Page 73 - Proceeding of Plenary Abstract of Parallel Symposim

Management after Diabetic Ketoacidosis

Muhammad Faizi , Nur Rochmah , Yuni Hisbiyah 2
1
1
Department of Child Health, Faculty of Medicine Universitas Airlangga, RSU Pendidikan Daerah Dr. Soetomo1, RS Universitas Airlangga2, Surabaya, East
Java, Indonesia
Abstract
Background Diabetic ketoacidosis (DKA) is a metabolic emergency and life-threatening condition that
often experience by people with type 1 diabetes mellitus. DKA patients often require treatment in the
intensive care unit (ICU) including fluid therapy, intravenous insulin administration, correction of electrolyte
imbalance, and close monitoring. The improvement of DKA requires transitional subcutaneous insulin
therapies; these transitions are associated with increased risks of hypoglycemia and rebound hyperglycemia.
Several specific steps must be carefully taken to ensure the patients are fully prepared for the transitional
treatments, have a clear written protocol, and recognize when the transitions have been successful.
Objective Preparing and managing the smooth transitions of intravenous to subcutaneous insulin by
minimizing the risks of hypoglycemia, rebound hyperglycemia, or other complications related to the DKA.
Results DKA: hyperglycemia (blood glucose >200 mg/dL), metabolic acidosis (venous blood pH <7.30 or
HCO3 <15 mmol/L), and the presence of blood or urine ketones. DKA Resolution: defined as venous blood
pH 7.30, serum bicarbonate >15 mmol/L, blood ketones (ßOHB) <1 mmol/L, and/or closure of the anion
gap. Assessment of readiness for transitional therapy, clinical signs: Alert and oriented, rehydrated, able to eat
and tolerate food - no nausea or vomiting. Metabolic status: meet the DKA resolution criteria, blood glucose
<200 mg/dL; absence of urinary ketones should not be used as indicator to determine the DKA resolution.
The most convenient time to switch intravenous insulin to subcutaneous is before meals. To prevent rebound
hyperglycemia, the first subcutaneous insulin should be given 15-60 minutes (fast-acting insulin) or 1-2
hours (regular insulin) before stopping the intravenous insulin, depending on the blood glucose level, to allow
time for absorption of the insulin administered. Dosage and type of subcutaneous insulin according to the
preference and protocol used. The recommended starting dose is 0.8 to 1 unit per kg per 24 hours; 24 hours
dose divided by 6 to be injected every 4 hours. The dose can be increased or decreased by 10% to 20% based
on the blood glucose level before the next insulin injection.Administration of medium or long-acting insulin
(basal insulin) once or twice daily (e.g., detemir, glargine) in combination with short or rapid-acting insulin
with meals (bolus insulin). Glargine and detemir provide fairly constant basal insulin action for 24 hours, and
are generally given once daily. Basal insulin doses range from 30% (when combined with regular insulin) to
50% (when combined with rapid-acting insulin) of the total daily dose insulin, with combined bolus insulin
of 50% (fast-acting insulin) to 70% (regular insulin). The first dose of basal insulin is often given at the
evening or night, followed by discontinuation of intravenous insulin in the next day.
Keywords: DKA, diabetic ketoacidosis, diabetic resolution, transitional insulin.

58 Abstract