What should be monitored in a patient with Diabetic Ketoacidosis (DKA)?

Monitoring Parameters for Patients with Diabetic Ketoacidosis (DKA)

Nurses caring for patients with DKA should monitor blood glucose, electrolytes, venous pH, and anion gap every 2-4 hours until resolution, while maintaining vigilance for hypokalemia and hypoglycemia during insulin therapy.

Essential Monitoring Parameters

Blood Glucose Monitoring

• Check blood glucose hourly during active treatment to guide insulin therapy and detect hypoglycemia early 1
• Target glucose between 150-200 mg/dL until DKA resolution parameters are met 1
• Add dextrose 5% to IV fluids when serum glucose reaches 250 mg/dL while continuing insulin infusion to prevent hypoglycemia 1

Electrolyte Monitoring

• Monitor serum electrolytes, especially potassium, every 2-4 hours until stable 1, 2
• Hypokalaemia is common (about 50%) during treatment of DKA, and severe hypokalaemia (<2.5 mEq/L) is associated with increased mortality 2
• Maintain serum potassium between 4-5 mmol/L through appropriate replacement 1

Acid-Base Status Monitoring

• Check venous pH and anion gap every 2-4 hours to monitor resolution of acidosis 2, 1
• Direct measurement of β-hydroxybutyrate (β-OHB) in blood is the preferred method for monitoring ketosis 1
• Do not rely on nitroprusside method (urine ketones) as it only measures acetoacetic acid and acetone, not β-OHB 1

Resolution Parameters to Monitor For

• DKA resolution requires all of the following parameters:
  • Glucose <200 mg/dL 1
  • Serum bicarbonate ≥18 mEq/L 1
  • Venous pH >7.3 1
  • Anion gap ≤12 mEq/L 1

Fluid Status Monitoring

• Monitor vital signs, including blood pressure and heart rate, to assess response to fluid resuscitation 3
• Assess for signs of volume overload, especially in patients with renal or cardiac disease 4
• Track fluid input and output to guide ongoing fluid management 3

Common Pitfalls to Avoid

• Do not interrupt insulin infusion when glucose levels fall below 200-250 mg/dL; instead, add dextrose to IV fluids 1
• Avoid relying on urine ketones to monitor resolution, as β-OHB converts to acetoacetate during treatment, which may falsely suggest worsening ketosis 1
• Be vigilant for hypoglycemia, especially when transitioning from IV to subcutaneous insulin 5
• Remember that ketonemia typically takes longer to clear than hyperglycemia, requiring continued insulin therapy even after glucose normalizes 1

Transition from IV to Subcutaneous Insulin

• When DKA resolves and patient can eat, prepare to transition to subcutaneous insulin 1
• Administer basal insulin 2-4 hours before stopping IV insulin infusion to prevent recurrence of ketoacidosis 1
• Continue IV insulin for 1-2 hours after starting subcutaneous insulin to ensure adequate plasma insulin levels 1

Additional Considerations

• Evaluate for possible causes of persistent or worsening ketoacidosis despite insulin therapy 1
• Monitor for signs of infection, which is the most common precipitating cause of DKA 6
• For patients with mild DKA who are stable, subcutaneous rapid-acting insulin combined with aggressive fluid management can be as effective as IV insulin 3

By following these monitoring parameters diligently, nurses can help ensure optimal outcomes for patients with DKA while minimizing the risk of complications during treatment.