Diabetic ketoacidosis medical therapy: Difference between revisions

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Revision as of 19:57, 9 August 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Medical Therapy

The United States (US) and United Kingdom (UK) follow slightly different guidelines for the management of diabetic ketoacidosis but the basic principles are same.

Basic principles

The basic principles of diabetic ketoacidosis treatment (DKA) are:

Rapid restoration of adequate circulation and perfusion with intravenous fluids.
Gradual rehydration and restoration of depleted electrolytes (especially sodium and potassium), even if serum levels appear adequate.
Insulin to reverse ketosis and lower glucose levels.
Careful monitoring to detect and treat complications.

US guidelines

The American Diabetes Association (ADA) recommends the following therapy for diabetic ketoacidosis (DKA):

Fluid therapy

Initial fluid therapy is aimed towards expansion of the intravascular, interstitial, and intracellular volume, all of which are reduced in hyperglycemic crises.
Fluid restoration also leads to increased renal perfusion and improves renal function.
The following options may be used for fluid restoration:
- Isotonic saline (0.9% NaCl) is infused at a rate of 15–20 ml/kg/h or 1–1.5 L during the first hour. It may also be infused at a rate of 250-500 ml/h if serum sodium is low.
- Subsequent choice for fluid replacement depends on hemodynamics, the volume status of the body (signs and symptoms of dehydration), serum electrolyte levels, and urinary output.
- Half normal saline (0.45% NaCl ) infused at 250–500 ml/h is beneficial if the corrected serum sodium is normal or increased.
- Successful progress with fluid replacement is judged by hemodynamic monitoring (improvement in blood pressure), measurement of fluid input/output, laboratory values, and clinical examination.
- Fluid replacement should correct estimated deficits within the first 24 h.
- In patients with renal or cardiac compromise, monitoring of serum osmolality and frequent assessment of cardiac, renal, and mental status must be performed during fluid resuscitation to avoid iatrogenic fluid overload.
- Aggressive rehydration with subsequent correction of the hyperosmolar state has been shown to result in a more robust response to low-dose insulin therapy

Contraindicated medications

Diabetic ketoacidosis is considered an absolute contraindication to the use of the following medications:

References

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 ==Medical Therapy==
-Treatment consists of hydration to lower the [[osmolality]] of the blood, replacement of lost electrolytes, insulin to force glucose and [[potassium]] into the cells, and eventually glucose simultaneously with insulin in order to correct other [[metabolic]] abnormalities, such as lowered blood potassium ([[hypokalemia]]) and elevated ketone levels.  Many patients require admission to a step-down unit or an [[intensive care unit]] (ICU) so that [[vital signs]], urine output, and blood tests can be monitored frequently. Brain [[edema]] is not rare, and so this may suggest intensive monitoring as well. In patients with severe alteration of mental status, [[intubation]] and [[mechanical ventilation]] may be required. Survival is dependent on how badly-deranged the metabolism is at presentation to a [[hospital]], but the process is only occasionally fatal.
+The United States (US) and United Kingdom (UK) follow slightly different guidelines for the management of diabetic ketoacidosis but the basic principles are same.
-DKA occurs more commonly in type 1 diabetes because insulin deficiency is most severe, though it can occur in type 2 diabetes. In about a quarter of young people who develop type 1 diabetes, insulin deficiency and hyperglycemia lead to ketoacidosis before the disease is recognized and treated. This can occur at the onset of type 2 diabetes as well, especially in young people. In a person known to have diabetes and being adequately treated, DKA usually results from omission of [[insulin]], mismanagement of acute [[gastroenteritis]], the flu, or the development of a serious new health problem (e.g., [[bacterial infection]], [[myocardial infarction]]).
-Insulin deficiency switches many aspects of metabolic balance in a catabolic direction. The liver becomes a net producer of glucose by way of [[gluconeogenesis]] (from protein) and [[glycogenolysis]] (from glycogen, though this source is usually exhausted within hours). Fat in [[adipose tissue]] is reduced to [[triglycerides]] and fatty acids by [[lipolysis]]. Muscle is degraded to release amino acids for gluconeogenesis. The rise of fatty acid levels is accompanied by increasing levels of ketone bodies ([[acetone]], [[acetoacetate]] and beta-hydroxybutyrate; only one, acetone, is chemically a ketone -- the name is an historical accident). As ketosis worsens, it produces a [[metabolic acidosis]], with [[anorexia]], abdominal distress, and eventually vomiting. The rising level of glucose increases the volume of urine produced by the kidneys (an osmolar [[diuresis]]). The high volume of urination ([[polyuria]]) also produces increased losses of electrolytes, especially [[sodium]], [[potassium]], [[chloride]], [[phosphate]], and [[magnesium]]. Reduced fluid intake from [[vomiting]] combined with amplified urination produce dehydration. As the [[metabolic acidosis]] worsens, it induces obvious [[hyperventilation]] (termed [[Kussmaul breathing|Kussmaul respiration]]). [[Kussmaul breathing | Kussmaul's respirations]] are the body's attempt to remove carbon dioxide from the blood that would otherwise form [[carbonic acid]] and further worsen the ketoacidosis.  See also [[arterial blood gas]].
+=== Basic principles ===
+The basic principles of diabetic ketoacidosis treatment (DKA) are:
+* Rapid restoration of adequate circulation and perfusion with intravenous fluids.
+* Gradual rehydration and restoration of depleted electrolytes (especially sodium and potassium), even if serum levels appear adequate.
+* Insulin to reverse ketosis and lower glucose levels.
+* Careful monitoring to detect and treat complications.
-On presentation to hospital, patients in DKA are typically suffering dehydration and breathing both fast and deeply. [[Abdominal pain]] is common and may be severe. Consciousness level is typically normal until late in the process, when [[obtundation]] (dulled or reduced level of alertness or consciousness) may progress to [[coma]]. Dehydration can become severe enough to cause shock. Laboratory tests typically show [[hyperglycemia]], [[metabolic acidosis]], normal or elevated potassium, and severe [[ketosis]]. Many other tests can be affected.
+=== US guidelines ===
+The American Diabetes Association (ADA) recommends the following therapy for diabetic ketoacidosis (DKA):
-At this point the patient is urgently in need of intravenous fluids. The basic principles of DKA treatment are:
+'''Fluid therapy'''
-* Rapid restoration of adequate circulation and perfusion with [[isotonic]] intravenous fluids
+* Initial fluid therapy is aimed towards expansion of the intravascular, interstitial, and intracellular volume, all of which are reduced in hyperglycemic crises.
-* Gradual rehydration and restoration of depleted electrolytes (especially sodium and potassium), even if serum levels appear adequate
+* Fluid restoration also leads to increased renal perfusion and improves renal function.
-* Insulin to reverse ketosis and lower glucose levels
+* The following options may be used for fluid restoration:
-* Careful monitoring to detect and treat complications
+** Isotonic saline (0.9% NaCl) is infused at a rate of 15–20 ml/kg/h or 1–1.5 L during the first hour. It may also be infused at a rate of 250-500 ml/h if serum sodium is low.
+** Subsequent choice for fluid replacement depends on hemodynamics, the volume status of the body (signs and symptoms of dehydration), serum electrolyte levels, and urinary output.
-Treatment usually results in full recovery, though death can result from inadequate treatment or a variety of complications, such as cerebral edema (occurs mainly in children).
+** Half normal saline (0.45% NaCl ) infused at 250–500 ml/h is beneficial if the corrected serum sodium is normal or increased.
+** Successful progress with fluid replacement is judged by hemodynamic monitoring (improvement in blood pressure), measurement of fluid input/output, laboratory values, and clinical examination.
+** Fluid replacement should correct estimated deficits within the first 24 h.
+** In patients with renal or cardiac compromise, monitoring of serum osmolality and frequent assessment of cardiac, renal, and mental status must be performed during fluid resuscitation to avoid iatrogenic fluid overload.
+** Aggressive rehydration with subsequent correction of the hyperosmolar state has been shown to result in a more robust response to low-dose insulin therapy
 ===Contraindicated medications===