Pediatric emergency medicine trisk 1865 1865
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TABLE 89.2
PRINCIPLES OF MANAGEMENT OF DIABETIC KETOACIDOSIS
Life-threatening complications
Cerebral edema
Cardiovascular collapse
Profound metabolic acidosis
Hyperkalemia
Hypokalemia
Hypophosphatemia
Areas of management decisions
• Fluids. Treat hypovolemia with crystalloid extracellular fluid expander. Use normal saline
(0.9%) and infuse 10 mL/kg in the first 1–2 hrs. (Avoid hypotonic solutions initially
because they are inefficient volume expanders and may contribute to cerebral edema.)
Continue infusion at this rate until perfusion is improved and urine output is reestablished.
After first 1–2 hrs, start half-normal saline—use greater tonicity, up to normal saline, if the
initial serum sodium is less than 135 mmol/L or if the serum sodium falls with therapy.
Total fluid administration in first 48 hrs should rarely exceed one and one-half to two
times maintenance.
• Alkali. Avoid bicarbonate therapy in DKA. Only consider if arterial pH <6.9 and impaired
cardiac contractility and vascular tone, or if patient has life-threatening hyperkalemia.
• Potassium. Start potassium therapy with administration of insulin. Starting concentration in
fluid should be 40 mEq/L as a combination of potassium acetate and potassium phosphate.
If the patient is hypokalemic (<4 mmol/L), a higher concentration of potassium, 60–80
mEq/L, may be necessary. Administer high concentrations of potassium only with
electrocardiographic monitoring. If hyperkalemic (>6 mmol/L), decrease the concentration
to 0–20 mEq/L.
• Insulin. Should be given as a continuous IV infusion (0.1 Unit/kg/hr).
• Glucose. Add 5% glucose to solutions when plasma glucose is approximately 300 mg/dL.
Continue adding glucose up to 12.5% in a peripheral IV in order to keep plasma glucose
in target range of 200–300 mg/dL.
• Phosphate. Add one-half of potassium in IVF as potassium phosphate up to 20 mEq/L.
Monitoring
• Clinical monitoring. Blood pressure, pulse, respirations, neurologic status, and fluid intake
and output.
• Laboratory monitoring. Obtain initial glucose, electrolytes, blood gases, blood urea
nitrogen, and beta-hydroxybutyrate. Measure blood glucose every hour initially as guide
to insulin dosage. Repeat electrolytes, beta-hydroxybutyrate, and pH measurements every
2 to 4 hrs as necessary, every hour if severe abnormalities.
• Use flow sheet.
DKA, diabetic ketoacidosis; IV, intravenous; IVF, intravenous fluids; ETCO2 , end-tidal CO2 .
