Diabetic ketoacidosis

más – intravenous insulin

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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 Joint British Diabetes Societies for Inpatient Care (JBDS-IP) advise that a systolic blood pressure (SBP) cutoff of 90 mmHg may be used in assessing the severity of hydration (with patients who have SBP <90 mmHg on admission considered to have severe hypovolemia), caveating that age, sex, presence of heart failure, and concomitant drugs should also be taken into account.[66]

Severe hypovolemia should be treated by infusion of isotonic saline (or other crystalloid) at the rate of 1 L/hour until signs of severe volume depletion have resolved.[1][14][66] Once SBP is ≥90 mmHg or other methods of clinical assessment indicate resolution of severe hypovolemia, patients should continue to receive fluid therapy as for mild hypovolemia,[1]

Electrolytes, renal function, venous pH, osmolality, and glucose should be checked every 2-4 hours until stable.[1]

When glucose reaches <250 mg/dL (<13.9 mmol/L), 5% or 10% dextrose should be added to the isotonic saline or crystalloid solution to avoid hypoglycemia.[1]

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más –

intravenous insulin

Se recomienda el tratamiento para TODOS LOS pacientes en el grupo de pacientes seleccionados

A continuous fixed-rate intravenous infusion of short-acting regular insulin at 0.1 units/kg/hour should be started after exclusion of hypokalemia (potassium level should be >3.5 mEq/L [>3.5 mmol/L] before initiation of insulin therapy). Frequent close monitoring in an ICU setting is required for administration of intravenous insulin infusion. If there is a delay in setting up the infusion (e.g., if a delay in obtaining venous access is anticipated), an intravenous bolus of short-acting regular insulin 0.1 units/kg (or intramuscularly if intravenous administration is not possible) should be given, followed by the intravenous infusion.[1] Once blood glucose falls below 250 mg/dL (13.9 mmol/L), 5% or 10% dextrose should be added to the isotonic saline (0.9% sodium chloride)/crystalloid infusion and the insulin infusion rate should be reduced to 0.05 units/kg/hour. Thereafter, the insulin infusion should be adjusted to maintain glucose levels between 150 and 200 mg/dL (8.3 and 11.0 mmol/L) and continued until the ketoacidosis is resolved (plasma/capillary ketones <0.6 mmol/L and venous pH ≥7.3 or bicarbonate ≥18 mEq/L [≥18 mmol/L]).[1]

Electrolytes, renal function, venous pH, osmolality, and glucose should be checked every 2-4 hours until stable.[1]

If plasma potassium falls below 3.5 mEq/L (3.5 mmol/L) at any point, insulin should be discontinued and potassium replaced intravenously. Insulin therapy can be restarted when the potassium level returns to 3.5 mEq/L (3.5 mmol/L).

Opciones primarias

insulin regular: consult local protocols for dosing guidelines

más – potassium therapy

más – supportive care + ICU admission

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más –

supportive care + ICU admission

Se recomienda el tratamiento para TODOS LOS pacientes en el grupo de pacientes seleccionados

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Considerar –

bicarbonate therapy

Tratamiento adicional recomendado para ALGUNOS pacientes del grupo seleccionado

Routine bicarbonate administration is not recommended in diabetic ketoacidosis (DKA).[1][4] The American Diabetes Association guidelines note that several studies have failed to show any difference in acidosis resolution or time to discharge in people with DKA when bicarbonate was used.[4] At arterial blood pH >7.0, administration of insulin blocks lipolysis and resolves ketoacidosis without the need to add bicarbonate. Administering bicarbonate therapy in these patients may result in increased risk of hypokalemia, decreased tissue oxygen uptake, and cerebral edema.[1] However, because severe metabolic acidosis may lead to adverse vascular effects, bicarbonate therapy should be considered in patients with arterial blood pH <7.0 (i.e., severe acidosis).[1]

The decision to give bicarbonate therapy is individualized. If indicated, an isotonic solution of 100 mEq (100 mmol) sodium bicarbonate in 400 mL sterile water (8.4% solution) can be given every 2 hours until the pH is >7.0.[1]

serum potassium >5 mEq/L (>5 mmol/L)

más – intravenous insulin

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Primera línea –

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 Joint British Diabetes Societies for Inpatient Care (JBDS-IP) advise that a systolic blood pressure (SBP) cutoff of 90 mmHg may be used in assessing the severity of hydration (with patients who have SBP <90 mmHg on admission considered to have severe hypovolemia), caveating that age, sex, presence of heart failure, and concomitant drugs should also be taken into account.[66]

Electrolytes, renal function, venous pH, osmolality, and glucose should be checked every 2-4 hours until stable.[1]

When glucose reaches <250 mg/dL (<13.9 mmol/L), 5% or 10% dextrose should be added to the isotonic saline or crystalloid solution to avoid hypoglycemia.[1]

Back

más –

intravenous insulin

Se recomienda el tratamiento para TODOS LOS pacientes en el grupo de pacientes seleccionados

Electrolytes, renal function, venous pH, osmolality, and glucose should be checked every 2-4 hours until stable.[1]

Potassium replacement is not required, but serum potassium should be checked every 2 hours. If levels drop to less than 5 mEq/L (5 mmol/L), intravenous potassium replacement should be commenced.[1]

Opciones primarias

insulin regular: consult local protocols for dosing guidelines

más – supportive care + ICU admission

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más –

supportive care + ICU admission

Se recomienda el tratamiento para TODOS LOS pacientes en el grupo de pacientes seleccionados

Back

Considerar –

bicarbonate therapy

Tratamiento adicional recomendado para ALGUNOS pacientes del grupo seleccionado

Routine bicarbonate administration is not recommended in diabetic ketoacidosis (DKA).[1][4] The American Diabetes Association guidelines note that several studies have failed to show any difference in acidosis resolution or time to discharge in people with DKA when bicarbonate was used.[4] At arterial blood pH >7.0, administration of insulin blocks lipolysis and resolves ketoacidosis without the need to add bicarbonate. Administering bicarbonate therapy in these patients may result in increased risk of hypokalemia, decreased tissue oxygen uptake, and cerebral edema.[1] However, because severe metabolic acidosis may lead to adverse vascular effects, bicarbonate therapy should be considered in patients with arterial blood pH <7.0 (i.e., severe acidosis).[1]

mild to moderate volume depletion

serum potassium <3.5 mEq/L (<3.5 mmol/L)

más – potassium therapy

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Primera línea –

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. An intravenous solution of isotonic saline or other crystalloid should be given at a clinically appropriate rate, with the aim of replacing 50% of the estimated fluid deficit in the first 8-12 hours.[1]

Electrolytes, renal function, venous pH, osmolality, and glucose should be checked every 2-4 hours until stable.[1]

When glucose reaches <250 mg/dL (<13.9 mmol/L), 5% or 10% dextrose should be added to the isotonic saline or crystalloid solution to avoid hypoglycemia.[1]

Caution should be exercised in the following groups: young people ages 18-25 years; elderly people; pregnant people; people with heart or kidney failure; and people with other serious comorbidities.[66] In these situations, admission to an intermediate care unit should be considered. Fluids should be replaced cautiously with close hemodynamic monitoring.[1][66]

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más –

potassium therapy

Se recomienda el tratamiento para TODOS LOS pacientes en el grupo de pacientes seleccionados

Electrolytes, renal function, venous pH, osmolality, and glucose should be checked every 2-4 hours until stable.[1]

If potassium is <3.5 mEq/L (<3.5 mmol/L) at any point of therapy, insulin should be discontinued and potassium replaced intravenously.

más – insulin once serum potassium reaches 3.5 mEq/L (3.5 mmol/L)

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más –

insulin once serum potassium reaches 3.5 mEq/L (3.5 mmol/L)

Se recomienda el tratamiento para TODOS LOS pacientes en el grupo de pacientes seleccionados

Insulin therapy should not be commenced until serum potassium reaches 3.5 mEq/L (3.5 mmol/L).

Insulin therapy is the cornerstone of diabetic ketoacidosis (DKA) management.[1] The goal is the steady but gradual reduction of serum glucose and plasma osmolality by low-dose insulin therapy, in order to reduce the risk of treatment complications including hypoglycemia and hypokalemia.

Electrolytes, renal function, venous pH, osmolality, and glucose should be checked every 2-4 hours until stable.[1]

Patients with mild to moderate DKA (plasma glucose ≥200 mg/dL [≥11.1 mmol/L], arterial pH 7.00 to 7.29, serum bicarbonate 10-18 mEq/L [10-18 mmol/L], serum beta-hydroxybutyrate 3-6 mmol/L, alert/drowsy) that is not complicated by acute myocardial infarction, congestive heart failure, end-stage renal or hepatic failure, corticosteroid use, or pregnancy, may be given rapid-acting insulin subcutaneously as an alternative to intravenous regular insulin, with studies showing no significant difference in outcomes when using either approach alongside aggressive fluid management for mild or moderate DKA.[1][4][91][92][93][94] [ ] 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.[4]

The American Diabetes Association advises, however, that continuous intravenous infusion of short-acting regular insulin should remain the preferred route in all patients with DKA because of intravenous insulin's short half-life and easy titration (compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin).[4] However, if there are prolonged waiting times for intensive care unit (ICU) admission or limited medical resources, the use of rapid-acting insulin analogs for the treatment of mild or moderate uncomplicated DKA episodes can be considered for outpatients, in general floors, or in emergency departments.[1][94] The use of rapid-acting subcutaneous insulin analogs is not recommended for the treatment of severe and complicated DKA.[1]

Opciones primarias

insulin regular: consult local protocols for dosing guidelines

Opciones secundarias

insulin aspart: consult local protocols for dosing guidelines

insulin lispro: consult local protocols for dosing guidelines

más – supportive care ± ICU admission

Back

Considerar –

bicarbonate therapy

Tratamiento adicional recomendado para ALGUNOS pacientes del grupo seleccionado

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Considerar –

phosphate therapy

Tratamiento adicional recomendado para ALGUNOS pacientes del grupo seleccionado

Phosphate should not be given unless there is muscle weakness, such as respiratory or cardiac compromise, and a phosphate level <3.1 mg/dL (<1 mmol/L).[1]

If replacement is indicated, 20-30 mEq/L (20-30 mmol/L) potassium phosphate should be added to each liter of intravenous fluid.[1]

serum potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)

más – potassium therapy

Back

Primera línea –

intravenous fluids

Electrolytes, renal function, venous pH, osmolality, and glucose should be checked every 2-4 hours until stable.[1]

When glucose reaches <250 mg/dL (<13.9 mmol/L), 5% or 10% dextrose should be added to the isotonic saline or crystalloid solution to avoid hypoglycemia.[1]

más – insulin

Back

más –

insulin

Se recomienda el tratamiento para TODOS LOS pacientes en el grupo de pacientes seleccionados

Electrolytes, renal function, venous pH, osmolality, and glucose should be checked every 2-4 hours until stable.[1]

The American Diabetes Association advises, however, that continuous intravenous infusion of short-acting regular insulin should remain the preferred route in all patients with DKA because of intravenous insulin's short half-life and easy titration (compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin).[4] However, if there are prolonged waiting times for intensive care unit (ICU) admission or limited medical resources, the use of rapid-acting insulin analogs for the treatment of mild or moderate uncomplicated DKA episodes can be considered for outpatients, in general floors, or in emergency departments.[1][94] The use of rapid-acting subcutaneous insulin analog is not recommended for the treatment of severe and complicated DKA.[1]

The intravenous or subcutaneous regimens should be followed until all criteria for DKA resolution are met, i.e., plasma/capillary ketones <0.6 mmol/L AND serum bicarbonate ≥18 mEq/L (≥18 mmol/L) or venous pH ≥7.3.[1]

Opciones primarias

insulin regular: consult local protocols for dosing guidelines

Opciones secundarias

insulin aspart: consult local protocols for dosing guidelines

insulin lispro: consult local protocols for dosing guidelines

más – supportive care ± ICU admission

Back

Considerar –

bicarbonate therapy

Tratamiento adicional recomendado para ALGUNOS pacientes del grupo seleccionado

Routine bicarbonate administration is not recommended in diabetic ketoacidosis (DKA).[1][4] The American Diabetes Association guidelines note that several studies have failed to show any difference in acidosis resolution or time to discharge in people with DKA when bicarbonate was used.[4] At arterial blood pH >7.0, administration of insulin blocks lipolysis and resolves ketoacidosis without the need to add bicarbonate. Administering bicarbonate therapy in these patients may result in increased risk of hypokalemia, decreased tissue oxygen uptake, and cerebral edema.[1] However, because severe metabolic acidosis may lead to adverse vascular effects, bicarbonate therapy should be considered in patients with arterial blood pH <7.0 (i.e., severe acidosis).[1]

serum potassium >5 mEq/L (>5 mmol)

más – supportive care ± ICU admission

Back

Primera línea –

intravenous fluids

Electrolytes, renal function, venous pH, osmolality, and glucose should be checked every 2-4 hours until stable.[1]

When glucose reaches <250 mg/dL (<13.9 mmol/L), 5% or 10% dextrose should be added to the isotonic saline or crystalloid solution to avoid hypoglycemia.[1]

más – insulin

Back

más –

insulin

Se recomienda el tratamiento para TODOS LOS pacientes en el grupo de pacientes seleccionados

Patients with mild to moderate DKA (plasma glucose ≥200 mg/dL [≥11.1 mmol/L], arterial pH 7.00 to 7.29, serum bicarbonate 10-18 mEq/L [10-18 mmol/L], serum beta-hydroxybutyrate 3-6 mmol/L, alert/drowsy) that is not complicated by acute myocardial infarction, congestive heart failure, end-stage renal or hepatic failure, corticosteroid use, or pregnancy, may be given rapid-acting insulin subcutaneously as an alternative to intravenous regular insulin, with studies showing no significant difference in outcomes when using either approach alongside aggressive fluid management for mild or moderate DKA).[1][4][91][92][93][94] [ ] 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.[4]

The American Diabetes Association advises, however, that continuous intravenous infusion of short-acting regular insulin should remain the preferred route in all patients with DKA because of intravenous insulin's short half-life and easy titration (compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin).[4] However, if there are prolonged waiting times for ICU admission or limited medical resources, the use of rapid-acting insulin analogs for the treatment of mild or moderate uncomplicated DKA episodes can be considered for outpatients, in general floors, or in emergency departments.[1][94] The use of rapid-acting subcutaneous insulin analogs is not recommended for the treatment of severe and complicated DKA.[1]

The intravenous or subcutaneous regimens should be followed until all criteria for resolution are met, i.e., plasma/capillary ketones <0.6 mmol/L AND serum bicarbonate ≥18 mEq/L (≥18 mmol/L) or venous pH ≥7.3.[1]

Opciones primarias

insulin regular: consult local protocols for dosing guidelines

Opciones secundarias

insulin aspart: consult local protocols for dosing guidelines

insulin lispro: consult local protocols for dosing guidelines

Back

Considerar –

bicarbonate therapy

Tratamiento adicional recomendado para ALGUNOS pacientes del grupo seleccionado

Routine bicarbonate administration is not recommended in diabetic ketoacidosis (DKA).[1][4] The American Diabetes Association guidelines note that several studies have failed to show any difference in acidosis resolution or time to discharge in people with DKA when bicarbonate was used.[4] At arterial blood pH >7.0, administration of insulin blocks lipolysis and resolves ketoacidosis without the need to add bicarbonate. Administering bicarbonate therapy in these patients may result in increased risk of hypokalemia, decreased tissue oxygen uptake, and cerebral edema.[1] However, because severe metabolic acidosis may lead to adverse vascular effects, bicarbonate therapy should be considered in patients with arterial blood pH <7.0 (i.e., severe acidosis).[1]