Type 1 Diabetes in Diabetic Ketoacidosis with Shock or Reduced Consciousness — When Initial Resuscitation Has Not Restored Circulation
Clinical Scenario
This protocol addresses patients with Type 1 diabetes presenting in diabetic ketoacidosis (DKA) who have either shock — evidenced by reduced peripheral pulses — or significantly reduced consciousness or coma.
Previous Step — Escalation Trigger
The preceding step consists of immediate resuscitation: securing the airway, providing breathing support with oxygen, and circulatory support with intravenous 0.9% NaCl. This protocol is the structured next step when that resuscitation has not achieved restoration of circulation.
Approach — Partial Overview
Once escalation criteria are met, management centres on carefully calculated intravenous fluid therapy extended over an appropriate period, followed — after a mandatory interval — by a continuous intravenous insulin infusion. The complete sequence, monitoring requirements, and transition criteria are available in the full protocol.
Treatment Goals
- Acidosis improving with normalisation of pH and clearance of ketones
- Blood glucose decreasing to ≤17.0 mmol/L
- Clinically well and tolerating oral fluids
References
DOI: 10.1016/j.jcjd.2017.10.036
- Shock (reduced peripheral pulses)
- Reduced consciousness or coma
- Replacement of fluid deficit should be extended over a 48-hour period with regular reassessments of fluid status.
- The insulin infusion should not be started for at least 1 hour after starting fluid replacement therapy.
- The insulin infusion should be maintained until pH normalizes and ketones have mostly cleared.
- Clinically well
- Tolerating oral fluids
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