Diabetic ketoacidosis medical therapy: Difference between revisions
Jump to navigation
Jump to search
No edit summary |
|||
| Line 17: | Line 17: | ||
* Careful monitoring to detect and treat complications. | * Careful monitoring to detect and treat complications. | ||
=== <u> | === <u>ADA guidelines</u> === | ||
The American Diabetes Association (ADA) recommends the following therapy for diabetic ketoacidosis (DKA):<ref name="pmid2699725">{{cite journal |vauthors=Radhakrishna Pillai M, Balaram P, Bindu S, Hareendran NK, Padmanabhan TK, Nair MK |title=Interleukin 2 production in lymphocyte cultures: a rapid test for cancer-associated immunodeficiency in malignant cervical neoplasia |journal=Cancer Lett. |volume=47 |issue=3 |pages=205–10 |year=1989 |pmid=2699725 |doi= |url=}}</ref><ref name="urlDiabetes Care">{{cite web |url=http://care.diabetesjournals.org/content/32/7/1335?ijkey=34356f79daf21d51f95018c32e74e6df627e513c&keytype2=tf_ipsecsha |title=Diabetes Care |format= |work= |accessdate=}}</ref><ref name="pmid21978840">{{cite journal |vauthors=Nyenwe EA, Kitabchi AE |title=Evidence-based management of hyperglycemic emergencies in diabetes mellitus |journal=Diabetes Res. Clin. Pract. |volume=94 |issue=3 |pages=340–51 |year=2011 |pmid=21978840 |doi=10.1016/j.diabres.2011.09.012 |url=}}</ref> | The American Diabetes Association (ADA) recommends the following therapy for diabetic ketoacidosis (DKA):<ref name="pmid2699725">{{cite journal |vauthors=Radhakrishna Pillai M, Balaram P, Bindu S, Hareendran NK, Padmanabhan TK, Nair MK |title=Interleukin 2 production in lymphocyte cultures: a rapid test for cancer-associated immunodeficiency in malignant cervical neoplasia |journal=Cancer Lett. |volume=47 |issue=3 |pages=205–10 |year=1989 |pmid=2699725 |doi= |url=}}</ref><ref name="urlDiabetes Care">{{cite web |url=http://care.diabetesjournals.org/content/32/7/1335?ijkey=34356f79daf21d51f95018c32e74e6df627e513c&keytype2=tf_ipsecsha |title=Diabetes Care |format= |work= |accessdate=}}</ref><ref name="pmid21978840">{{cite journal |vauthors=Nyenwe EA, Kitabchi AE |title=Evidence-based management of hyperglycemic emergencies in diabetes mellitus |journal=Diabetes Res. Clin. Pract. |volume=94 |issue=3 |pages=340–51 |year=2011 |pmid=21978840 |doi=10.1016/j.diabres.2011.09.012 |url=}}</ref> | ||
| Line 46: | Line 46: | ||
* Goal is to maintain serum potassium levels within the normal range of 4–5 mEq/L. | * Goal is to maintain serum potassium levels within the normal range of 4–5 mEq/L. | ||
'''Bicarbonate''' | '''Bicarbonate''' | ||
* The use of bicarbonate in DKA is controversial. It lacks evidence-based prospective clinical trials (especially in patients with pH <6.85 and pediatric population), and there has been no proven clinical efficacy of bicarbonate use.<ref name="pmid219063672">{{cite journal |vauthors=Chua HR, Schneider A, Bellomo R |title=Bicarbonate in diabetic ketoacidosis - a systematic review |journal=Ann Intensive Care |volume=1 |issue=1 |pages=23 |year=2011 |pmid=21906367 |pmc=3224469 |doi=10.1186/2110-5820-1-23 |url=}}</ref> | |||
* The use of bicarbonate in emergent settings depends on the clinical judgment, opinion, and expertise. The perceived benefit in acute reversal of severe acidemia is only based on animal and experimental studies. | |||
* Bicarbonate is administered if arterial pH is < 6.9 to prevent acidotic complications. | * Bicarbonate is administered if arterial pH is < 6.9 to prevent acidotic complications. | ||
* 100 mmol sodium bicarbonate (two ampules) in 400 ml sterile water (an isotonic solution) with 20 mEq KCI administered at a rate of 200 ml/h for 2 h until the venous pH is >7.0. | * 100 mmol sodium bicarbonate (two ampules) in 400 ml sterile water (an isotonic solution) with 20 mEq KCI administered at a rate of 200 ml/h for 2 h until the venous pH is >7.0. | ||
Revision as of 14:01, 11 August 2017
|
Diabetic ketoacidosis Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Diabetic ketoacidosis medical therapy On the Web |
|
American Roentgen Ray Society Images of Diabetic ketoacidosis medical therapy |
|
Risk calculators and risk factors for Diabetic ketoacidosis medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Please help WikiDoc by adding content here. It's easy! Click here to learn about editing.
Overview
Medical Therapy
The United States (US) and United Kingdom (UK) follow slightly different guidelines for the management of diabetic ketoacidosis but the basic principles are same.
Basic principles
The basic principles of diabetic ketoacidosis treatment (DKA) are:
- Rapid restoration of adequate circulation and perfusion with intravenous fluids.
- Gradual rehydration and restoration of depleted electrolytes (especially sodium and potassium), even if serum levels appear adequate.
- Insulin to reverse ketosis and lower glucose levels.
- Careful monitoring to detect and treat complications.
ADA guidelines
The American Diabetes Association (ADA) recommends the following therapy for diabetic ketoacidosis (DKA):[1][2][3]
Fluid therapy
- Initial fluid therapy is aimed towards expansion of the intravascular, interstitial, and intracellular volume, all of which are reduced in hyperglycemic crises.
- Fluid restoration also leads to increased renal perfusion and improves renal function.
- The following options may be used for fluid restoration:
- Isotonic saline (0.9% NaCl) is infused at a rate of 15–20 ml/kg/h or 1–1.5 L during the first hour. It may also be infused at a rate of 250-500 ml/h if serum sodium is low.
- Subsequent choice for fluid replacement depends on hemodynamics, the volume status of the body (signs and symptoms of dehydration), serum electrolyte levels, and urinary output.
- Half normal saline (0.45% NaCl ) infused at 250–500 ml/h is beneficial if the corrected serum sodium is normal or increased.
- Successful progress with fluid replacement is judged by, blood pressure monitoring, measurement of fluid input/output, laboratory values, and clinical examination.
- Fluid replacement usually leads to successful treatment of volume deficit within the first 24 hours.
- In patients with renal or cardiac compromise, monitoring of serum osmolality and frequent assessment of cardiac, renal, and mental status must be performed during fluid resuscitation to avoid iatrogenic fluid overload.
- Aggressive rehydration with subsequent resolution of the hyperosmolar state has been shown to be linked to a better response to low dose insulin.
- Once the plasma glucose is ∼ 200 mg/dl, 5% dextrose should be added to replacement fluids to allow continued insulin administration.
Insulin therapy
- Insulin therapy helps control hyperglycemia, hyperkalemia and ketosis.
- The following routes and rates of insulin administration may be used:
- Route: Intravenous route is preferred because of rapid onset of action, although subcutaneous route can also be used.
- Rate of administration: An initial intravenous dose of regular insulin (0.1 units/kg) followed by the infusion of 0.1 units/kg/h insulin.
- The initial bolus of insulin may be skipped, if patients receive an hourly insulin infusion of 0.14 units/kg body weight (equivalent to 10 units/h in a 70 kg patient).
- Low-dose insulin infusion protocols decrease plasma glucose concentration at a rate of 50–75 mg/dl/h.
- Titration:If plasma glucose does not decrease by 50–75 mg from the initial value in the first hour, the insulin infusion should be increased every hour until a steady glucose decline is achieved.
- When the blood glucose level reaches 200 mg/dl, the rate of insulin infusion should be changed to 0.02 units/kg/h - 0.05 units/kg/h and dextrose may be added to the IV fluids.
Potassium replacement
- Potassium replacement is started when the levels fall below the upper limit of normal (5.0-5.2 mEq/L).
- Goal is to maintain serum potassium levels within the normal range of 4–5 mEq/L.
Bicarbonate
- The use of bicarbonate in DKA is controversial. It lacks evidence-based prospective clinical trials (especially in patients with pH <6.85 and pediatric population), and there has been no proven clinical efficacy of bicarbonate use.[4]
- The use of bicarbonate in emergent settings depends on the clinical judgment, opinion, and expertise. The perceived benefit in acute reversal of severe acidemia is only based on animal and experimental studies.
- Bicarbonate is administered if arterial pH is < 6.9 to prevent acidotic complications.
- 100 mmol sodium bicarbonate (two ampules) in 400 ml sterile water (an isotonic solution) with 20 mEq KCI administered at a rate of 200 ml/h for 2 h until the venous pH is >7.0.
Phosphate
- Phosphate therapy may be given to avoid potential cardiac and skeletal muscle weakness and respiratory depression due to hypophosphatemia.
- Phosphate replacement may sometimes be indicated in patients with cardiac dysfunction, anemia, or respiratory depression and when serum phosphate concentration is <1.0 mg/dl.
- Aggressive phosphate replacement may lead to hypocalcemia.
Criteria for resolution
- According to American Diabetes Association, the following criteria must be met for labeling resolution of DKA:
- Blood glucose <200mg/dl
PLUS
- Any two of the following:
- Bicarbonate greater than equal to 15 mEq/L
- Venous pH > 7.3
- Anion gap less than equal to 12 mEq/L
- Bicarbonate level should not be relied upon to assess the resolution of DKA. This is because high volumes of 0.9 % saline (NaCl) may lead to hyperchloremia in patients. The hyperchloremic acidosis will lower the bicarbonate and thus lead to difficulty is assessing whether the ketosis has resolved. The hyperchloremic acidosis may cause renal vasoconstriction and be a cause of oliguria.
- DKA usually resolves in 24 hours with appropriate treatment.
Differences in management between US and UK
- American Diabetes Association guidelines in the US recommend treating DKA based on the severity.
- Joint British Diabetes Societies in the UK recommend treating DKA based on rate of fall of glucose and serum ketones, with a corresponding rise in bicarbonate.
The following are differences in management of DKA between the US and UK:[1][5][6][7][8]
| Region | Treatment | ||
|---|---|---|---|
| Insulin | Intravenous fluids | Bicarbonate | |
| United states |
|
|
|
| United Kingdom |
|
|
|
Contraindicated medications
Diabetic ketoacidosis is considered an absolute contraindication to the use of the following medications:
- Glipizide
- Glyburide
- Glyburide and Metformin
- Linagliptin and Metformin hydrochloride
- Repaglinide
- Saxagliptin hydrochloride and Metformin hydrochloride
References
- ↑ 1.0 1.1 Radhakrishna Pillai M, Balaram P, Bindu S, Hareendran NK, Padmanabhan TK, Nair MK (1989). "Interleukin 2 production in lymphocyte cultures: a rapid test for cancer-associated immunodeficiency in malignant cervical neoplasia". Cancer Lett. 47 (3): 205–10. PMID 2699725.
- ↑ "Diabetes Care".
- ↑ Nyenwe EA, Kitabchi AE (2011). "Evidence-based management of hyperglycemic emergencies in diabetes mellitus". Diabetes Res. Clin. Pract. 94 (3): 340–51. doi:10.1016/j.diabres.2011.09.012. PMID 21978840.
- ↑ Chua HR, Schneider A, Bellomo R (2011). "Bicarbonate in diabetic ketoacidosis - a systematic review". Ann Intensive Care. 1 (1): 23. doi:10.1186/2110-5820-1-23. PMC 3224469. PMID 21906367.
- ↑ Morris LR, Murphy MB, Kitabchi AE (1986). "Bicarbonate therapy in severe diabetic ketoacidosis". Ann. Intern. Med. 105 (6): 836–40. PMID 3096181.
- ↑ Fleming TN, Runge PE, Charles ST (1992). "Diode laser photocoagulation for prethreshold, posterior retinopathy of prematurity". Am. J. Ophthalmol. 114 (5): 589–92. PMID 1443021.
- ↑ Chua HR, Schneider A, Bellomo R (2011). "Bicarbonate in diabetic ketoacidosis - a systematic review". Ann Intensive Care. 1 (1): 23. doi:10.1186/2110-5820-1-23. PMC 3224469. PMID 21906367.
- ↑ Dhatariya KK, Vellanki P (2017). "Treatment of Diabetic Ketoacidosis (DKA)/Hyperglycemic Hyperosmolar State (HHS): Novel Advances in the Management of Hyperglycemic Crises (UK Versus USA)". Curr. Diab. Rep. 17 (5): 33. doi:10.1007/s11892-017-0857-4. PMC 5375966. PMID 28364357.