ketonemia in its early stages, as reflected by a normal arterial pH associated with a basedeficit and a mild anion gap.When the accumulated ketones exceed the body's capacity to extract them, they overflowinto urine (ie, ketonuria). If the situation is not treated promptly, a greater accumulation of organic acids leads to frank clinical metabolic acidosis (ie, ketoacidosis), with a drop in pHand bicarbonate
serum levels. Respiratory compensation for this acidotic condition resultsin rapid shallow breathing (Kussmaul respirations).2.
Describe the medical management of a patient in DKA?a.
How is fluid status monitored in the acute stage of DKA?
lood tests for glucose every 1-2 h until patient is stable, then every 6 h
Serum electrolyte determinations every 1-2 h until patient is stable, then every 4-6h
Initial blood urea nitrogen (
Initial arterial blood gas (A
) measurements, followed with bicarbonate asnecessary
Also by weighing the patient. b.
How is hypovolemia corrected? How rapidly is fluid volume replaced? And why?Patients with DKA and HHS are invariably volume depleted, with an estimated water deficit of
100 ml/kg of body weight.28The initial fluid therapy is directed towardexpansion of intravascular volume and restoration of renal perfusion. Isotonic saline(0.9% NaCl) infused at a rate of 500±1,000 mL/h during the first 2 h is usuallyadequate, but in patients with hypovolemic shock, a third or fourth liter of isotonicsaline may be needed to restore normal blood pressure and tissue perfusion.After intravascular volume depletion has been corrected, the rate of normal salineinfusion should be reduced to 250 mL/h or changed to 0.45% saline (250±500 mL/h)depending on the serum sodium concentration and state of hydration. The goal is toreplace half of the estimated water deficit over a period of 12±24 h.Once the plasma glucose reaches 250 mg/dl in DKA and 300 mg/dl in HHS,replacement fluids should contain 5±10% dextrose to allow continued insulinadministration until ketonemia is controlled while avoiding hypoglycemia. Anadditional important aspect of fluid management in hypoglycemic states is to replacethe volume of urinary losses. Failure to adjust fluid replacement for urinary lossesmay delay correction of electrolytes and water deficit.
lood tests for glucose every 1-2 h until patient is stable, then every 6 hSerum electrolyte determinations every 1-2 h until patient is stable, then every 4-6 h