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Improve circulatory volume and perfusion Decrease serum glucose Clear serum of ketoacids at steady rate Correct electrolyte imbalances Treat the cause Prevent complications

Fluids, fluids, fluids!

CAUTION: NOT TO OVERLO AD

Fluids, fluids, fluids!

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Mainstay of initial therapy Expands the intravascular volume and improves the renal blood flow 2-3 L of 0.9% NS over 1-3 hr (10-15ml/kg/hr) After the initial bolus of NS, replacement of the Na & free water deficit is carried out over the next 24hr

When hemodynamic stability & adequate urine output are achieved IV fluids should be switched to 0.45% Saline at a rate of 200-300ml/h depending on the calculated volume deficit The change to 0.45% saline helps to reduce the trend toward hyperchloremia later in the course of DKA

Role of Insulin: Lower serum glucose  Reduce ketogenesis in liver by lipolysis and glucagon secretion  Increase ketone utilization Insulin IV bolus and continuous drip is standard of care

Check Potassium first- if K+ is <3.3 meq/L , delay insulin until K is supplemented to >3.3 meq/L
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IV bolus of regular insulin: 0.1 U/Kg Continuous infusion, start at 0.1 U/Kg/hr Goal is to decrease glucose by 50-70 mg/dl per hour; will require further titration of drip

When the plasma glucose reaches 250 mg/dL, glucose should be added to 0.45% saline infusion to maintain the plasma glucose in 200-250 mg/dL range and the insulin infusion should be continued. If blood sugar decreases to <80, stop insulin for no more than 1 hr and restart

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K stores are depleted in DKA If the initial serum K level is elevated, then K repletion should be delayed until it falls to normal range To prevent hypokalemia, add KCl to IVF If K normal, 20-30 meq/liter of IVF is adequate If K low, may need more aggressive rx Try to avoid the chloride salt of K+ to reduce the hyperchloremic metabolic acidosis Goal is to maintain the serum K > 3.5 meq/L

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Controversial subject Concerns with use: Rapid rise in pCO2 which may lead to fall in cerebral pH contributing to edema May increase hepatic ketogenesis Post-treatment metabolic alkalosis

Consider use with pH <7 after initial hydration Dose:50-100meq NaHCO3 (1-2 amps) over 2hr

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Most patients phosphate depleted Usually level will fall with initial therapy Driven into the cells with resolving acidosis Improved renal perfusion excretion Most patients do not have symptoms related to hypophosphatemia Routine use not necessary If evidence of cardiac dysfunction, hemolytic anemia, or respiratory depression in pts with phos<1.0 mg/dl 20-30 meq/L of Potassium Phosphate, added to IVF

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Catheterisation if no urine passed after 3hrs Nasogastric tube to keep stomach empty in unconscious patients Central venous line if cvs compromised Plasma expander if SBP is <90 or doest not rise with iv saline Antibiotic to treat infection

  

Keep a flow chart Measure capillary glucose every 1-2hr Measure electrolytes and AG every 4hr for first 24hr Monitor BP, Pulse, RR, mental status, fluid intake and output every 1-4hr Continue above until pt is stable, glu goal is 150250 mg/dL& acidosis is resolved.

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Cerebral edema oWorsening mental status 12-24 hrs after starting rx o0.5-1% of cases, mostly in children oMortality 20-25% oReduce risk by gradual replacement of Na & H2O deficits in hyperosmolar patients & adding dextrose to IV solution once appropriate ARDS Acute circulatory failure

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Resume regular diet Add long-acting insulin, based on prior dosing or 24 hr insulin requirements on drip Stop insulin infusion 1-2 hrs after SC insulin dose It is crucial to continue insulin infusion until adequate insulin levels are achieved by SC routle

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Improved access to medical care Education When to contact doctor if illness occurs Increased use of short-acting insulin during illness Continued use of insulin & BS monitoring when illness prevents eating Continued nutrition during times of illness

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