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The management of diabetic ketoacidosis (DKA) in an intensive care unit during the first 24 to 48 hours is always recommended. When treating patients with DKA, the following points should be considered and closely monitored:
Correction of fluid loss with intravenous fluids.
Correction of hyperglycemia with insulin.
Correction of electrolyte disturbances, particularly loss of potassium
Correction of the acid-base balance.
Treatment of concurrent infection, if present
It is essential to maintain extreme vigilance for any concomitant process, such as infection, stroke, myocardial infarction, sepsis or deep vein thrombosis.
It is important to pay close attention to the correction of fluid and electrolyte loss during the first hour of treatment. This should always be followed by a gradual correction of hyperglycemia and acidosis. The correction of fluid loss clarifies the clinical picture and may be sufficient to correct acidosis. The presence of even mild signs of dehydration indicates that at least 3 L of fluid have already been lost.
In general, patients are not discharged from hospital unless they have been able to return to their daily insulin regimen without a recurrence of ketosis. When the condition is stable, the pH exceeds 7.3 and the bicarbonate is higher than 18 mEq / L, the patient is allowed to eat a meal preceded by a subcutaneous (SC) dose of regular insulin.
Insulin infusion can be interrupted 30 minutes later. If the patient still has nausea and can not eat, the dextrose infusion should continue and SC of regular or ultra-fast insulin should be administered every 4 hours, depending on the level of blood glucose, while trying to maintain glucose levels in the blood. blood at 100-180 mg / dL.
The 2011 JBDS guide recommends intravenous infusion of insulin at a fixed rate based on weight until ketosis has decreased. If the blood glucose falls below 14 mmol / L (250 mg / dL), 10% glucose must be added to allow the continuation of the infusion of fixed-rate insulin. [14, 15]
In patients with established diabetes, long-acting insulin SC (eg, Insulin glargine, Detemir) should be started at the dose used before the manifestation of DKA. However, if previously Hagedorn insulin (NPH) with neutral protamine was used, start again at the usual dose only when the patient eats well and can retain the meals without vomiting; otherwise, the dose should be reduced to avoid hypoglycaemia during its period of maximum effectiveness.
In newly diagnosed patients with type 1 diabetes, a careful estimation of the long-acting insulin dose should be considered. Generally, it is recommended to start with smaller doses to avoid hypoglycemia.
Treatment of diabetic ketoacidosis.
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