A patient presents with DKA. Initial management?
Ans. c. 0.9% salineDiabetic ketoacidosis (DKA) is a result of severe insulin insufficiency.It occurs in type 1 diabetics and may be the presenting manifestation.Precipitating factors of DKA include insufficient or interrupted insulin therapy, infection, emotional stress, and excessive alcohol ingestion.The main problems in DKA stem from acidosis with increased anion gap and dehydration.Clinical findings:Anorexia, nausea or vomiting, abdominal pain, rapid breathing (Kussmaul respiration), "fruity" breath odour of acetone, signs of dehydration (dry skin and mucous membranes and poor skin turgor), and altered consciousness to coma. Acidosis can result in fatal rhythm disturbance.Diagnosis:The diagnosis of DKA can be made by finding elevated blood glucose, increased serum levels of acetoacetate, acetone, and hydroxybutyrate, metabolic acidosis (low serum bicarbonate and low blood pH), and increased anion gap (sodium-).DKA is managed with insulin, fluids, and electrolyte replacement.Normal saline should be given in high volume with insulin replacement.Bolus with 5-10 units of regular insulin. Acutely, DKA is associated with hyperkalemia. The total body level of potassium is depleted because of the urinary loss of potassium. As soon as the potassium level falls to <5 mEq/L, potassium replacement should be given.Fig. 5: Pathophysiology of DKAClinical points in the management of DKABegin management with IV insulin, and then switch to subcutaneous insulin when the anion gap normalizes and serum bicarbonate levels are normal.Do not stop the IV insulin before starting subcutaneous insulin; instead, overlap them both for 6-8 hours.Add 5% dextrose to the normal saline as blood glucose reaches 200-250 mg/dL, and continue IV insulin until the anion gap normalizes.
3% saline
5% dextrose
0.9% saline
Colloids
Endocrinology