Monitoring

Diabetic ketoacidosis (DKA) is complicated to manage and needs close monitoring and timely treatment modifications.[20]

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

Review the patient hourly to ensure clinical and biochemical improvement and continue the fixed-rate intravenous insulin infusion (FRIII).[2][56]

  • 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 mmol/L/hour or a reduction in blood glucose of 3 mmol/L/hour.

    • If the target rates for blood ketones, blood glucose, and venous bicarbonate are not achieved:[2]

      • 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 and 5 mmol/L.

    • Maintain an accurate fluid balance chart.[2]

      • Aim for a minimum urine output of 0.5 ml/kg/hour.

Monitor for complications regularly throughout treatment of DKA.[2][56]

  • Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2] 

  • 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:[1]​​

  • Blood ketone level <0.6 mmol/L AND

  • Venous pH ≥7.3 or bicarbonate ≥18 mmol/L

Ideally, plasma glucose should also be <11.1 mmol/L.[1]

12 to 24 hours

Check venous pH, bicarbonate, potassium, ketones, and glucose at 12 hours. Ensure DKA has resolved within 24 hours.[2][56]​ Request senior or consultant input if DKA has not resolved within this timeframe.[2]

On discharge

In the UK, all patients with type 1 diabetes mellitus should be offered continuous glucose monitoring (CGM).[56] Results from a nationwide study in France reported that access to a CGM system was associated with a subsequent decrease in the rate of DKA hospitalisations by 53% in people with type 1 diabetes and by 47% in those with type 2 diabetes.[172]​ These results were observed both in patients treated with multidose insulin and in those treated with continuous insulin infusion (pump) therapy.[173]

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