Acute management of mild ketoacidosis
Mild DKA (pH 7.25 to 7.3) in someone who can tolerate oral fluids and does not have altered sensorium can be managed with oral rehydration and subcutaneous insulin and monitoring of electrolytes.
Acute management of moderate–severe DKA
The normal protocol would include:
- fluid replacement (N saline + KCl)
- insulin - infusion
- observation sheet - hourly BSLs, 4th hourly EUC/pH
- correction of electrolytes (IV potassium replacement)
Bicarbonate replacement is not usually required, but if so, would require consultation with ICU/endocrine senior staff prior to commencement.
While in hospital:
- meticulous monitoring of progress
- review of diabetes management, including diet by diabetes management team
- assessment by adolescent team or social worker
Longer term management
In a patient such as Lisa, the principles would include:
- Refer to her regular endocrinologist for review.
- Refer Lisa to an adolescent clinic (if available) for further assessment and individual and family counselling about illness, peer group, relationships with parent/siblings.
- Contact school counsellor - give update, outline needs and request regular support.
- Discharge to GP for ongoing monitoring of compliance and follow-up of adolescent clinic referral.
- A full psychosocial assessment such as HEADDSS