The following therapeutic principles are recommended for DKA:
- Initial volume administration of 1 l isotonic solution (e.g., 0.9% NaCl) within the first hour to stabilize the circulation. Subsequently, fluids and electrolytesshould be administered depending on concomitant diseases, age, height, and weight (the supply of 6 l / 24 h may be required in the process [Haak 2018]).
In patients with known heart failure, there is a risk of pulmonary edema due to too rapid an infusion rate. In this case, infusion should therefore be slow (Herold 2020).
Hypokalemia must be compensated before insulin treatment, since insulin shifts potassium to intracellular levels, posing a risk of hypoglycemic ventricular fibrillation (Herold 2020).
- Substitution of potassium at a pH of > 7.1:
- for potassium > 4 - 5 mmol /l substitution of 10 - 15 mmol / l
- with potassium 3 - 4 mmol / l substitution of 15 - 20 mmol / l
- for potassium < 3 mmol / l substitution of 20 - 25 mmol / l (Herold 2020)
A maximum of 40 mmol of potassium chloride should be infused per 1,000 ml of NaCl 0.9% at a time (Haak 2018). Contraindication to potassium administration is anuria (Herold 2020).
If hypokalemia of < 3 mmol / l occurs during insulin therapy, insulin administration should be interrupted - if possible (Herold 2020).
The target value of serum potassium should be > 3.5 mmol / l (Kasper 2015).
Insulin delivery should be via a perfusor.
In exsiccosis, insulin can act poorly, so primary volume administration is required to achieve a good effect of insulin (Reitgruber 2021).
In shock, patients should be treated with normal ins ulin only; the duration of action is 20-40 min, and the half-life is <10 min (Herold 2020).
Blood glucose concentration should be reduced by 50 mg / dl / h (2.8 mmol / l), but not lower than 250 mg / dl during the first 24 h to avoid cerebral edema and retinal damage (Herold 2020).
From a blood glucose concentration of 300 mg / dl (16.7 mmol / l), an infusion with 10% glucose should run in parallel to avoid
- a too rapid drop in blood glucose (Haak 2018)
- of lipolysis with an increase in free fatty acids (Herold 2020).
"Low-dose" insulin therapy is recommended in most patients, i.e.:
- initial bolus of 0.10 - 0.15 IU / kg bw i. v. and subsequently about 5 IU normal insulin / h i. v. via the dosing pump (Herold 2020).
If blood glucose does not drop within 2 h, the patient requires higher doses of insulin due to insulin resistance. To break this resistance, the insulin dose should be doubled. In rare cases, an even higher amount of insulin may be needed beyond that (Herold 2020).
Bicarbonate should only be substituted from a pH- value < 7.0 and only until correction to pH 7.1 (Haak 2018), since lipolysis is inhibited under insulin therapy anyway. The dosage should be only 25% of the calculated requirement to avoid hypokalemia (Herold 2020). Too high a dose of bicarbonate also increases the risk of cerebral edema (Kasper 2015).
Sodium is substituted as part of infusion therapy (Herold 2020).
Phosphate is usually within the normal range. If the value is < 0.5 mmol / l, substitution of about 50 mmol / 24 h may be recommended. However, phosphate is contraindicated in renal insufficiency (Herold 2020).
Magnesium deficiency may occur under treatment of DKA, which requires appropriate substitution (Kasper 2015).
- specific therapy such as.
- Causal research (Haak 2018).
The complication rate can be reduced by:
- low-dose insulin therapy
- slow compensation of the metabolic derailments (Herold 2020).
The CNS needs some time to normalize the water shifts triggered by the coma. Therefore, the patient may remain unconscious despite normalization of blood glucose, electrolytes, pH and volume balance. This disturbance usually disappears with a delay (Herold 2020).
The diet should start with a light diet. A small amount of normal insulin s. c. should be injected before each meal. Subsequently, readjustment of DM is required (Herold 2020).