From the FDA Drug Label
Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. Therefore, it is important that you obtain medical assistance immediately.
The management for Diabetic Ketoacidosis (DKA) is to obtain medical assistance immediately 1.
From the Research
Introduction to Diabetic Ketoacidosis (DKA) Management
Diabetic ketoacidosis (DKA) is a serious complication of diabetes that requires prompt and effective management. The goal of treatment is to correct the metabolic acidosis, dehydration, and electrolyte imbalances that characterize this condition.
Fluid Resuscitation
The initial step in managing DKA is fluid resuscitation, which aims to restore circulating volume and improve renal function. Isotonic normal saline is the preferred fluid for initial resuscitation, although balanced solutions may be used as an alternative [ 2 ]. The choice of fluid and the rate of administration should be tailored to the individual patient's needs.
Insulin Therapy
Insulin therapy is a critical component of DKA management. Continuous intravenous (IV) insulin infusion is the preferred method of administration, as it allows for precise control of insulin delivery 2, 3 ]. The initial dose of insulin should be based on the patient's weight, and the infusion rate should be adjusted to achieve a gradual decline in blood glucose levels. The use of an initial insulin bolus is controversial, and some studies suggest that it may not be necessary [ 4 ].
Electrolyte Replacement
Electrolyte imbalances, particularly hypokalemia, hypophosphatemia, and hypomagnesemia, are common in DKA. Regular monitoring of electrolyte levels is essential, and replacement therapy should be initiated as needed 2, 3 ].
Prevention of Cerebral Edema
Cerebral edema is a rare but potentially life-threatening complication of DKA. To prevent cerebral edema, it is essential to avoid rapid overcorrection of hyperglycemia and to maintain a steady rate of insulin infusion [ 2 ].
Airway Management
In patients with impending respiratory failure, intubation and mechanical ventilation may be necessary. However, bilevel positive airway pressure is not recommended due to the risk of aspiration [ 2 ].
Use of Sodium Bicarbonate
The use of sodium bicarbonate in DKA management is controversial. While it may be beneficial in severe metabolic acidosis, it can also worsen ketosis and hypokalemia 2, 3 ]. Sodium bicarbonate should only be used in specific situations, such as when the serum pH falls below 6.9 or when there is a high risk of hemodynamic collapse.
Special Considerations
In patients with insulin allergy, desensitization protocols may be necessary to allow for the safe administration of insulin 5, 6 ]. Rapid desensitization with IV insulin can be an effective approach in these cases.
Conclusion
The management of DKA requires a comprehensive approach that includes fluid resuscitation, insulin therapy, electrolyte replacement, and prevention of complications such as cerebral edema. By following established guidelines and tailoring treatment to the individual patient's needs, healthcare providers can improve outcomes and reduce the risk of morbidity and mortality in patients with DKA.
Treatment Protocol
- Fluid resuscitation with isotonic normal saline or balanced solutions
- Continuous IV insulin infusion at a dose of 0.1 units/kg/hour
- Electrolyte replacement as needed
- Prevention of cerebral edema by avoiding rapid overcorrection of hyperglycemia
- Airway management with intubation and mechanical ventilation as needed
- Use of sodium bicarbonate in specific situations, such as severe metabolic acidosis or high risk of hemodynamic collapse
- Desensitization protocols for patients with insulin allergy
Dosing Information
- Insulin: 0.1 units/kg/hour IV infusion
- Sodium bicarbonate: may be used in specific situations, but dosing information is not provided
Caveats
- The use of sodium bicarbonate is controversial and should only be used in specific situations
- Desensitization protocols may be necessary in patients with insulin allergy
- The management of DKA requires a comprehensive approach that includes fluid resuscitation, insulin therapy, electrolyte replacement, and prevention of complications.