Management Of Diabetic Ketoacidosis

Therapy for patients with diabetic ketoacidosis DKA involves careful replacement of fluid deficits, correction of acidosis and hyperglycemia via insulin administration, correction of electrolyte imbalances and monitoring for complications of treatment.

1. Dehydration
A patient with severe DKA is assumed to be approximately 10% dehydrated. An initial IV fluid bolus of a glucose-free isotonic solution ( normal saline, lactated Ringer’s solution) at 10-20 ml/kg should be given to restore intravascular volume and renal perfusion. The remaining fluid deficit after the initial bolus should be added to maintenance fluid requirements, and the total should be replaced slowly over 36 to 48 hrs. To avoid rapid shifts in serum osmolality, 0.9% sodium chloride can be used as the replacement fluid for the initial 4 to 6 hrs followed by 0.45% sodium chloride.

2. Hyperglycemia
Fast-acting soluble insulin should be administered as a continuous IV infusion (0.1U/kg/hr). Serum glucose concentration should decrease at a rate no faster than 100 mg/dl/hr. When serum glucose concentration decreases to less than 250-300 mg/dl, glucose should be added to IV fluids.

3. Acidosis
Insulin therapy lowers glucagon and diminishes its activity on liver, decreases the production of free fatty acids and protein catabolism, and enhances glucose usage in target tissues. theses processes correct acidosis. Bicarbonate therapy should be avoided unless there is severe acidosis ( pH < 7.0).

4. Electrolyte ImbalancesRegardless of the serum potassium concentration at presentation, total body potassium depletion is likely. When adequate urin output is shown potassium should be added to the IV fluids. Potassium replacement should be given as 50% KCl and 50% KPO4 at a concentration of 20-40 mEq/L.

5. Monitoring
A flow sheet should be used to record and monitor fluid balance and laboratory measurements. Serum glucose measurements should be repeated every hour during therapy and electrolyte concentrations should be repeated every 2 to 3 hours. Calcium, phosphate and magnesium concentrations should be measured initially and then every 4 to 6 hours during therapy.

Neurologic and mental status should be assessed at frequent intervals. Any deterioration of mental status or headache may be due to cerebral edema as a possible complication.

Transition to Out patient management
When the acidosis has been corrected, and the patient tolerates oral feedings, the IV insulin infusion can be discontinued and a regimen of SC insulin injections can be initiated. The first SC insulin dose should be given 30 to 45 minutes before discontinuation of the IV insulin infusion. Further adjustment of the insulin dose should be made over the following 2 to 3 days.