Management of diabetic ketoacidosis
Mainstay of treatment are: fluid therapy, insulin therapy, potassium replacement and antibiotics for precipitating infections.
Typical requirement of fluid is 6 litres in 1st 24 hours, ideally with a central line. Start with 1 litre normal saline in 1st 30 minutes. Caution is needed in cardiac and renal impairment.
Aims of insulin therapy: reduce lipolysis and ketone body formation; reduce hepatic glucose output, increase peripheral glucose utilization. Low dose, IV, regular insulin. Subcutaneous and intra muscular insulin may not be absorbed well. Reduce the dosage when blood sugar falls below 270 mg/dl
Potassium replacement: Anticipate hypokalemia while treating diabetic ketoacidosis, which can cause life threatening arrhythmia, especially in those with associated cardiac problems. Start infusion of potassium chlorde in normal saline if serum potassium is less than 3.3 mEq/Litre.
Empirical systemic antibiotics are started initially. Add amphotericin if fungal infection is suspected. Change antibiotic when culture and sensitivity is available.
ECG monitoring is needed when there is cardiac or renal failure as there is a higher chance of cardiac arrhythmias in this setting.
Prevention of diabetic ketoacidosis
Patient education is the mainstay in prevention of diabetic ketoacidosis. Increase insulin dosage is needed during prodromal sick days as the insulin requirement increases with concomittant illnesses. Adequate hydration, frequent blood glucose monitoring and urine ketones are needed in this situtaion. Most important, the need to seek early medical advice if blood glucose control is not satisfactory has to be stressed.