Treatment of Diabetic Ketoacidosis

Diabetic ketoacidosis may either result from or be aggravated by infection, surgery, trauma, shock, emotional stress, or failure to take sufficient amounts of insulin. Treatment is focused on reversing the hypokalemia by administering potassium chloride and on offsetting the acidosis by providing bicarbonate. The dehydration and electrolyte imbalance are treated with appropriate measures and crystalline zinc insulin is administered to counter the hyperglycemia. 

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Insulin Exenatide is not a substitute for insulin in insulin-requiring patients. Do not use exenatide in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis. The concurrent use of exenatide with insulin, thiazolidinediones, D-phenylalanine derivatives, meglitinides, or alpha-glucosidase inhibitors has not been studied. 

What is the main reason for administering insulin in the treatment of diabetic ketoacidosis (DKA) ... 

Foster DW, McGarry JD The metabolic derangements and treatment of diabetic ketoacidosis. N Engl J Med 309 159-169,1983. 

Success in treatment of diabetic ketoacidosis and its complications (hypokalaemia, aspiration of stomach contents, infection, shock, thromboembolism, cerebral oedema) depends on close, constant, informed supervision. 

Wiggam MI, O Kane MJ> Harper R, Atkinson AB, Hadden DR, Trimble ER, et al. Treatment of diabetic ketoacidosis using normalization of blood 3-hydroxybutyrate concentration as the endpoint of emergency management. A randomized controlled study. Diabetes Care 1997 20 1347-52. 

The manifestations of hypophosphatemia depend on the chronicity and severity of the phosphate depletion. The major conditions associated with symptomatic hypophosphatemia are chronic alcoholism, intravenous hyperalimentation without adequate phosphate supplementation, and the chronic ingestion of antacids. Severe hypophosphatemia can also be seen during treatment of diabetic ketoacidosis and with prolonged hyperventilation. 

D-Fructose is the sweetest natural sugar. Its use as a natural sweetener is, therefore, increasing rapidly. It is absorbed slowly from the intestine, and thus does not cause abrupt changes in the serum levels of carbohydrates. It has little, if any, effect on insulin secretion. Thus, it exerts beneficial effects as a component of diets for mild and well-balanced diabetes, but should be taken within caloric restriction,445 as obesity impairs D-glucose tolerance and increases the insulin resistance of peripheral tissue.446 Use of D-fructose in the direct treatment of diabetic ketoacidosis does not offer advantages over routine, fluid therapy, and may even be dangerous on the basis that rapid infusion of large amounts of D-fructose may cause lactate acidosis. 

Puttha R, Cooke D, Subbarayan A, Odeka E, Ariyawansa I, Bone M, Doughty I, Patel L, Amin R North West England Paediatric Diabetes Network. Low dose (0.05 units/kg/h) is comparable with standard dose (0.1 units/kg/h) intravenous insulin infusion for the initial treatment of diabetic ketoacidosis in children with type 1 diabetes—an observational study. Pediatr Diabetes 2010 11 12-7. 

NIDDM is a much more common disease than IDDM, accounting for about 85—90% of all cases of diabetes meUitus. Whereas NIDDM may be present at any age, the incidence increases dramatically with advanced age over 10% of the population reaching 70 years of age has NIDDM. Patients with NIDDM do not require insulin treatment to maintain life or prevent the spontaneous occurrence of diabetic ketoacidosis. Therefore, NIDDM is frequendy asymptomatic and unrecognized, and diagnosis requires screening for elevations in blood or urinary sugar. Most forms of NIDDM are associated with a family history of the disease, and NIDDM is commonly associated with and exacerbated by obesity. The causes of NIDDM are not well understood and there may be many molecular defects which lead to NIDDM. 

In 40 patients aged 4-25 years with type 1 diabetes who were given continuous subcutaneous insulin infusion for 6 months the number of episodes of hypoglycemia was reduced by a half (192). There were two episodes of diabetic ketoacidosis. In 10 patients lipohypertrophy developed at the insertion site and three patients had signs of skin redness, which improved with local antibiotic treatment. 

In a meta-analysis of the metabolic and psychosocial impact of pumps, 52 studies were found 22 were published before 1987 and 13 after 1993, the year in which the results of the DCCT were published (225). The authors stated that therefore conclusions about efficacy are not definitive. All pump malfunctions were reported before 1988. All types of changes were reported when the frequency and severity of hypoglycemia were compared with prepump times. Infection and skin irritation were expressed in different ways in the various studies. The risk of diabetic ketoacidosis fell after 1993. Most users preferred to continue pump treatment, mainly because of more flexibility, greater freedom, and improved glycemic control. 

Insulin is an endogenous hormone produced by fi-cells of islets of Langerhans of the pancreas, which consist of two chains of amino acids. It is required to be administered by a parenteral routes as it is destroyed when given orally. Insulin is used for the control of IDDM and in the emergency management of diabetic ketoacidosis.30 Insulin promotes the intracellular uptake of potassium and is used in hyperkalemia. Baker et al.31 have used insulin and glucagon in the treatment of liver disorders. Recent evidence indicates that the effects of insulin with glucose and potassium in ischemic heart disease have proved beneficial.32 It also is used in acute myocardial infarction.32... 

Even in patients without known diabetes, be vigilant for the rare but life threatening onset of diabetic ketoacidosis, which always requires immediate treatment by... 

Even in patients without known diabetes, be vigilant for the rare but life threatening onset of diabetic ketoacidosis, which always requires immediate treatment, by monitoring for the rapid onset of polyuria, polydipsia, weight loss, nausea, vomiting, dehydration, rapid respiration, weakness and clouding of sensorium, even coma... 

Rg. 3 Effective treatment of a severe case of diabetic ketoacidosis. 

Kaufman FR, Halvorson M. The treatment and prevention of diabetic ketoacidosis in children and adolescents with type 1 diabetes mellitus. Pediatr Ann. 1999 28 576-582. 

Insulin is necessary for controlling type 1 diabetes mellitus that is caused by a marked decrease in the amount of insulin produced by die pancreas. Insulin is also used to control the more severe and complicated forms of type 2 diabetes mellitus. However, many patients can control type 2 diabetes with diet and exercise alone or with diet, exercise, and an oral antidiabetic drug (see section Oral Antidiabetic Dmgp ). Insulin may also be used in the treatment of severe diabetic ketoacidosis (DKA) or diabetic coma. Insulin is also used in combination with glucose to treat hypokalemia by producing a shift of potassium from die blood and into die cells. 

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