Management of DKA in a 68-Year-Old Noncompliant Type 2 Diabetic
The appropriate treatment for this 68-year-old noncompliant type 2 diabetic with DKA requires immediate fluid resuscitation with balanced fluids, continuous IV insulin infusion, electrolyte replacement (particularly potassium), and identification and treatment of precipitating factors. 1, 2
Assessment of Severity
This patient presents with:
- Blood glucose: 24 mg/dL (fingerstick)
- pH: 7.3 (VBG)
- pCO2: 29 mmHg
- Serum bicarbonate: 14 mEq/L
- Anion gap: 18
- WBC: 21,000
Based on American Diabetes Association criteria, this represents mild-to-moderate DKA 1:
- Arterial pH 7.3 (mild DKA: 7.25-7.30)
- Bicarbonate 14 mEq/L (moderate DKA: 10-14 mEq/L)
- Elevated anion gap (18)
- Leukocytosis suggesting possible infection as precipitant
Treatment Algorithm
1. Fluid Resuscitation
- Begin with balanced crystalloid fluids rather than normal saline 2
- Recent evidence shows balanced fluids lead to faster DKA resolution (13 hours vs 17 hours) compared to normal saline 2
- Initial bolus: 15-20 mL/kg in first hour (approximately 1-1.5L for average adult)
- Continue with 250-500 mL/hr based on hemodynamic status and cardiac function
- Replace 50% of estimated fluid deficit in first 8-12 hours 1
- Use caution with fluid administration due to patient's age and potential cardiac compromise 1
2. Insulin Therapy
- Start continuous IV insulin infusion at 0.1 units/kg/hour 1
- Do not give insulin bolus (risk of hypokalemia)
- Monitor blood glucose hourly
- Target glucose reduction rate: 50-75 mg/dL/hour
- Once blood glucose reaches 200 mg/dL, reduce insulin infusion to 0.02-0.05 units/kg/hour and add dextrose to IV fluids 1
- Continue insulin infusion until DKA resolves (bicarbonate ≥18 mEq/L, pH >7.3, and anion gap normalized) 1
3. Electrolyte Replacement
- Potassium replacement is critical
- If serum K+ <3.3 mEq/L: Hold insulin and give potassium until level >3.3 mEq/L
- If serum K+ 3.3-5.3 mEq/L: Add 20-30 mEq potassium to each liter of IV fluid
- If serum K+ >5.3 mEq/L: Do not add potassium initially, but check levels frequently
- Bicarbonate therapy
4. Identify and Treat Precipitating Factors
- Evaluate for infection given leukocytosis (WBC 21,000)
- Obtain blood cultures, urine cultures, chest X-ray
- Start empiric antibiotics if infection suspected
- Other common precipitating factors to consider:
- Medication non-compliance (already identified)
- Myocardial infarction (obtain ECG)
- Stroke
- Pancreatitis (check lipase)
Monitoring and Follow-up
- Hourly monitoring of vital signs, neurological status, blood glucose, and fluid input/output 1
- Check electrolytes, BUN, creatinine, and venous pH every 2-4 hours 1
- Continue treatment until DKA resolution criteria are met:
- Blood glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3 1
Transition to Subcutaneous Insulin
- Once DKA resolves, transition to subcutaneous insulin
- Give subcutaneous insulin 1-2 hours before stopping IV insulin infusion 1
- Check blood glucose 2 hours after IV insulin discontinuation 1
- Continue monitoring every 3-4 hours for first 24 hours after transition 1
Discharge Planning
- Comprehensive diabetes education is essential for this noncompliant patient 1
- Education should include:
- Proper insulin administration
- Blood glucose monitoring
- Sick-day management
- When to seek medical attention
- Importance of medication adherence
- Schedule follow-up within 1-2 weeks 1
Special Considerations
- Cardiac monitoring is advisable given patient's age and risk for cardiovascular disease 1
- Evaluate for underlying causes of noncompliance (financial barriers, cognitive issues, depression)
- Consider simplified insulin regimen to improve compliance
- Screen for diabetes complications that may have developed due to poor control