Keterangan
The management of diabetic ketoacidosis (DKA) in hospitalized patients is a time-sensitive process that aims to correct dehydration and electrolyte imbalances, reverse the ketoacidosis, and identify and treat the underlying cause.Fluid resuscitation is the cornerstone of treatment, typically done with normal saline (0.9% sodium chloride) at a rate of 1-2 liters per hour. Once the patient is clinically stable, fluids can be switched to half-normal saline (0.45% sodium chloride) or dextrose 5% in water.Electrolyte replacement is also essential, with the most important electrolytes to replace being sodium, potassium, and phosphate. Sodium is replaced with normal saline or half-normal saline, potassium with potassium chloride, and phosphate with potassium phosphate or sodium phosphate.Insulin therapy is used to reverse the ketoacidosis, typically initiated with a bolus dose of regular insulin, followed by a continuous infusion of regular insulin. The dose of insulin is adjusted based on the patient's blood glucose levels.
Ringkasan
- Diabetic Ketoacidosis (DKA) is a severe complication of diabetes characterized by hyperglycemia, ketosis, and metabolic acidosis, requiring prompt intervention in the ICU setting. DKA primarily arises from insulin deficiency, leading to increased hepatic glucose production and lipolysis, resulting in the accumulation of ketone bodies and electrolyte imbalances, especially hyperkalemia.
- Patients with DKA typically exhibit polyuria, polydipsia, nausea, vomiting, abdominal pain, weakness, confusion, and Kussmaul respirations. Diagnosis relies on elevated blood glucose levels (≥250 mg/dL), presence of ketones in urine or blood, arterial pH <7.3, and bicarbonate levels <18 mEq/L.
- Initial management follows an ABCDE approach: Airway maintenance, Breathing assessment, Circulation support with fluid resuscitation, Disability evaluation via neurological status, and Exposure to identify dehydration signs and infection sources.
- Treatment principles include rehydration with isotonic saline, insulin administration to correct hyperglycemia and suppress ketogenesis, electrolyte management (particularly potassium), and identification/treatment of underlying causes.
- Fluid resuscitation is crucial, starting with isotonic saline at 15-20 mL/kg/hour, adjusted based on clinical assessment. Insulin infusion, using regular insulin, should aim for a glucose reduction of 50-75 mg/dL per hour.
- Electrolyte imbalances, especially potassium, require close monitoring and correction. Hyperkalemia is common initially, followed by potential hypokalemia during treatment. Underlying triggers like infections and medication non-compliance must be addressed.
- Continuous monitoring of blood glucose, ketone levels, electrolytes, and vital signs is essential. Potential complications, like cerebral edema, require cautious fluid administration. New developments include continuous glucose monitoring (CGM) for real-time data and trend identification.
- Patient education on insulin administration, glucose monitoring, ketone testing, warning sign recognition, medication adherence, and regular follow-up is critical for preventing DKA recurrence.
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