Diabetik ketoasidoz ve tedavi

Treatment of Diabetic Ketoacidosis

The following is not intended to be considered as routine orders for the diagnosis and treatment of all cases of DKA but is presented only as one possible treatment regimen. Each case of DKA must be treated on an individual basis.

Initial Assessment of DKA

blood glucose > 250mg/dL

arterial pH <7.3

serum bicarbonate <15mEq/L

urinary ketones ≥ 3+ and/or serum ketones are positive

Monitoring

vital signs every hour

serum glucose every hour and as needed

blood gas pH every 2 hrs (use arterial for 1st measurement then can use venous)

electrolytes every 1-2 hrs

urine ketones on each void

fluid input and output continuously

magnesium and phopshorous immediately and then every 1-2 hrs

Fluid Management

start normal saline at 1L/hr or 15-20ml/kg/hr initially

determine hydration status, goal being to replace 50% of estimated volume loss in the 1st 4hrs then remainder over next 8-12 hrs

infuse normal saline 125-500 ml/hr, rate dependent on hydration status

once serum Na+ is corrected infuse 1/2 normal saline at 4-14ml/kg/hr

when serum glucose reaches 250mg/dL change fluid to D5W 1/2 normal saline at same rate

Insulin Managementdiscontinue all oral diabetic medications and

previous insulin orders

give regular insulin iv bolus of 10 units

start insulin infusion usually at a rate of 0.15units/kg

insulin administration goal is to reduce serum glucose 50-70mg/dL/hr

when serum glucose is ≤ 150mg/dL then can switch to adult sq insulin with basal insulin

Potassium Management

if serum K+ is <3.3 give 40mEq/hr until it is >3.3

if serum K+ is >3.3 but <5.0 give 20-30mEq/L of iv fluids to keep serum K+ between 4-5mEq/L

if serum K+ is ≥5.0 do not give K+ but check serum levels every 2hrs

when replacing K+ both potassium chloride and potassium phosphate can be used

hold K+ replacement if patient urine output is <30ml/hr

Bicarbonate Management

assess need for bicarbonate by arterial pH measurement

if pH <6.9 give 100mEq sodium bicarbonate in 1L D5W and infuse at 200ml/hr

if pH is 6.9 - 7.0 give 50mEq sodium bicarbonate in 1L D5W and infuse at 200ml/hr

if pH >7.0 do not give bicarbonate

continue sodium bicarbonate administration until pH is >7.0

monitor serum K+