Diabetic%20ketoacidosis%20-and-%20hyperosmolar%20hyperglycemic%20state Treatment

• DKA & HHS patients are best managed in the intensive care unit w/ the care of a specialist/endocrinologist

Intravenous (IV) Fluids

• Initial therapy aims to restore renal perfusion, & expand intravascular & extravascular volume
• Fluid deficits should be corrected w/in the first 24 hours of treatment
• Serum Na should be corrected for hyperglycemia (for each 5.6 mmol/L glucose >5.6 mmol/L, add 1.6 mmol to Na value for corrected serum Na value)
• Serum osmolality change should not be >3 mOsm/kg H₂O/hour
• Avoid iatrogenic fluid overload by frequently monitoring cardiac, renal & mental status
• In pediatric patients, initial fluid expansion should not be >50 mL/kg over first 4 hours of treatment
  
  • Fluid deficits should be corrected over 48 hours of treatment

Insulin

• Ketonemia usually takes longer to clear than hyperglycemia
• May or may not be aggressive w/ insulin administration depending on patient hydration
• If patient presents w/ severe hypokalemia, insulin treatment should be delayed until K serum concentration is restored to >3.3 mmol/L to avoid respiratory arrest & arrhythmias
• There should be an overlap of IV insulin & subcutaneous (SC) insulin of 1-2 hours to ensure adequate glucose control
  
  • An abrupt discontinuation of IV insulin w/ a delayed onset of SC insulin may result in inadequate glucose control
• In newly diagnosed diabetics the initial total insulin dose should be ~0.5-1 U/kg/day given in ≥2 divided doses
  
  • Include both short-acting & long-acting insulin
  • Continue until optimal dosing is established

Potassium

• Correction of acidosis, volume expansion & insulin therapy decrease serum K concentration
  
  • Hypokalemia may be avoided by K replacement 

Bicarbonate

• Studies have failed to show benefit or deleterious changes in morbidity or mortality w/ bicarbonate use in diabetic ketoacidosis (DKA) patients w/ pH between 6.9-7.1
• Insulin & bicarbonate can lower serum K & supplementation may be required

Phosphate

• Patients w/ cardiac dysfunction, anemia or respiratory depression may benefit from careful phosphate replacement
  
  • Hypophosphatemia may cause cardiac & skeletal muscle weakness, & respiratory depression

Somatostatin

• Though not considered standard therapy, Somatostatin may be added if patients are resistant to conventional DKA therapy
• Effects: Decrease glucagon secretion & inhibit ketogenesis