Simply put, DKA is caused by too little insulin and a response from the endocrine system that causes an increase in catecholamines, cortisol, glucagon, and growth hormone. The lack of glucose utilization and increase in gluconeogenesis and glycogenolysis causes hyperglycemia. Hyperglycemia further causes diuresis, leading to dehydration, electrolyte abnormalities, and kidney dysfunction. The typical signs and symptoms of DKA include polyuria, polydipsia, weight loss, nausea, vomiting, weakness, lethargy, altered mental status, acetone breath, tachycardia, hypotension, and deep hyperventilation.
Laboratory parameters are crucial in the diagnosis of DKA. The initial workup should include plasma glucose, blood urea nitrogen, serum creatinine, electrolytes with anion gap, osmolality, serum ketones, arterial blood gas, CBC with differentials, urine ketones, urinalysis, chest x-ray, ECG, and urine, blood, and sputum cultures. The American Diabetes Association consensus guideline outlines diagnostic criteria for DKA, classified according to severity Table 2.
The goals of DKA treatment are to normalize fluid-volume status, hyperglycemia, electrolytes, and ketoacidosis. Any other potential precipitating factors should also be identified and addressed. In DKA, fluid loss can range from 6 to 9 L. Approximately one-half of the total volume loss should be replaced during the first 8 to 12 hours and the remaining volume within 24 to 36 hours. Rehydration is essential for tissue perfusion and resolution of the associated metabolic abnormalities.
In addition, rehydration optimizes low-dose insulin therapy. Crystalloid fluids are preferred, with 1 to 1. No significant differences were found in any of the metabolic abnormalities, complications, or mortality rates between the two groups. Afterward, the rate of hydration should be guided by hydration status, hemodynamic status, electrolytes, and urinary output.
Normal saline 0. Urine output is particularly important in monitoring these patients. Volume resuscitation is essential prior to initiating insulin therapy because insulin may worsen dehydration. Prior to initiation of insulin therapy, potassium should be at least 3.
In addition, dextrose should be added to the maintenance IV fluids at this point to prevent potential hypoglycemia. IV is the preferred route of administration of insulin in patients with DKA. A randomized, prospective trial conducted by Fisher and colleagues compared the use of low-dose insulin therapy by IV, IM, and SC routes. The three groups showed similar responses 8 hours after treatment. Insulin aspart and insulin lispro SC every 1 to 2 hours are as safe and effective as continuous insulin infusion in an ICU setting.
Dosing regimens consist of 0. At this point, insulin should be decreased to 0. The time to DKA resolution, rate of hypoglycemia, and the length of hospital stay were similar between the two groups. Once DKA has resolved, patients who are capable of eating may be started on long-acting insulin for basal insulin requirements and a premeal rapid-acting insulin to control plasma glucose. Insulin infusion should be continued for at least an hour after the SC insulin is given to ensure that plasma insulin levels are adequate.
Potassium is generally depleted in DKA and other hyperglycemic emergencies. Insulin causes the intracellular movement of potassium into muscle cells by binding to its receptor on skeletal muscle. About two-thirds of patients will develop hypokalemia in the course of treatment for DKA. Twenty to 30 mEq of potassium may be supplemented to each liter of fluids.
Patients with severe hypokalemia may require more potassium during the first hour of insulin treatment. Cite Cite Haralampos J. Select Format Select format. Permissions Icon Permissions. Open in new tab Download slide. Diabetes Res Clin Pract. Nephrol Dial Transplant. Issue Section:. Download all slides. Comments 0. Add comment Close comment form modal. I agree to the terms and conditions. You must accept the terms and conditions.
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Citing articles via Web of Science 5. Cancer risk in patients with IgA nephropathy: a Swedish population-based cohort study. Management of obesity in kidney transplant candidates and recipients: A clinical practice guideline by the Descartes working group of ERA. The systematic search can be carried of the literature that reports either retrospective or prospective, cohorts or case series, prevalence or incidence of DKA, or the clinical trials reporting efficacy of main components of DKA management that may affect serum concentration of potassium ion.
In addition of mentioned criteria, by targeting only the studies reporting effects of potassium ions on CVS as a primary, secondary, or subsidiary outcome of the research will help to determine practicality of this opinion.
Should there be the data to compile so as to establish a statistical association or dissociation, it will help to understand and modify all the major current guidelines and hence may improve the CVS outcomes for the DKA patients.
Idea, conceptualization for further research, and authorship are developed and undertaken by AU at School of Pharmacy, Monash University Malaysia. The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor declared a shared affiliation, though no other collaboration with the author AU.
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