How to manage hypothermia associated with diabetic ketoacidosis (DKA)?

Management of Hypothermia in Diabetic Ketoacidosis (DKA)

Patients with DKA who present with hypothermia require immediate rewarming while simultaneously addressing the metabolic derangements of DKA, as hypothermia is a poor prognostic sign that increases mortality risk.

Initial Assessment and Recognition

• Hypothermia (core temperature <35°C) can be a presenting feature of DKA and is associated with increased mortality 1
• Physical findings in hypothermic DKA patients may include poor skin turgor, Kussmaul respirations, tachycardia, hypotension, altered mental status, and potentially coma 1
• Patients with DKA may be normothermic or hypothermic primarily due to peripheral vasodilation, despite ongoing infection 1

Rewarming Protocol for Hypothermic DKA

Immediate Interventions

• Move the patient to a warm environment and remove wet clothing immediately 1
• Begin passive rewarming with dry blankets and active rewarming methods simultaneously 1
• For severe hypothermia (temperature <28°C) with decreased responsiveness, activate emergency response system while initiating rewarming 1

Active Rewarming Methods

• Apply chemical heat packs or forced air warming systems to trunk areas (axilla, chest, back, and groin) 1
• When using rewarming devices, follow manufacturer's instructions, place insulation between heat source and skin, and monitor frequently for burns 1
• Avoid body-to-body rewarming as it is less effective than other active rewarming techniques 1

Concurrent DKA Management

Fluid Therapy

• Begin with isotonic saline at 15-20 mL/kg/h during the first hour to restore circulatory volume and tissue perfusion 2
• Continue fluid replacement to correct estimated deficits within the first 24 hours 2
• Monitor fluid input/output, hemodynamic parameters, and clinical examination to assess progress with fluid replacement 2

Insulin Therapy

• Once hypokalemia is excluded, administer an intravenous bolus of regular insulin at 0.15 U/kg body weight, followed by a continuous infusion at 0.1 U/kg/h 2
• If plasma glucose does not fall by 50 mg/dL from the initial value in the first hour, double the insulin infusion every hour until a steady glucose decline between 50-75 mg/h is achieved 2
• Target blood glucose levels of 100-180 mg/dL 2

Electrolyte Management

• Monitor potassium levels closely as total body potassium deficits are common despite potentially normal or elevated initial serum levels due to acidosis 2
• Once renal function is assured and serum potassium is known, add 20-40 mEq/L potassium to the infusion when serum levels fall below 5.5 mEq/L 2
• Bicarbonate administration is generally not recommended in DKA patients as it does not improve outcomes 2

Special Considerations for Hypothermic DKA

• Handle hypothermic patients gently to avoid triggering cardiac arrhythmias 1
• Provide high-calorie foods or drinks for patients who are alert and can safely consume oral intake to support shivering thermogenesis 1
• Monitor for rhabdomyolysis, which can develop during rewarming, especially in patients with hypokalemia 3
• Be aware that laboratory values may be affected by hypothermia; coagulation tests may appear normal when performed at standard 37°C but may be abnormal at the patient's actual body temperature 1

Monitoring During Treatment

• Monitor core temperature continuously until normothermia is achieved 1
• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 2
• Perform continuous cardiac monitoring, especially during rewarming, as patients are at risk for arrhythmias 2
• Monitor for signs of cerebral edema during treatment 2

Resolution Criteria

• DKA resolution requires glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 2
• Normothermia should be achieved (core temperature 36-37°C) 1

Case Evidence Supporting This Approach

• Case reports have demonstrated successful management of severe hypothermia (as low as 26°C) in DKA patients using active external rewarming without requiring extracorporeal methods 4
• Hypothermia with hypokalemia in DKA can lead to rhabdomyolysis and acute kidney injury if not properly managed 3
• Successful rewarming and DKA management can result in good outcomes even in patients with severe hypothermia 5

Discharge Planning

• A structured discharge plan should be tailored to the individual to reduce length of hospital stay and readmission rates 1
• Include education on the recognition, prevention, and management of DKA 2
• Schedule follow-up appointments prior to discharge 2