Aims of therapy

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Treatment comprises rehydration with intravenous fluids, the administration of insulin and replacement of electrolytes. The treatment of ketoacidosis in children in considered in Chapter 2. The importance of general medical care and close supervision by trained medical and nursing staff deserves emphasis. A treatment flow-chart should be used (see Chapter 3) and updated meticulously. Accurate recording of fluid balance may necessitate a urinary catheter if no urine is passed in the first 4 h or so. An initial treatment plan for diabetic ketoacidosis in adults is shown in Table 1.6.

Table 1.6 Guide to treatment of diabetic ketoacidosis Fluids and electrolytes

Volumes

• 1 L/h x 2-3, thereafter adjusted according to requirements Fluids

• Hypotonic (0.45%) if serum sodium exceeds 150 mmol/L (no more than 1-2 L - consider 5% dextrose with increased insulin if marked hypernatraemia)

• 5% dextrose 1 L every 4-6 h when blood glucose has fallen to <15 mmol/L (severely dehydrated patients may require simultaneous saline infusion)

Sodium bicarbonate

• ~700 mL of 1.26% or 100 mL of 8.4% (if large vein cannulated) if pH < 7.0 (with extra potassium)

Potassium

• No potassium in first 1 L of fluid unless initial plasma potassium < 3.5 mmol/L

• Thereafter, add dosages below to each 1 L of fluid. If plasma K+

o <3.5 mmol/L, add 40 mmol KCl (severe hypokalaemia may require more aggressive KCl replacement) o 3.5-5.5. mmol/L, add 20 mmol KCl o >5.5 mmol/L, add no KCl.

Insulin

Continuous intravenous infusion

• 5-10 U/h (average 6 U/h) initially until blood glucose has fallen to <15 mmol/L. Thereafter, adjust rate (1-4 U/h usually) during dextrose infusion

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Table 1.6 (continued )

to maintain blood glucose ~6-11 mmol/L until patient is eating again. Measure, and record, capillary glucose hourly.

• Capillary blood glucose (mmol/L) • Soluble insulin infusion rate

Other measures

• Search for and treat precipitating cause, e.g. infection.

• Hypotension usually responds to adequate fluid replacement.

• Central venous pressure monitoring in elderly patients or if cardiac disease present.

• Pass nasogastric tube - with airway protection - if conscious level impaired.

• Pass urinary catheter if conscious level impaired or no urine passed within 4 h of start of therapy.

• Continuous electrocardiographic monitoring may warn of hyper- or hypokalaemia (potassium should be measured at 0, 2 and 6 h - and more often if indicated by levels outside target range).

• Adult respiratory distress syndrome - mechanical ventilation (100% O2, postive pressure ventilation); avoid fluid overload.

• Mannitol (up to 1 g/kg intravenously) if cerebral oedema suspected. Parenteral dexamethasone as alternative; N.B. induces insulin resistance. Consider cranial CT scan to exclude alternative pathology (e.g. cerebral haemorrhage, venous sinus thrombosis).

• Treat thrombo-embolic complications if they occur.

• Meticulous clinical and biochemical record using a purpose-designed flowchart.

*Note: Intravenous insulin should not be interrupted if at all possible. However, errors leading to significant hypoglycaemia, e.g. inadvertent interruption of i.v. dextrose, may necessitate temporary cessation of insulin while corrective action is taken, e.g. increasing the dextrose infusion rate and/or bolus of 20-30 mL of 50% dextrose into a large vein if symptomatic (see Chapter 4). Aim to restart i.v. insulin within 15-30 min, at a reduced rate if indicated, and/or with a higher rate of dextrose infusion; consider 10% dextrose. Since interruption of i.v. insulin risks relapse of ketoacidosis, some clinicians advocate continuing insulin at a reduced rate while correcting lesser degrees of hypoglycaemia with i.v. dextrose. Careful monitoring with attention to infusion apparatus and hourly checks on the volumes infused will help to minimise the risk of hypoglycaemia.

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