Diabetic ketoacidosis: Treatments
DKA and HHS are among the most urgent complications of diabetes.
DKA is known as Diabetic and Ketoacidosis is found. It is mainly caused by lack of insulin administration or infection in patients with type 1 diabetes. HHS is the hyperglycemic hyperosmolar state most commonly caused by infection in patients with type 2 diabetes. In DKA, metabolic acidosis is frequently found and serum glucose is found to be less than 800 mg / dl. However, occasional severe DKA patients may exceed 900 mg / dl. HHS shows differences in the presence or absence of DKA and ketone acidosis and the elevation of blood glucose. However, DKA and HHS coexist in approximately one-third of all acute complications.
Treatment
The treatment of DKA and HHS is similar in that the fluid and electrolytes are matched and insulin is administered.
The first step of treatment is the supplementation of the extracellular volume by administering isotonic saline. First, treatment is meaningful because it can stabilize cardiovascular status and lower plasma osmolality to increase the responsiveness of insulin. The beginning of treatment is mainly started with isotonic saline. Administration should be done as soon as possible. The rate of administration will depend on the condition of the patient. Patients who do not show signs of shock will receive 15 to 20 ml / kg per hour. A maximum of 50 ml / kg is recommended. After the first 1-2 hours of administration, the next fluid is selected based on the subsequent hydration state, electrolyte concentration, and urine volume. At this time, the concept of corrected sodium concentration appears. After converting to 2mEq / L per 100 blood glucose exceeding the normal blood glucose level, the corrected sodium concentration is obtained if it is added to Na now. If the corrected sodium concentration is lower than 135 mEq / L, keep isotonic saline at 250-500 ml / hr. If it is higher than 135mEq / L, the fluid is changed to Half saline and then administered at 250 ~ 500ml / hr. In addition, when serum glucose is reduced to 200, Dextrose is added to the fluid. This evaluation of fluid therapy is done by reviewing hemodynamic parameters and Labs. Patients with kidney or cardiac problems should be evaluated more frequently for fluid therapy. Also, the osmotic pressure should not fall too quickly, because cerebral edema can occur.
Low dose IV insulin should be administered rapidly. If serum potassium is below 3.3 mEq / L, it should be delayed until potassium supplementation is achieved. Insulin administration can lead to the migration of potassium into cells, which can worsen hypokalemia. Insulin is mainly IV regular insulin. The reason why regular insulin is used more than fasting hygiene is the result of considering cost effectiveness. The choice of the type of IV insulin may vary depending on the choice of medical institution and physician. The recommended treatment depends on the severity of the illness. The IV bolus of RI (0.1 U / kg) is recommended for HHS and moderate to severe DKA. At the end of the bolus administration, infusion of 0.14 U / kg / hour is recommended. Insulin dosing is the same in HHS and DKA. Insulin as mentioned above is known to lower blood glucose levels from 50 to 70 mg / dL per hour. Because insulin receptors are already saturated with the above-mentioned doses of insulin, it is known that administration of higher doses does not result in a faster decrease in blood glucose. However, higher insulin doses can be considered if there is no blood glucose reduction of 50 to 70 mg / dL per hour. This reduction in blood glucose is not simply due to insulin therapy. Diabetes mellitus itself shows a blood glucose reduction of 35 to 70 mg / dL. Especially in patients with severe volume depletion, it is known that blood glucose reduction due to fluid therapy is more important. If your blood glucose is different from 200 mg / dL, you can not only add Dextrose to IV Saline, but also lower your insulin dose rate to 0.02 to 0.05 unit / kg. Further lowering of blood sugar can cause cerebral edema. There were several trials in which different insulins were administered instead of regular insulins. All of them showed no difference in blood glucose control according to insulin type. Considering cost effectiveness, it is most reasonable to use regular insulin.
Replacement of K + should be done immediately if serum potassium is less than 5.3. IV potassium chloride should be administered, especially if it is less than 3.3. The rate of administration should be 20-40 mEq / L. If between 3.3 and 5.3, KCl should be added to the fluid until it reaches the normal level of 4.0 to 5.0 mEq / L. If the blood potassium level is higher than 5.3mEq / L, potassium supplementation is not necessary. Also, throughout the course of treatment, the concentration of potassium needs to be constantly monitored. The patient's serum potassium concentration is higher than the actual patient's potassium status, which is due to insulin deficiency. As insulin treatment progresses, the concentration of potassium may decrease rapidly, so an evaluation of the electrolyte concentration continues.
Supplementation of bicarbonate is recommended mainly when the arterial pH is less than 6.9. A solution of 100 mEq of sodium bicarbonate and 20 mEq of KCl in 400 mL of water is recommended. An assessment of the acid base condition is then required and bicarbonate can be given until the pH rises above 7.0. When bicarbonate is given, an assessment of the K + level is also necessary and supplementation of KCl may be necessary since serum potassium may decrease more rapidly. Still, the effect and role of Bicarbonate sedation is controversial and lacks definitive evidence. Many studies have had such and such results, but the study size has been too small, and the results vary from study to study. However, there are some obvious effects and side effects. First, bicarbonate therapy has a definite effect in patients with a pH of 6.9 or less and is also recommended for patients with severe hyperkalemia. Side effects include elevating serum bicarbonate to block the hyperventilation drive and raise the pCO2 in the blood to lower the pH. Although rare, many of these side effects have been reported. In addition, the rate of recovery of ketosis can be slowed by placing Alkali. There have also been reports of metabolic alkalosis after treatment.
DKA is known as Diabetic and Ketoacidosis is found. It is mainly caused by lack of insulin administration or infection in patients with type 1 diabetes. HHS is the hyperglycemic hyperosmolar state most commonly caused by infection in patients with type 2 diabetes. In DKA, metabolic acidosis is frequently found and serum glucose is found to be less than 800 mg / dl. However, occasional severe DKA patients may exceed 900 mg / dl. HHS shows differences in the presence or absence of DKA and ketone acidosis and the elevation of blood glucose. However, DKA and HHS coexist in approximately one-third of all acute complications.
Treatment
The treatment of DKA and HHS is similar in that the fluid and electrolytes are matched and insulin is administered.
The first step of treatment is the supplementation of the extracellular volume by administering isotonic saline. First, treatment is meaningful because it can stabilize cardiovascular status and lower plasma osmolality to increase the responsiveness of insulin. The beginning of treatment is mainly started with isotonic saline. Administration should be done as soon as possible. The rate of administration will depend on the condition of the patient. Patients who do not show signs of shock will receive 15 to 20 ml / kg per hour. A maximum of 50 ml / kg is recommended. After the first 1-2 hours of administration, the next fluid is selected based on the subsequent hydration state, electrolyte concentration, and urine volume. At this time, the concept of corrected sodium concentration appears. After converting to 2mEq / L per 100 blood glucose exceeding the normal blood glucose level, the corrected sodium concentration is obtained if it is added to Na now. If the corrected sodium concentration is lower than 135 mEq / L, keep isotonic saline at 250-500 ml / hr. If it is higher than 135mEq / L, the fluid is changed to Half saline and then administered at 250 ~ 500ml / hr. In addition, when serum glucose is reduced to 200, Dextrose is added to the fluid. This evaluation of fluid therapy is done by reviewing hemodynamic parameters and Labs. Patients with kidney or cardiac problems should be evaluated more frequently for fluid therapy. Also, the osmotic pressure should not fall too quickly, because cerebral edema can occur.
Low dose IV insulin should be administered rapidly. If serum potassium is below 3.3 mEq / L, it should be delayed until potassium supplementation is achieved. Insulin administration can lead to the migration of potassium into cells, which can worsen hypokalemia. Insulin is mainly IV regular insulin. The reason why regular insulin is used more than fasting hygiene is the result of considering cost effectiveness. The choice of the type of IV insulin may vary depending on the choice of medical institution and physician. The recommended treatment depends on the severity of the illness. The IV bolus of RI (0.1 U / kg) is recommended for HHS and moderate to severe DKA. At the end of the bolus administration, infusion of 0.14 U / kg / hour is recommended. Insulin dosing is the same in HHS and DKA. Insulin as mentioned above is known to lower blood glucose levels from 50 to 70 mg / dL per hour. Because insulin receptors are already saturated with the above-mentioned doses of insulin, it is known that administration of higher doses does not result in a faster decrease in blood glucose. However, higher insulin doses can be considered if there is no blood glucose reduction of 50 to 70 mg / dL per hour. This reduction in blood glucose is not simply due to insulin therapy. Diabetes mellitus itself shows a blood glucose reduction of 35 to 70 mg / dL. Especially in patients with severe volume depletion, it is known that blood glucose reduction due to fluid therapy is more important. If your blood glucose is different from 200 mg / dL, you can not only add Dextrose to IV Saline, but also lower your insulin dose rate to 0.02 to 0.05 unit / kg. Further lowering of blood sugar can cause cerebral edema. There were several trials in which different insulins were administered instead of regular insulins. All of them showed no difference in blood glucose control according to insulin type. Considering cost effectiveness, it is most reasonable to use regular insulin.
Replacement of K + should be done immediately if serum potassium is less than 5.3. IV potassium chloride should be administered, especially if it is less than 3.3. The rate of administration should be 20-40 mEq / L. If between 3.3 and 5.3, KCl should be added to the fluid until it reaches the normal level of 4.0 to 5.0 mEq / L. If the blood potassium level is higher than 5.3mEq / L, potassium supplementation is not necessary. Also, throughout the course of treatment, the concentration of potassium needs to be constantly monitored. The patient's serum potassium concentration is higher than the actual patient's potassium status, which is due to insulin deficiency. As insulin treatment progresses, the concentration of potassium may decrease rapidly, so an evaluation of the electrolyte concentration continues.
Supplementation of bicarbonate is recommended mainly when the arterial pH is less than 6.9. A solution of 100 mEq of sodium bicarbonate and 20 mEq of KCl in 400 mL of water is recommended. An assessment of the acid base condition is then required and bicarbonate can be given until the pH rises above 7.0. When bicarbonate is given, an assessment of the K + level is also necessary and supplementation of KCl may be necessary since serum potassium may decrease more rapidly. Still, the effect and role of Bicarbonate sedation is controversial and lacks definitive evidence. Many studies have had such and such results, but the study size has been too small, and the results vary from study to study. However, there are some obvious effects and side effects. First, bicarbonate therapy has a definite effect in patients with a pH of 6.9 or less and is also recommended for patients with severe hyperkalemia. Side effects include elevating serum bicarbonate to block the hyperventilation drive and raise the pCO2 in the blood to lower the pH. Although rare, many of these side effects have been reported. In addition, the rate of recovery of ketosis can be slowed by placing Alkali. There have also been reports of metabolic alkalosis after treatment.
