Preventing and treating diabetic ketoacidosis

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The basis of ketoacidosis treatment is to simultaneously i Restore the proper amount of water to the body i Reduce the acid condition of the blood by getting rid of the ketones i Restore substances such as potassium that have been lost i Return blood glucose to its normal level of around 80 to 120 mg/dl

The treatment of DKA is left in the hands of the experts, but you should know what's being done, in general, so that you understand what your child is going through. In the following sections, I explain what happens during treatment and give you a few pointers for preventing DKA entirely.

Although you can't take care of your child with diabetic ketoacidosis on your own, it's important that you recognize the signs and symptoms (see the previous section). Like most illnesses, the earlier you begin to reverse the abnormalities with treatment, the quicker the patient recovers and the lower the chance of further complications or death.

Taking measures to prevent DKA

Because infection is the major precipitating cause of DKA, prevention begins with the best possible sick-day care (see Chapter 15 for details). An important first step is realizing that just because your child's sick and not eating doesn't mean that he doesn't still need insulin — and perhaps needs more than usual. Performing more testing of glucose more frequently, especially on sick days, is another key step. It's also important to be very aware of the signs and symptoms of DKA.

Receiving treatment at the hospital

Traditionally, DKA has been treated in intensive care units, but there's no evidence that this setting has any benefit over the conventional medicine ward. Death rates, length of stay in the hospital, and rapidity of recovery are no lower in the intensive care unit, which is far more expensive. Ask the doctor if care in the intensive care unit is necessary before your child is admitted there.

In the hospital, your child's doctor sets up a flowchart to keep track of glucose, acid, potassium, and ketones. Although your child may have lost a lot of potassium, for example, the initial blood reading for potassium may be normal. As treatment progresses, potassium enters cells along with glucose to replenish the losses there, so his blood potassium may fall. Then the doctor administers potassium to fix the problem. As he does this, he looks for the underlying cause that may have set off the DKA, such as an infection, and treats it with antibiotics as necessary.

The first step in treatment is to begin replacing the large amounts of fluids that have been lost. At the same time, your child receives insulin to shut down fat metabolism and allow the large amount of glucose in the blood to enter cells. Traditionally, insulin is given as a constant intravenous (IV) drip, but if the hospital doesn't permit IV treatment outside the intensive care unit, injections of rapid-acting insulin every one to two hours are just as safe and effective. Injected insulin begins to work in ten minutes and continues for three to four hours, although it peaks in the first hour (see Chapter 10 for the basics of insulin use).

At some point, your child's blood glucose may fall towards hypoglycemia (which I discuss earlier in this chapter). When this begins to happen, the intravenous fluids that have contained no glucose up until then begin to contain glucose along with normal levels of sodium. Potassium is added in the IV if blood tests indicate that your child's potassium has fallen to low levels.

The doctor gives your child large volumes of a saltwater solution intravenously to replace the 6 or more liters of fluids lost during DKA. Replenishing body fluids relieves the nausea and vomiting that he's endured, and he should be able to eat and keep down liquid and solid food once again. Your child's normal mental function is returning as well. If you already were aware of your child's diabetes, you're ready to help him resume self-care. If not, you both have to begin the lifetime learning that diabetes requires (see Chapter 2 for an introduction).

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Watching out for potential complications

Most cases of DKA respond to treatment, and the patient is able to resume daily life after a few days in the hospital. If the patient is being carefully monitored with frequent tests for blood glucose, potassium, and so forth, the most common complications can be avoided. Occasionally, a complication occurs; the major complications in order of frequency are

1 Hypoglycemia: This usually happens because glucose hasn't been added to the intravenous fluids after the blood glucose reaches 250 mg/dl. Hypoglycemia also may result because the insulin being given isn't reduced sufficiently as the glucose falls. This complication is avoided by measuring the blood glucose every hour or two.

1 Low potassium: A patient with DKA loses a lot of potassium from inside cells that have to regain their potassium in order to return to a normal state. Typically, glucose and potassium enter cells as insulin is given. However, prior to giving insulin, the blood potassium level can fall to dangerously low levels, which may result in serious abnormal heart rhythms. If the initial potassium measurement is low in the blood, it may be safer to replenish the potassium along with fluids before giving insulin to avoid this complication.

1 Relapse of DKA: This may happen when there's a lack of insulin during the time between giving intravenous insulin for treatment of the DKA and giving subcutaneous insulin to return the patient to his usual program. To be safe, a long-acting subcutaneous insulin should be given two hours before the intravenous insulin is stopped. Or if only subcutaneous insulin is used, long-acting insulin may be given several hours before the frequent doses of subcutaneous insulin are stopped to provide some basal insulin until the next mealtime shot of insulin.

1 Cerebral edema: This complication is a swelling of the brain that occurs less than 1 percent of the time, more often in children, and is associated with the rare deaths that occur in DKA. Symptoms include headaches, decreased consciousness, seizures, and urinary incontinence. The cause of cerebral edema is unknown. It begins about 12 hours after treatment begins for DKA, and drugs that are given to reduce the brain swelling are sometimes effective.

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