Add a D10w infusion at an equal rate e. The D10W can actually be infused together with the LR using a single intravenous line, because these two fluids are compatible. The advantage of giving the components separately is that it provides you greater control with regards to adjusting the amount of sodium you are giving versus the amount of dextrose.
For example, if you want to give additional dextrose you can up-tirate the D10W infusion without giving the patient more sodium and causing volume overload. Evidence supports the ability of balanced crystalloid to accelerate resolution of DKA. In some hospital units, this is a more convenient strategy for potassium repletion. Using normal saline for resuscitation is fine, particularly if this is the only way to appropriately replete the patient's potassium.
However, clinicians should be aware that using saline will promote the development of NAGMA that may require active management with intravenous bicarbonate later on as discussed below. Thus, hypokalemia impairs our ability to treat DKA.
Hypokalemia may be treated with aggressive doses of IV potassium e. More on hypokalemia management here. In severe hyperkalemia, IV insulin is indicated e. IV calcium may also be indicated.
More on hyperkalemia management here. Aggressive potassium repletion is generally needed, usually with repeated doses of IV potassium. Oral potassium can be used, but patients are often nauseous and unable to tolerate this.
In renal failure, be more conservative with potassium repletion. Potassium chloride is generally used. However, oral potassium citrate or IV potassium acetate may offer the advantage of reducing the chloride load and thus decreasing the tendency to develop NAGMA. More on hypomagnesemia here. Therefore, our overall goal is to titrate insulin as needed to treat the ketoacidosis figure above. Unfortunately, it's a bit more complicated than this.
Glucose levels are easier to repeat than measurements of ketoacidosis e. Thus, glucose levels are often used as a surrogate measurement of the biological efficacy of insulin for example, during the initial phase of resuscitation, if the glucose level isn't falling, that indicates that insulin isn't working and should be up-titrated. Every hospital will have a DKA protocol, which can generally be followed. However, it's still useful to understand the broad strokes of how insulin is utilized in DKA, as described below.
However, an insulin bolus may be helpful in the following situations: 1 There is a delay in receiving an insulin infusion from the pharmacy. The main advantage of an insulin bolus is that this can usually be given immediately most units have unit insulin vials immediately available , whereas an insulin infusion needs to be mixed up in pharmacy.
An insulin infusion is usually started at 0. However, for patients with severe acidosis e. Occasionally, if the patient's anion gap isn't clearing, you might need to simultaneously increase both the insulin infusion rate and the glucose infusion rate. Remember, the insulin is being used to clear the ketoacidosis.
Hypoglycemia may generally be managed by the use of additional IV dextrose and down-titration of insulin rather than shutting the insulin off entirely. An exception here is a patient with end-stage renal disease, who may chronically have an elevated anion gap due to uremia which never normalizes. Many patients will develop a NAGMA, leading to a persistent acidosis that doesn't respond to insulin. This may be treated with IV bicarbonate as described below.
If the insulin infusion is stopped and the patient doesn't eat anything or receive any IV glucose, this increases the risk of recurrent DKA. An exception can be made for patients with gastroenteritis or diabetic gastroparesis, who may not be hungry for several days. In this situation, the insulin infusion can be stopped, but patients should remain on low-dose intravenous glucose e. If the patient's glucose level increases, they should be treated with PRN short-acting insulin.
Follow glucose carefully and titrate to effect. Encourage patients to eat. Carbohydrate intake along with meal-associated and sliding-scale insulin is important at this point, to prevent recurrent DKA. Glargine has a delayed onset compared to some older forms of insulin e. For patients naive to insulin, a starting dose of 0.
B ritish guidelines For patients on an insulin pump: Some patients have a backup dosing regimen of long-acting insulin e. You can use that as their daily basal insulin dose. The basal insulin requirement may also be calculated from the pump's basal rate e. Sick DKA patients are receiving lots of IV dextrose and they are acidotic , which will temporarily increase their insulin requirements. If the glargine is given at an inopportune time e. Please give patients their full home-dose of basal insulin.
Critical illness causes insulin resistance , so patients may have a tendency to require more insulin not less. Some patients are on twice daily glargine for reasons which aren't entirely clear to me. If such patients are continued on twice daily glargine, the insulin infusion shouldn't be stopped until after they receive their second dose of glargine. Alternatively, both doses can be compiled into a single daily dose this is preferred as it may accelerate weaning off the insulin infusion.
Please check and double-check the glargine dose and when it is scheduled to be delivered. Patients generally tolerate this surprisingly well. Avoid giving bicarbonate during the initial resuscitative phase for management of ketoacidosis. The proper treatment of ketoacidosis is insulin.
Thus, if the patient has a severe ketoacidosis which requires aggressive management, the most effective strategy is to increase the insulin dose usually along with administration of additional glucose and potassium : a Don't wait for the insulin to arrive from pharmacy: bolus 10 units IV immediately.
High-flow nasal cannula HFNC may be helpful to support respiratory compensation for metabolic acidosis. High-flow nasal cannula is a safe way to support the patient's breathing note that patients are not good BiPAP candidates, due to a tendency to vomit. High-flow nasal cannula may reduce the anatomic dead space, thereby reducing the work of breathing and avoiding respiratory fatigue.
The flow rate is what does the work of reducing dead space and thereby blowing off CO2. If the patient is very sick and air-hungry, they will tolerate high flow rates. More on the management of severe acidosis here. Inadequately low insulin dose. Malfunction of insulin infusion e. Festering, underlying problem which hasn't been addressed.
Interventions if the anion gap isn't closing: Evaluate fluid status e. Consider increasing the insulin infusion rate which may require a simultaneous increase in dextrose administration. Reevaluate for a missed underlying problem. Sign In. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Volume 4. Article Contents Abstract. McGill University, Montreal.
Oxford Academic. Google Scholar. Jaclyn Ferris, MD. Dalhousie University, Halifax. Kara Matheson, MSc. Sodium: serum sodium is usually low due to osmotic reflux of water from the intracellular to extracellular space in the presence of hyperglycemia. Hypernatremia in the presence of hyperglycemia indicates profound volume depletion. Alternately, in the presence of high serum chylomicron concentration, pseudonormoglycemia and pseudohyponatremia may occur.
Calculation of the corrected sodium: the corrected serum sodium level should be evaluated as this is used to guide appropriate fluid replacement. Serum potassium is usually elevated due to extracellular shift of potassium caused by insulin insufficiency, hypertonicity, and acidemia, but the total body potassium concentration is low due to increased diuresis.
Therefore, low potassium level on admission indicates severe total-body potassium deficit. Magnesium: usually low. Phosphate: despite the total body phosphate deficit averaging 1. Normalization of the anion gap reflects correction of the ketoacidosis as these anions are removed from the blood. Rhabdomyolysis is common in cocaine users with concurrent DKA, and creatine phosphokinase levels should be assessed in known or suspected cocaine users who present with DKA.
In rhabdomyolysis, pH and serum osmolality are usually mildly elevated and plasma glucose and ketones are normal. Measured to exclude lactic acidosis. Lactate levels are normal in DKA but elevated in lactic acidosis. Usually normal, and are used to screen for an underlying hepatic precipitant. Abnormal LFTs indicate underlying liver disease such as fatty liver, or other conditions such as congestive heart failure.
Amylase is elevated in the majority of patients with DKA, but this may be due to nonpancreatic sources such as parotid glands. Serum lipase is usually normal and may be beneficial in differentiating pancreatitis in patients with elevated amylase level. However, mildly elevated serum lipase level in the absence of pancreatitis has also been reported in patients with DKA. Leukocytosis is present in hyperglycemic crises and correlates with blood ketone levels.
Used to exclude myocardial infarction MI as a precipitant or to look for cardiac effects of electrolyte disturbances usually of potassium. Evidence of hypokalemia U waves or hyperkalemia tall T waves may be present. A high index of suspicion for MI should be maintained as diabetic patients often present with atypical symptoms. Indicated to exclude pneumonia. In pneumonia, may show typical changes of pneumonia including infiltration, consolidation, effusions, and cavitation.
Should be obtained if there are signs of infection such as chills, constitutional upset e. The most common precipitating infections are pneumonia and urinary tract infections. Patients are usually normothermic or hypothermic due to peripheral vasodilation so fever may not be seen. Usually normal, but are elevated if MI is the precipitant. A high index of suspicion should be maintained as diabetic patients often present with atypical symptoms.
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