What is the best treatment for a type 1 diabetic patient presenting with abdominal pain, vomiting, hyperglycemia, and significant ketonuria and glucosuria?

Treatment of Diabetic Ketoacidosis in Type 1 Diabetes

The best treatment for a type 1 diabetic presenting with abdominal pain, vomiting, hyperglycemia, and significant glucosuria and ketonuria is insulin therapy combined with intravenous fluid resuscitation (option A and B together). 1

Clinical Assessment

The patient's presentation is consistent with diabetic ketoacidosis (DKA), which is characterized by:

• Abdominal pain and vomiting
• Hyperglycemia
• Significant ketonuria (+3)
• Glucosuria (+3)

These findings represent a medical emergency requiring immediate intervention.

Treatment Algorithm

First-Line Treatment (0-1 hour):

1. IV Fluid Resuscitation

   • Begin with isotonic saline (0.9% NaCl) at 15-20 ml/kg/hour for the first hour (typically 1-1.5 L in adults) 1
   • This addresses the dehydration that accompanies DKA and helps restore renal perfusion

2. Insulin Therapy

   • Start regular insulin as continuous IV infusion at 0.1 U/kg/hour (typically 5-7 U/hour in adults) 1
   • Do NOT give insulin bolus if continuous infusion is used
   • Goal: Decrease plasma glucose by 50-75 mg/dl per hour

Subsequent Management (1-24 hours):

1. Continue IV Fluids

   • After initial bolus, switch to 0.45% NaCl at 4-14 ml/kg/hour if corrected serum sodium is normal or elevated
   • Continue 0.9% NaCl if corrected sodium is low
   • Add dextrose (D5W) when blood glucose falls below 250 mg/dl

2. Electrolyte Replacement

   • Add potassium (20-30 mEq/L) to IV fluids once renal function is assured and serum potassium is known 1
   • Use a mix of KCl and KPO4 (2/3 KCl and 1/3 KPO4)

3. Continue Insulin

   • Maintain insulin infusion until ketoacidosis resolves
   • Do not stop basal insulin in type 1 diabetes even when glucose normalizes, as this can lead to recurrent ketoacidosis 1

Monitoring Parameters

• Blood glucose: Check hourly until stable
• Electrolytes: Every 2-4 hours
• Arterial blood gases: Initially and as needed
• Fluid input/output
• Mental status
• Vital signs

Important Considerations

Avoid These Common Pitfalls:

1. Never discontinue insulin completely in a type 1 diabetic patient, even when glucose normalizes, as basal insulin is always required to prevent ketosis 1
2. Don't delay fluid resuscitation - dehydration is a major component of DKA
3. Don't neglect potassium replacement - total body potassium is depleted in DKA despite possible initial hyperkalemia
4. Don't treat with oral hypoglycemic drugs (option D) - these are ineffective in type 1 diabetes and inappropriate for acute DKA management 1
5. Don't start antibiotics empirically (option C) unless there is clear evidence of infection as the precipitating cause

Special Considerations:

• Look for precipitating factors: infection, stress, insulin omission
• Cerebral edema risk is higher in pediatric patients - fluid resuscitation should be more cautious in children 1
• Transition to subcutaneous insulin should occur only after resolution of DKA, with overlap between IV insulin discontinuation and subcutaneous insulin initiation 1

Conclusion on Treatment Options

From the options provided:

• Option A (Insulin) - Essential but incomplete alone
• Option B (IV Fluids) - Essential but incomplete alone
• Option C (Antibiotics) - Not indicated unless infection is confirmed
• Option D (Oral hypoglycemic drugs) - Contraindicated in type 1 diabetes with DKA

The correct approach combines options A and B as the cornerstone of DKA management, with insulin addressing the metabolic derangement and IV fluids correcting dehydration and electrolyte imbalances.