsia
Clinical
manifestation  Nausea and vomitting
 Abdominal pain
 Dysnea(kussmal breathing)
 Fruity odor breath (ketone odor)
Diagnosis of DKA (ADA 2009)
Diagnosis of DKA (JBDS 2021)

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Management
0 – 60 min
Action 1 : IV Access and Initial Investigation
initial investigation
 DTX, plasma glucose, blood ketones

 BUN , Cr , Elytes(including phosphate)
 CBC , HC , UA , UC
 CXR , EKG , continuous cardiac monitoring
 continuous pulse oximetry

initial investigation
- considering precipitate cause and treat properly
- establish usual medications 
- UPT in bearing age women
- Covid –19 test 
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 Action 2 : Restoration of circulating volume 

SBP <90 SBP≥90

• 500 ml of NSS in 15
min >>SBP still below
90 >> maybe repeat 

• If no improvement >>
find the cause ,
consider critical care
team 

• once SBP above 90 >> 

Action 3 : Potassium Replacement
Action 4 : commence a fixed rate IV insulin infusion

• Infuse at a fixed rate of 0.1 unit/kg/hr

• Only give a bolus dose  of IM insulin if  a delay setting up 

a FRII 

• If the individual normally takes long acting basal insulin  ,

continue this at usual dose and usual time 
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60 min to 6 Hr
Aim of treatment

 Ketone fall 0.5 mmol /hr   OR

 Bicarbonate rise 3 mmol/L  And
 Glucose fall 3 mmol/L/hr
 Maintain serum K in normal range 
 Avoid Hypoglycemia
 Action 1 : Re assess patient, monitor vital signs
 Action 2 : continue fluid replacement via ifusion pump
 Action 3 : Access response to treatment 
 Action 1: Reassess and monitor vital signs

• Monitor vital signs

• Monitor GCS 
• urine output keep > 0.5 ml/kg/hr
 Action 2 :Review metabolic parameters
• Blood glucose , Blood ketone q1 hr 
• VBG(for pH ,bicarbonate,K) at 60min, 2hr 2hourly)

• Adjust IV insulin 1 unit/hr  if not correlate to aim of treatment

• Reducing rate IV insulin to 0.05 U/kg/hrwhen glucose fall below 14 mmol/L
• Add 10% glucose 125ml/hr if glucose fall below 14 mmol/L
• Cont FRII until 
• ketone less than 0.6 mmol/L 
• Venous pH >7.3
• And/or Venous bicarbonate over 18 mmol/L
 Action 3 :Identify and treat precipitating factors

Action 4 :
Newly diagnosed  Type I DM  should be given long acting basal insulin 0.25u/kg
6 hr to 12 hr
12hr to 24 hr
 Resolution Of DKA
ADA JDBS

•  Blood glucose < 200 mg/dl • Serum glucose < 14 mmol/L/

    with >2/3 following criteria  (250 mg/dl)
• Serum ketones < 0.6 mmol/L
• 1.Serum bicarbonate >= 15 mEq/l 
• 2.Venous pH > 7.3 
• Venous pH > 7.3 
• 3.Calculated anion gap <=
12 mEq/l 
  Patients should be eating
and drinking back on normal insulin 
 Transfer to  insulin SC when  
 blood ketones <0.6mmol/L AND
  pH over 7.3 and 
Resolution Of DKA  the patients is raedy and ableto eat  
 Do not discontinue IV insulin
until giving short acting insulin for 30
min 
 Follow up  with Specialist 
complications and treatment

- hypokalemia and hyperkalemia

- hypoglycemia
- Cerebral edema
- volume overload 
- Others complications
  Find and Treat the causes
Take home  Always concern euglycemic DKA in
messages patient who take SGLt inhibitors 
  - Joint British diabetes societies for inpatient care (JBDS-
IP). The management of diabetic ketoacidosis in adults
guideline. 2021
 - Kitabchi, A. E., Umpierrez, G. E., Miles, J. M., & Fisher, J.
N. (2009). Hyperglycemic Crises in Adult Patients With
Reference Diabetes. Diabetes Care, 32(7), 1335–1343.
https://doi.org/10.2337/dc09-9032 (ADA guideline 2009)
 -A Comprehensive Study Guide, 9th edition
Tintinalli, Ma, Yealy, Meckler, Stapczynski, Cline, and
Thomas
Thank you If you have any questions please
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