Rescue ketoacidosis
Posted on November 13, 2009
Filed Under Ketoacidosis | Leave a Comment
Diabetic ketoacidosis (DKA) is the acute complications of diabetes, but also accident and emergency medicine, one of the common condition dangerous, it is reported the case-fatality rate of about 1% to 19% [1]. Its high mortality, often as a result of clinical errors in the rescue if they can master the proper rescue measures, the patient can be turned the corner. Common mistakes in clinical emergency treatment can be summed up as “three little more than one”, that is less than the dose of insulin, potassium, and fluids insufficient to make up base too. To improve the clinical success rate of rescue, reduce mortality, this article on the issue are outlined below.
1, insulin dose less than
The correct application of insulin is the key to saving DKA patients. If given enough doses of insulin, it can not effectively control high blood sugar and ketoacidosis, the patient whose condition had deteriorated, leading to death. Influence clinicians insulin dose less than the common factors are:
(1) ignored the individual medication, stick or a theoretical calculation of insulin dosage of conventional doses;
(2) Long-term application of insulin in patients may have combined with insulin antibodies, so that delay of insulin action and the decline;
(3) prematurely out normal saline, while the choice of 5% glucose solution, so that the relative lack of insulin dosage;
(4) The early infusion of insulin instead im out;
(5) co-infection and other factors. In order to avoid the above mistakes, according to the patient’s body weight, body surface area, given the sensitivity of different doses of insulin, so that individualized medicine. With regard to delivery method, now considered low-dose continuous intravenous infusion of insulin administration is a more reasonable way, it can be avoided in the past hypokalemia, cerebral edema, low blood sugar and other complications, more importantly, can be individualized medicine. DKA patients who are hospitalized, first in order to regular insulin 10 ~ 20U intramuscular or subcutaneous injection, and then 2 ~ 12U / h (average 6U / h) speed plus normal saline infusion, during this process can be carried out at any time to monitor blood sugar and urine sugar in order to adjust the speed of intravenous insulin. When the blood sugar dropped to 13.9mmol / L, it will be changed to 5% glucose saline solution, and to include insulin, so insulin-2U / h maintenance infusion until the ketone (-), replaced by intramuscular injection.
Low-dose insulin infusion in the application process should pay attention to several issues: (1) review 2h intravenous infusion of glucose, blood sugar dropped if less than the original value of 10% to 30%, insulin dosage should be doubled; (2) saline changed to 5% glucose solution, such as in grass-roots hospitals unconditional review blood sugar, according to urine (+ +) to perform; (3) infusion into the indications for intramuscular injection: blood glucose 11.1mmol / L, ketone (– ), urine (++), 1h in the cessation of pre-4U intramuscular injection of insulin, blood sugar to prevent rebound.
2, the liquid volume of the shortfalls
DKA patients due to osmotic diuresis, eating less, vomiting and other reasons, often there is severe dehydration, often up to more than 10% of body weight. Therefore, hospitalized patients often have dry skin and mucous membranes and flexibility is poor, orbital depression, oliguria, and low blood pressure, dehydration, severe or even hypovolemic shock. If the lack of clinical rescue in rehydration, severe dehydration helps organizations microcirculation bad, so that insulin can not effectively enter the interstitial fluid play a biological effect, high blood sugar can not effectively control or hypovolemic shock occurs. The above have been mistaken for insulin resistance or severe acidosis due, thereby increasing the insulin dose or make up base and hypoglycemia or cerebral edema, endangering the patient’s life.
Rehydration, when a general proposition: In the first 1 ~ 2h enter 1000 ~ 2000ml, in the 2 ~ 6h Input 500 ~ 1000ml / h, in the first 24h average input 6000ml. Our hospital usage: If inadvertent failure when, in the first 1h rapid infusion 1000ml normal saline, so as to supplement blood volume; and then according to blood pressure, pulse, urine output per hour, peripheral micro-circulation to adjust the input volume and speed, when the blood pressure to maintain In the 83/53mmHg (lmmHg ≈ 0.133kPa) above (at this time able to maintain the normal glomerular off rate), urine volume greater than 30ml / h, the peripheral microcirculation is good, that there has been a basic complement of liquid, so the patient No. 1 days of liquid volume is about 4000 ~ 6000ml.
3, not given sufficient quantities of potassium
DKA patients due to eating less, vomiting and with a large number of discharged urine, body potassium heavier, usually up to 300 ~ 1000mmol. However, some patients on admission serum potassium is not low but increased due to some reasons:
(1) hemolysis caused by high-K illusion;
(2) the patient due to water loss caused by a large number of blood concentration;
(3) acidosis and potassium ions from the cells, when transferred to the cells, causing the illusion potassium potassium shortage addition, diabetes was a negative magnesium balance [2], hypomagnesemia can lead to potassium supplement is not easy, but hypokalemia cardiac arrest can occur;
(4) The application of insulin to enable glucose to enter cells, (1.4mg per gram of glucose substitution of potassium). When a patient’s urine output> 40ml / h, serum potassium <5.5mmol / h when the serum potassium monitoring and ECG monitoring carried out under the potassium; if serum potassium <3.0mmol / L, the added potassium chloride 2 ~ 3g / h; potassium 3.0 ~ 4.0mmol / L, the make up 1.5 ~ 2.0g / h; potassium 4.0 ~ 5.0mmol / L, the slow potassium supplement, complement 0.5 ~ 1.0g / h. Which could later be adjusted according to urine output and serum potassium potassium volume and speed, when the serum potassium to 5.5mmol / L, it can stop potassium. Full potassium 2 ~ 3 days later, such as the serum potassium remained low, suggesting low magnesium, may be granted 10% magnesium sulfate 5ml, intramuscular or intravenous injection to join.
4, make up base too much
DKA is due to excessive ketone bodies, rather than alkaline missing, so make up base too many deaths due to brain edema is also one of the reasons. Treatment of error for the following reasons:
(1) a clear understanding of the mechanism of ketoacidosis that the metabolic acidosis and other similar decrease in the Department of alkaline reserves, so as a general metabolic acidosis fill base. In fact, DKA is due to accelerated decomposition of fat in the liver produces ketone bodies, and ketone bodies in the β-hydroxybutyric acid and acetylcholine as the strong acid. In the clinical application by rehydration and insulin, the inhibition generated excess ketones ketone is metabolized, the acidosis may be a natural ease, without added alkali [3].
(2) to hypovolemic shock is a serious mistake acidosis due to the wrong fill base.
(3) make up the speed and the concentration of alkali too fast, too big. DKA patients after treatment, blood glucose decreased acidosis improved, the following conditions should be considered brain edema: (1) coma actually worsened; (2) convulsions; (3) changes in respiratory rhythm; (4) blood pressure suddenly increased, slow heart rate, and even brain herniation. The mechanism of this complication [4]: ① fill alkaline pH, abnormal cerebrospinal fluid decreased (because of the diffusion of carbon dioxide through the blood-brain barrier faster than bicarbonate); ② sudden jump in blood pH, oxygen dissociation curve to the left, to increase oxygen affinity of hemoglobin and increased tissue hypoxia; ③ blood sugar dropped too quickly. Hyperactivity and intracranial bypass sorbitol hyperosmolar state, may induce or aggravate cerebral edema.
Of clinical indications should be strictly controlled fill base [4], only when the pH <7.0 ~ 7.1 or HCO3-<5mmol / L (equivalent to CO2-CP is 4.5 ~ 6.7mmol / L); and blood gas analysis monitored carefully fill base . When the pH reached 7.2 or CO2-CP reached 11.23mmol / L (equivalent to 25Vol%), stop fill base. Currently advocated [5] the first time around to give 50mmolNaHCO3 (about 5% SB80ml), diluted with isotonic saline solution (1.25%) after the infusion, slow down after that in 2 ~ 4h injection. May, under 5% NaHCO30.5ml/kg to CO2-CP increased 1Vol%, or by the formula: [normal CO2CP (50Vol%) - measured CO2CP] × 0.5 × body weight (kg) = 5% sodium bicarbonate ml number. Press on the estimated amount of type 1 / 3 ~ 1 / 2 added. Make up base, generally use 5% NaCO3, and diluted with 1.25% isotonic saline solution, and does not suitably sodium lactate, lactic acid build-up due to DKA patients often, and even concurrent lactic acidosis.
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