Diabetic ketoacidosis

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Teoria 
Diagnóstico 
Tratamento 
ACOMPANHAMENTO 
Recursos 

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Observe que as formulações/vias e doses podem diferir entre nomes e marcas de medicamentos, formulários de medicamentos ou localidades. As recomendações de tratamento são específicas para os grupos de pacientes:ver aviso legal

AGUDA

severe volume depletion

serum potassium <3.3 mEq/L

1ª linha – intravenous fluids

Back

1ª linha –

intravenous fluids

Severe volume depletion is indicated by the presence of orthostatic hypotension or supine hypotension, dry mucous membranes, and poor skin turgor. Extreme cases may be hemodynamically unstable.

The goal of initial fluid therapy is to restore tissue perfusion. The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour. In patients with severe volume depletion or cardiogenic shock, isotonic fluid therapy and hemodynamic monitoring should continue in the intensive care unit until the patient becomes stable.

Electrolytes should be checked at least hourly (to monitor potassium levels) and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

When plasma glucose reaches 200 mg/dL, fluid therapy should be changed to 5% dextrose with 0.45% NaCl at 150-250 mL/hour in order to avoid hypoglycemia.[1]

加 – supportive care + ICU admission

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加 –

supportive care + ICU admission

针对特定患者群中所有患者的治疗建议

Indications for intensive care unit (ICU) admission include hemodynamic instability or cardiogenic shock, altered mental status, respiratory insufficiency, and severe acidosis.

After admission to ICU, central venous and arterial lines are required as well as Swan-Ganz catheterization and continuous percutaneous oximetry.

Intubation and mechanical ventilation are commonly required, with constant monitoring of respiratory parameters.

Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Nasogastric suctioning is always performed because of frequent ileus and danger of aspiration.[1]

加 – potassium therapy

Back

加 –

potassium therapy

针对特定患者群中所有患者的治疗建议

Insulin therapy and correction of hyperosmolarity and acidemia decrease plasma concentration of potassium. For this reason, insulin therapy should be withheld until the serum potassium level reaches 3.3 mEq/L.

Likewise, if plasma potassium falls <3.3 mEq/L at any point of therapy, insulin should be discontinued.

The dose of potassium replacement is 20-30 mEq added to each liter of infusion fluid.[1]

Choices are potassium phosphate or potassium chloride. One third of the potassium replacement should be administered as potassium phosphate to avoid excessive chloride administration.

The serum potassium level should be monitored at least hourly and replacement adjusted accordingly.

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

或

potassium chloride: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

加 – intravenous insulin once serum potassium reaches 3.3 mEq/L

Back

加 –

intravenous insulin once serum potassium reaches 3.3 mEq/L

针对特定患者群中所有患者的治疗建议

Insulin therapy should not be commenced until serum potassium reaches 3.3 mEq/L.

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the American Diabetes Association (ADA).[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is >0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

If plasma glucose does not fall by at least 10% or 50 mg/dL in the first hour of insulin infusion, then a dose of 0.14 units/kg of regular insulin should be administered as an intravenous bolus and the continuous insulin infusion rate should be continued (either 0.1 units/kg/hour or 0.14 units/kg/hour depending on the regimen selected).[1][53] Insulin injection by a sliding scale is no longer recommended. When serum glucose reaches 200 mg/dL, the infusion can be reduced to 0.02 to 0.05 units/kg/hour, at which time dextrose may be added to the intravenous fluids.[1][53] The rate of insulin infusion (or the dextrose concentration) should then be adjusted to maintain a plasma glucose level of between 150-200 mg/dL.[1]

This regimen should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

第一选择

insulin regular: consult local protocols for dosing guidelines

考虑 – vasopressors

Back

考虑 –

vasopressors

针对特定患者群中部分患者治疗的附加建议

In hemodynamically unstable patients, vasopressor therapy may also be required.[1][52]

Consult a specialist for guidance on suitable vasopressor regimens.

考虑 – bicarbonate therapy

Back

考虑 –

bicarbonate therapy

针对特定患者群中部分患者治疗的附加建议

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

In adults with pH <6.9, we recommend that 100 mmol sodium bicarbonate in 400 mL sterile water with 20 mEq KCl be administered at a rate of 200 mL/hour for 2 hours or until pH >7.0. Treatment should be repeated every 2 hours until pH >7.0. Bicarbonate therapy, like insulin therapy, lowers serum potassium; therefore, KCl is added to isotonic bicarbonate.[1][65]

第一选择

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

Considerar – phosphate therapy

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Considerar –

phosphate therapy

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

Routine replacement of phosphate is not recommended.

However, to avoid cardiac, respiratory, and skeletal muscle dysfunction, careful phosphate therapy may be indicated in patients with cardiac dysfunction (e.g., with signs of left ventricular dysfunction), symptomatic anemia, or respiratory depression (e.g., decreased oxygen saturation), and in those with confirmed hypophosphatemia (serum phosphate concentration <1.0 mg/dL).[1]

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

Opções primárias

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

serum potassium 3.3 to 5.3 mEq/L

1ª linha – intravenous fluids

Back

1ª linha –

intravenous fluids

Severe volume depletion is indicated by the presence of orthostatic hypotension or supine hypotension, dry mucous membranes, and poor skin turgor. Extreme cases may be hemodynamically unstable.

The goal of initial fluid therapy is to restore tissue perfusion. The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour. In patients with severe volume depletion (i.e., orthostatic or supine hypotension, dry mucous membranes, and poor skin turgor) or cardiogenic shock, isotonic fluid therapy and hemodynamic monitoring should continue in the intensive care unit until the patient becomes stable.

Electrolytes should be checked at least hourly (to monitor potassium levels) and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

When plasma glucose reaches 200 mg/dL, fluid therapy should be changed to 5% dextrose with 0.45% NaCl at 150-250 mL/hour in order to avoid hypoglycemia.[1]

associado a – supportive care + ICU admission

Back

associado a –

supportive care + ICU admission

Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado

Indications for intensive care unit (ICU) admission include hemodynamic instability or cardiogenic shock, altered mental status, respiratory insufficiency, and severe acidosis.

After admission to ICU, central venous and arterial lines are required as well as Swan-Ganz catheterization and continuous percutaneous oximetry.

Intubation and mechanical ventilation are commonly required, with constant monitoring of respiratory parameters.

Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Nasogastric suctioning is always performed because of frequent ileus and danger of aspiration.

associado a – intravenous insulin

Back

associado a –

intravenous insulin

Tratamento recomendado para TODOS os pacientes no grupo de pacientes selecionado

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50 to 75 mg/dL/hour.[1]

If plasma glucose does not fall by at least 10% or 50 mg/dL in the first hour of insulin infusion, then a dose of 0.14 units/kg of regular insulin should be administered as an intravenous bolus and the continuous insulin infusion rate should be continued (either 0.1 units/kg/hour or 0.14 units/kg/hour depending on the regimen selected).[1][53] Insulin injection by a sliding scale is no longer recommended. When serum glucose reaches 200 mg/dL, the infusion can be reduced to 0.05 units/kg/hour, at which time dextrose may be added to the intravenous fluids.[1][53] The rate of insulin infusion (or the dextrose concentration) should then be adjusted to maintain a plasma glucose level of between 150-200 mg/dL.[1]

This regimen should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

If plasma potassium falls below 3.3 mEq/L at any point, insulin should be discontinued and potassium replaced intravenously. Insulin therapy can be restarted when the potassium level returns to 3.3 mEq/L.

第一选择

insulin regular: consult local protocols for dosing guidelines

加 – potassium therapy

Back

加 –

potassium therapy

针对特定患者群中所有患者的治疗建议

Insulin therapy and correction of hyperosmolarity and acidemia decrease the plasma concentration of potassium. Concurrent potassium replacement is recommended if the serum potassium is in the range 3.3 to 5.3 mEq/L, to prevent cardiac arrhythmias due to hypokalemia. The dose is 20-30 mEq added to each liter of infusion fluid. If potassium is <3.3 mEq/L at any point of therapy, insulin should be discontinued and potassium replaced intravenously.[1]

Choices are potassium phosphate or potassium chloride. One third of the potassium replacement should be administered as potassium phosphate to avoid excessive chloride administration.

The serum potassium level should be monitored at least hourly and replacement adjusted accordingly.

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

或

potassium chloride: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

考虑 – vasopressors

Back

考虑 –

vasopressors

针对特定患者群中部分患者治疗的附加建议

In hemodynamically unstable patients, vasopressor therapy may also be required.[1][52]

Consult a specialist for guidance on suitable vasopressor regimen.

考虑 – bicarbonate therapy

Back

考虑 –

bicarbonate therapy

针对特定患者群中部分患者治疗的附加建议

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

第一选择

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

考虑 – phosphate therapy

Back

考虑 –

phosphate therapy

针对特定患者群中部分患者治疗的附加建议

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

serum potassium >5.3 mEq/L

一线治疗 – intravenous fluids

Back

一线治疗 –

intravenous fluids

Severe volume depletion is indicated by the presence of orthostatic hypotension or supine hypotension, dry mucous membranes, and poor skin turgor. Extreme cases may be hemodynamically unstable.

The goal of initial fluid therapy is to restore tissue perfusion. The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour. In patients with severe volume depletion (i.e., orthostatic or supine hypotension, dry mucous membranes, and poor skin turgor) or cardiogenic shock, isotonic fluid therapy and hemodynamic monitoring should continue in the intensive care unit until the patient becomes stable.

Electrolytes should be checked at least hourly (to monitor potassium levels), and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

When plasma glucose reaches 200 mg/dL, fluid therapy should be changed to 5% dextrose with 0.45% NaCl at 150-250 mL/hour in order to avoid hypoglycemia.[1]

加 – supportive care + ICU admission

Back

加 –

supportive care + ICU admission

针对特定患者群中所有患者的治疗建议

Indications for intensive care unit (ICU) admission include hemodynamic instability or cardiogenic shock, altered mental status, respiratory insufficiency, and severe acidosis.

After admission to ICU, central venous and arterial lines are required as well as Swan-Ganz catheterization and continuous percutaneous oximetry.

Intubation and mechanical ventilation are commonly required, with constant monitoring of respiratory parameters.

Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Nasogastric suctioning is always performed because of frequent ileus and danger of aspiration.

加 – intravenous insulin

Back

加 –

intravenous insulin

针对特定患者群中所有患者的治疗建议

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

This regimen should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

Potassium replacement is not required, but potassium levels should be checked every 2 hours.

第一选择

insulin regular: consult local protocols for dosing guidelines

考虑 – vasopressors

Back

考虑 –

vasopressors

针对特定患者群中部分患者治疗的附加建议

In hemodynamically unstable patients, vasopressor therapy may also be required.[1][52]

Consult a specialist for guidance on suitable vasopressor regimen.

考虑 – bicarbonate therapy

Back

考虑 –

bicarbonate therapy

针对特定患者群中部分患者治疗的附加建议

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

第一选择

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion over 2 hours or until pH >7.0

考虑 – phosphate therapy

Back

考虑 –

phosphate therapy

针对特定患者群中部分患者治疗的附加建议

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

mild to moderate volume depletion: hyponatremic

serum potassium <3.3 mEq/L

一线治疗 – intravenous fluids

Back

一线治疗 –

intravenous fluids

Mild to moderate volume depletion is indicated by the absence of orthostatic hypotension or supine hypotension, dry mucous membranes, and poor skin turgor. The goal is to gradually replace half of the fluid deficit over 12-24 hours, to prevent complications such as cerebral edema.

The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour.

Following the initial fluid replacement, corrected serum sodium level should be evaluated (corrected sodium [mEq/L] = measured sodium [mEq/L] + 0.016 [glucose (mg/dL) - 100]). In patients found to be hyponatremic, 0.9% NaCl should be started at 250-500 mL/hour.

Electrolytes should be checked at least hourly (to monitor potassium levels), and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

When plasma glucose reaches 200 mg/dL, fluid therapy should be changed to 5% dextrose with 0.45% NaCl at 150-250 mL/hour in order to avoid hypoglycemia.[1]

加 – supportive care ± ICU admission

Back

加 –

supportive care ± ICU admission

针对特定患者群中所有患者的治疗建议

Indications for intensive care unit (ICU) admission include altered mental status, respiratory insufficiency, and severe acidosis.

After admission to ICU, central venous and arterial lines are required as well as Swan-Ganz catheterization and continuous percutaneous oximetry. Intubation and mechanical ventilation are commonly required, with constant monitoring of respiratory parameters. Nasogastric suctioning is always performed because of frequent ileus and danger of aspiration.

Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Mild cases of DKA may be managed without ICU admission.[1]

加 – potassium therapy

Back

加 –

potassium therapy

针对特定患者群中所有患者的治疗建议

Likewise, if plasma potassium falls <3.3 mEq/L at any point of therapy, insulin should be discontinued.

The dose is 20-30 mEq added to each liter of infusion fluid.[1]

Choices for potassium therapy are potassium phosphate or potassium chloride. One third of the potassium replacement should be administered as potassium phosphate to avoid excessive chloride administration.

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

或

potassium chloride: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

加 – insulin once serum potassium reaches 3.3 mEq/L

Back

加 –

insulin once serum potassium reaches 3.3 mEq/L

针对特定患者群中所有患者的治疗建议

Insulin therapy should not be commenced until serum potassium reaches 3.3 mEq/L.

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

Patients with mild to moderate DKA (plasma glucose >250 mg/dL, arterial pH 7.00-7.30, serum bicarbonate 10-18 mEq/L) that is not complicated by acute MI, congestive heart failure, end-stage renal or hepatic failure, steroid use, or pregnancy, may be given rapid-acting insulin subcutaneously as an alternative to intravenous regular insulin (with no significant difference in outcomes when using either approach alongside aggressive fluid management for mild or moderate DKA).[3][61][62][63] [ ] A suggested protocol would be an initial subcutaneous injection of rapid-acting insulin at a dose of 0.3 units/kg, followed 1 hour later by another subcutaneous injection of 0.2 units/kg. Thereafter, they should receive 0.2 units/kg every 2 hours until blood glucose becomes <250 mg/dL. At this point, the insulin dose should be decreased by half to 0.1 units/kg every 2 hours until the resolution of DKA.[59] Patients treated with subcutaneous insulin should receive adequate fluid replacement, frequent bedside blood glucose testing and appropriate treatment of underlying causes to avoid recurrent DKA.[3] Continuous intravenous infusion of regular insulin should remain the preferred route because of intravenous insulin's short half-life and easy titration. This is compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin. However, if there are prolonged waiting times for intensive care unit (ICU) admission or limited medical resources, the use of insulin analogs for the treatment of mild uncomplicated DKA episodes can be considered for outpatient, general floors, or emergency departments.

Patients with severe DKA (plasma glucose >250 mg/dL, arterial pH <7.00, serum bicarbonate <10 mEq/L), hypotension, anasarca (severe generalized edema), or associated severe critical illness should be managed with intravenous regular insulin in the ICU using the regimen described above.[1][59][58][60]

This regimen should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

第一选择

insulin regular: consult local protocols for dosing guidelines

第二选择

insulin aspart: consult local protocols for dosing guidelines

或

insulin lispro: consult local protocols for dosing guidelines

考虑 – bicarbonate therapy

Back

考虑 –

bicarbonate therapy

针对特定患者群中部分患者治疗的附加建议

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

第一选择

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

考虑 – phosphate therapy

Back

考虑 –

phosphate therapy

针对特定患者群中部分患者治疗的附加建议

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

serum potassium 3.3 to 5.3 mEq/L

一线治疗 – intravenous fluids

Back

一线治疗 –

intravenous fluids

The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour.

Electrolytes should be checked at least hourly (to monitor potassium levels), and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

When plasma glucose reaches 200 mg/dL, fluid therapy should be changed to 5% dextrose with 0.45% NaCl at 150-250 mL/hour in order to avoid hypoglycemia.[1]

加 – supportive care ± ICU admission

Back

加 –

supportive care ± ICU admission

针对特定患者群中所有患者的治疗建议

Indications for intensive care unit (ICU) admission include altered mental status, respiratory insufficiency, and severe acidosis.

Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Mild cases of DKA may be managed without ICU admission.[1]

加 – insulin

Back

加 –

insulin

针对特定患者群中所有患者的治疗建议

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

Patients with mild to moderate DKA (plasma glucose >250 mg/dL, arterial pH 7.00 to 7.30, serum bicarbonate 10-18 mEq/L) that is not complicated by acute MI, congestive heart failure, end-stage renal or hepatic failure, steroid use, or pregnancy, may be given rapid-acting insulin subcutaneously as an alternative to intravenous regular insulin (with no significant difference in outcomes when using either approach alongside aggressive fluid management for mild or moderate DKA).[3][61][62][63] [ ] A suggested protocol would be an initial subcutaneous injection of rapid-acting insulin at a dose of 0.3 units/kg, followed 1 hour later by another subcutaneous injection of 0.2 units/kg. Thereafter, they should receive 0.2 units/kg every 2 hours until blood glucose becomes <250 mg/dL. At this point, the insulin dose should be decreased by half to 0.1 units/kg every 2 hours until the resolution of DKA.[59] Patients treated with subcutaneous insulin should receive adequate fluid replacement, frequent bedside blood glucose testing and appropriate treatment of underlying causes to avoid recurrent DKA.[3] Continuous intravenous infusion of regular insulin should, however, remain the preferred route because of intravenous insulin's short half-life and easy titration. This is compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin. However, if there are prolonged waiting times for intensive care unit (ICU) admission or limited medical resources, the use of insulin analogs for the treatment of mild or moderate uncomplicated DKA episodes can be considered for outpatients, in general floors, or in emergency departments.[3]

The intravenous or subcutaneous regimens should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

第一选择

insulin regular: consult local protocols for dosing guidelines

第二选择

insulin aspart: consult local protocols for dosing guidelines

或

insulin lispro: consult local protocols for dosing guidelines

加 – potassium therapy

Back

加 –

potassium therapy

针对特定患者群中所有患者的治疗建议

Choices are potassium phosphate or potassium chloride. One third of the potassium replacement should be administered as potassium phosphate to avoid excessive chloride administration.

The serum potassium level should be monitored at least hourly and replacement adjusted accordingly.

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

或

potassium chloride: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

考虑 – bicarbonate therapy

Back

考虑 –

bicarbonate therapy

针对特定患者群中部分患者治疗的附加建议

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

第一选择

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

考虑 – phosphate therapy

Back

考虑 –

phosphate therapy

针对特定患者群中部分患者治疗的附加建议

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

serum potassium >5.3 mEq/L

一线治疗 – intravenous fluids

Back

一线治疗 –

intravenous fluids

The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour.

Potassium replacement is not required, but potassium levels should be checked every 2 hours.

Electrolytes, BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

When plasma glucose reaches 200 mg/dL, fluid therapy should be changed to 5% dextrose with 0.45% NaCl at 150-250 mL/hour in order to avoid hypoglycemia.[1]

加 – supportive care ± ICU admission

Back

加 –

supportive care ± ICU admission

针对特定患者群中所有患者的治疗建议

Indications for intensive care unit (ICU) admission include altered mental status, respiratory insufficiency, and severe acidosis.

Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Mild cases of diabetic ketoacidosis may be managed without ICU admission.[1]

加 – insulin

Back

加 –

insulin

针对特定患者群中所有患者的治疗建议

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

Patients with mild to moderate DKA (plasma glucose >250 mg/dL, arterial pH 7.00 to 7.30, serum bicarbonate 10-18 mEq/L) that is not complicated by acute MI, congestive heart failure, end-stage renal or hepatic failure, steroid use, or pregnancy, may be given rapid-acting insulin subcutaneously as an alternative to intravenous regular insulin (with no significant difference in outcomes when using either approach alongside aggressive fluid management for mild or moderate DKA).[3][61][62][63] [ ] A suggested protocol would be an initial subcutaneous injection of rapid-acting insulin at a dose of 0.3 units/kg, followed 1 hour later by another subcutaneous injection of 0.2 units/kg. Thereafter, they should receive 0.2 units/kg every 2 hours until blood glucose becomes <250 mg/dL. At this point, the insulin dose should be decreased by half to 0.1 units/kg every 2 hours until the resolution of DKA.[59] Patients treated with subcutaneous insulin should receive adequate fluid replacement, frequent bedside blood glucose testing and appropriate treatment of underlying causes to avoid recurrent DKA.[3] Continuous intravenous infusion of regular insulin should remain the preferred route because of intravenous insulin's short half-life and easy titration. This is compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin. However, if there are prolonged waiting times for intensive care unit (ICU) admission or with limited medical resources, the use of insulin analogs for the treatment of mild or moderate uncomplicated DKA episodes can be considered for outpatients, in general floors, or in emergency departments.[3]

The intravenous or subcutaneous regimens should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

第一选择

insulin regular: consult local protocols for dosing guidelines

第二选择

insulin aspart: consult local protocols for dosing guidelines

或

insulin lispro: consult local protocols for dosing guidelines

考虑 – bicarbonate therapy

Back

考虑 –

bicarbonate therapy

针对特定患者群中部分患者治疗的附加建议

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

第一选择

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

考虑 – phosphate therapy

Back

考虑 –

phosphate therapy

针对特定患者群中部分患者治疗的附加建议

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

mild to moderate volume depletion: eunatremic or hypernatremic

serum potassium <3.3 mEq/L

一线治疗 – intravenous fluids

Back

一线治疗 –

intravenous fluids

The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour.

Following the initial fluid replacement, corrected serum sodium level should be evaluated (corrected sodium [mEq/L] = measured sodium [mEq/L] + 0.016 [glucose (mg/dL) - 100]). In patients found to be hypernatremic or eunatremic, 0.45% NaCl at 250 to 500 mL/hour is recommended.

Electrolytes should be checked at least hourly (to monitor potassium levels), and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

加 – supportive care ± ICU admission

Back

加 –

supportive care ± ICU admission

针对特定患者群中所有患者的治疗建议

Indications for intensive care unit (ICU) admission include altered mental status, respiratory insufficiency, and severe acidosis.

Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Mild cases of DKA may be managed without ICU admission.[1]

加 – potassium therapy

Back

加 –

potassium therapy

针对特定患者群中所有患者的治疗建议

Likewise, if plasma potassium falls <3.3 mEq/L at any point of therapy, insulin should be discontinued.

The dose is 20-30 mEq added to each liter of infusion fluid.[1]

The serum potassium level should be monitored at least hourly and replacement adjusted accordingly.

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

或

potassium chloride: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

加 – insulin once serum potassium reaches 3.3 mEq/L

Back

加 –

insulin once serum potassium reaches 3.3 mEq/L

针对特定患者群中所有患者的治疗建议

Insulin therapy should not be commenced until serum potassium reaches 3.3 mEq/L.

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is >0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50 to 75 mg/dL/hour.[1]

Patients with mild to moderate DKA (plasma glucose >250 mg/dL, arterial pH 7.00 to 7.30, serum bicarbonate 10-18 mEq/L) that is not complicated by acute MI, congestive heart failure, end-stage renal or hepatic failure, steroid use, or pregnancy, may be given rapid-acting insulin subcutaneously as an alternative to intravenous regular insulin (with no significant difference in outcomes when using either approach alongside aggressive fluid management for mild or moderate DKA).[3][61][62][63] [ ] A suggested protocol would be an initial subcutaneous injection of rapid-acting insulin at a dose of 0.3 units/kg, followed 1 hour later by another subcutaneous injection of 0.2 units/kg. Thereafter, they should receive 0.2 units/kg every 2 hours until blood glucose becomes <250 mg/dL. At this point, the insulin dose should be decreased by half to 0.1 units/kg every 2 hours until the resolution of DKA.[59] Patients treated with subcutaneous insulin should receive adequate fluid replacement, frequent bedside blood glucose testing and appropriate treatment of underlying causes to avoid recurrent DKA.[3] Continuous intravenous infusion of regular insulin should remain the preferred route because of intravenous insulin's short half-life and easy titration. This is compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin. However, if there are prolonged waiting times for intensive care unit (ICU) admission or limited medical resources, the use of insulin analogs for the treatment of mild or moderate uncomplicated DKA episodes can be considered for outpatient, general floors, or in emergency departments.[3]

This regimen should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

第一选择

insulin regular: consult local protocols for dosing guidelines

第二选择

insulin aspart: consult local protocols for dosing guidelines

或

insulin lispro: consult local protocols for dosing guidelines

考虑 – bicarbonate therapy

Back

考虑 –

bicarbonate therapy

针对特定患者群中部分患者治疗的附加建议

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

第一选择

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

考虑 – phosphate therapy

Back

考虑 –

phosphate therapy

针对特定患者群中部分患者治疗的附加建议

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

serum potassium 3.3 to 5.3 mEq/L

一线治疗 – intravenous fluids

Back

一线治疗 –

intravenous fluids

Mild to moderate volume depletion is indicated by the absence of orthostatic hypotension or supine hypotension, dry mucous membranes, and poor skin turgor. The goal is to gradually replace half of the fluid deficit over 12 to 24 hours, to prevent complications such as cerebral edema.

The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour.

Following the initial fluid replacement, corrected serum sodium level should be evaluated (corrected sodium [mEq/L] = measured sodium [mEq/L] + 0.016 [glucose (mg/dL) - 100]). In patients found to be hypernatremic or eunatremic, 0.45% NaCl at 250-500 mL/hour is recommended.

Electrolytes should be checked at least hourly (to monitor potassium levels), and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

加 – supportive care ± ICU admission

Back

加 –

supportive care ± ICU admission

针对特定患者群中所有患者的治疗建议

Indications for intensive care unit (ICU) admission include altered mental status, respiratory insufficiency, and severe acidosis.

Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Mild cases of DKA may be managed without ICU admission.[1]

加 – insulin

Back

加 –

insulin

针对特定患者群中所有患者的治疗建议

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

Continuous intravenous infusion of regular insulin should, however, remain the preferred route because of intravenous insulin's short half-life and easy titration. This is compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin. However, if there are prolonged waiting times for intensive care unit (ICU) admission or limited medical resources, the use of insulin analogs for the treatment of mild or moderate uncomplicated DKA episodes can be considered for outpatients, general floors, or in emergency departments.[3]

The intravenous or subcutaneous regimens should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

第一选择

insulin regular: consult local protocols for dosing guidelines

第二选择

insulin aspart: consult local protocols for dosing guidelines

或

insulin lispro: consult local protocols for dosing guidelines

加 – potassium therapy

Back

加 –

potassium therapy

针对特定患者群中所有患者的治疗建议

Choices are potassium phosphate or potassium chloride. One third of the potassium replacement should be administered as potassium phosphate to avoid excessive chloride administration.

The serum potassium level should be monitored at least hourly and replacement adjusted accordingly.

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

或

potassium chloride: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

考虑 – bicarbonate therapy

Back

考虑 –

bicarbonate therapy

针对特定患者群中部分患者治疗的附加建议

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

第一选择

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

考虑 – phosphate therapy

Back

考虑 –

phosphate therapy

针对特定患者群中部分患者治疗的附加建议

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

serum potassium >5.3 mEq/L

一线治疗 – intravenous fluids

Back

一线治疗 –

intravenous fluids

The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour.

Following the initial fluid replacement, corrected serum sodium level should be evaluated (corrected sodium [mEq/L] = measured sodium [mEq/L] + 0.016 [glucose (mg/dL) - 100]). In patients found to be hypernatremic or eunatremic, 0.45% NaCl at 250 to 500 mL/hour is recommended.

Potassium replacement is not required, but potassium levels should be checked every 2 hours.

Electrolytes, BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

加 – supportive care ± ICU admission

Back

加 –

supportive care ± ICU admission

针对特定患者群中所有患者的治疗建议

Indications for intensive care unit (ICU) admission include altered mental status, respiratory insufficiency, and severe acidosis.

Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Mild cases of DKA may be managed without ICU admission.[1]

加 – insulin

Back

加 –

insulin

针对特定患者群中所有患者的治疗建议

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

Patients with mild to moderate DKA (plasma glucose >250 mg/dL, arterial pH 7.00 to 7.30, serum bicarbonate 10-18 mEq/L) that is not complicated by acute MI, congestive heart failure, end-stage renal or hepatic failure, steroid use, or pregnancy, may be given rapid-acting insulin subcutaneously as an alternative to intravenous regular insulin (with no significant difference in outcomes when using either approach alongside aggressive fluid management for mild or moderate DKA).[3][61][62][63] [ ] A suggested protocol would be an initial subcutaneous injection of rapid-acting insulin at a dose of 0.3 units/kg, followed 1 hour later by another subcutaneous injection of 0.2 units/kg. Thereafter, they should receive 0.2 units/kg every 2 hours until blood glucose becomes <250 mg/dL. At this point, the insulin dose should be decreased by half to 0.1 units/kg every 2 hours until the resolution of DKA.[59] Patients treated with subcutaneous insulin should receive adequate fluid replacement, frequent bedside blood glucose testing and appropriate treatment of underlying causes to avoid recurrent DKA.[3] Continuous intravenous infusion of regular insulin should, however, remain the preferred route because of intravenous insulin's short half-life and easy titration. This is compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin. However, if there are increased waiting times for intensive care unit (ICU) admission or limited medical resources, the use of insulin analogs for the treatment of mild or moderate uncomplicated DKA episodes can be considered for outpatient, in general floors, or in emergency departments.[3]

The intravenous or subcutaneous regimens should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

Potassium replacement is not required, but potassium levels should be checked every 2 hours.

第一选择

insulin regular: consult local protocols for dosing guidelines

第二选择

insulin aspart: consult local protocols for dosing guidelines

或

insulin lispro: consult local protocols for dosing guidelines

考虑 – bicarbonate therapy

Back

考虑 –

bicarbonate therapy

针对特定患者群中部分患者治疗的附加建议

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

第一选择

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

考虑 – phosphate therapy

Back

考虑 –

phosphate therapy

针对特定患者群中部分患者治疗的附加建议

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][78]

第一选择

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

持续性治疗

DKA resolved and patient able to tolerate oral intake

一线治疗 – establish regular subcutaneous insulin regime

Back

一线治疗 –

establish regular subcutaneous insulin regime

Once DKA has resolved and the patient is able to tolerate oral intake, transition to subcutaneous insulin needs to be initiated. The ADA recommends using a transition protocol (as this is associated with reduced morbidity and costs), and advises that administration of basal insulin is required 2 to 4 hours before stopping intravenous insulin to prevent recurrence of DKA and rebound hyperglycemia.[3] The ADA further directs towards emerging evidence that administration of a low-dose basal insulin analog (0.15 to 0.3 units/kg) in addition to intravenous insulin infusion may reduce infusion duration and length of hospital stay, whilst preventing rebound hyperglycemia (without an increased risk of hypoglycemia).[3]

Intermediate- or long-acting insulin is recommended for basal use and short-acting insulin for prandial glycemic control.

If a patient used insulin as their diabetes treatment prior to DKA, the same dose can be started. Otherwise, the following regimen is recommended: total daily insulin dose of 0.5 to 0.8 units/kg/day, with 30% to 50% of the total daily dose given as basal long-acting insulin, usually at night as a single dose, and the remainder of the total daily dose given as divided doses of fast-acting insulin before each meal.[1][59][60] The ADA mentions that the total daily subcutaneous insulin dose can also be calculated from the rate of the insulin infusion in the previous 6-8 hours when stable glucose levels were attained.[3]

内容使用需遵循免责声明

Diabetic ketoacidosis

Algoritmo de tratamento

severe volume depletion

intravenous fluids

supportive care + ICU admission

potassium therapy

第一选择

intravenous insulin once serum potassium reaches 3.3 mEq/L

第一选择

vasopressors

bicarbonate therapy

第一选择

phosphate therapy

Opções primárias

intravenous fluids

supportive care + ICU admission

intravenous insulin

第一选择

potassium therapy

第一选择

vasopressors

bicarbonate therapy

第一选择

phosphate therapy

第一选择

intravenous fluids

supportive care + ICU admission

intravenous insulin

第一选择

vasopressors

bicarbonate therapy

第一选择

phosphate therapy

第一选择

mild to moderate volume depletion: hyponatremic

intravenous fluids

supportive care ± ICU admission

potassium therapy

第一选择

insulin once serum potassium reaches 3.3 mEq/L

第一选择

第二选择

bicarbonate therapy

第一选择

phosphate therapy

第一选择

intravenous fluids

supportive care ± ICU admission

insulin

第一选择

第二选择

potassium therapy

第一选择

bicarbonate therapy

第一选择

phosphate therapy

第一选择

intravenous fluids

supportive care ± ICU admission

insulin

第一选择

第二选择

bicarbonate therapy

第一选择

phosphate therapy

第一选择

mild to moderate volume depletion: eunatremic or hypernatremic

intravenous fluids

supportive care ± ICU admission

potassium therapy

第一选择

insulin once serum potassium reaches 3.3 mEq/L

第一选择

第二选择

bicarbonate therapy

第一选择

phosphate therapy

第一选择

intravenous fluids

supportive care ± ICU admission