Diabetic ketoacidosis Treatment
Initial treatment of dehydration caused by diabetic ketoacidosis should be carried out with 0.9% NaCl solution at a rate of 1 to 2 L every hour during the first 2 hours. Treatment is urgent and must be installed immediately, and has two main objectives, the correction of dehydration and correction of hyperglycaemia.
Additionally, they should monitor and treat electrolyte deficits and eliminate or treat the underlying cause or predisposing factors. In general, the goal is to remove the patient from acidosis in up to 6 hours. Correction of dehydration can be attempted by mouth if the patient is oriented and aware.
Unfortunately the vast majority of patients have some degree of impaired alertness (disorientation, drowsiness, stupor, coma), and in this case is formally contraindicated with oral fluids because of the risk of aspiration.
Fluid replacement is usually initiated with a hypotonic solution of 0.45% NaCl concentration, in order to manage water essentially “free”, restoring intravascular volume and correcting dehydration.
Gradually and according to the patient’s improvement, isotonic solutions can be alternated with NaCl 0.9%, continuing hydration and replenishing the lost sodium diuresis without causing an electrolyte imbalance.
The correction of hyperglycaemia is performed with the administration of insulin by injection. The dose depends on the route used and the method used, for example, using the intramuscular (IM) or subcutaneous (SC). Usually indicated by 0.1 IU / kg body weight as initial dose, split half intravenously (IV) and the other half by the method chosen (IM or SC).
When using only the intravenous route (more practical) an initial dose of 0.15 UIN / kg is given. In both cases treatment is with an insulin infusion at doses of 0.1 UIN / kg / h. Intramuscular insulin is an alternative when there is a continuous infusion pump or when intravenous access is difficult, as in the case of children.
It is essential to remember that monitoring blood levels of glucose, serum electrolytes, blood pH and serum osmolality must be closely monitored, once every hour. To avoid dosing errors, adjust the dose according to the evolution and preventing disorders such as dilutional hyponatremia-refund excess fluid, cerebral edema, by altering the osmolarity-or hypo-insulin overdose.
Besides the above, replacement should be considered if the potassium concentration is less than 3.3 mEq / L, and bicarbonate if the pH is less than 7.0, although none of these measures must be a priority to the restoration of fluid and treatment of hyperglycaemia.
Although the concentration of potassium in the blood appears to be physiological, every patient with diabetic ketoacidosis has a decrease in body potassium which may prove grave. Potassium is administered only if the patient has good renal function and is not disclosed in the early hours because that the patient is receiving rapid rehydration.
If potassium in blood plasma is less than 3.3 MEG / L they are usually given 40 mEq of potassium in 24 hours. If serum potassium is between 3.3 and 5 mEq / L they are given between 20 and 30 mEq in 24 hours. These measures must be maintained to achieve a glucose concentration exceeding 200 to 250 mg / dL. Once this is achieved, the rest of the therapy should be consistent with individual patient characteristics and evolution.