Diabetic ketoacidosis

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The condition is discussed in detail in medical texts and only the more pharmacological aspects will be dealt with here. Nevertheless, it should be emphasised that the patients are always severely dehydrated and that fluid replacement is the first priority.

In severe ketoacidosis the patient urgently needs insulin to stop ketogenesis. The objective is to supply, as continuously as possible, a moderate amount of insulin.

Soluble insulin, preferably from the same species the patient has been using (never a sustained-release form), should be given by continuous i.v. infusion of a 1 unit/ml solution of insulin in isotonic sodium chloride. It is best to use a pump, which allows independent control of insulin and electrolyte administration more readily than an i.v. drip. If a pump is not available, the insulin should be added in a concentration of 1 unit /ml to 50-100 ml of sodium chloride in a burette. The infusion rate is determined by a sliding scale, as illustrated in Table 35.2. The rate is adjusted hourly using the same scale. If an i.v. drip is used instead of a pump the concentration should be lower (40 units/l). Stringent precautions against septicaemia are necessary in these patients. Continuous infusion i.m. (not s.c.) can also be equally effective, provided the patient is not in shock and provided there is not an important degree of peripheral vascular disease.

Intermittent doses i.v. or i.m. may be used when circumstances demand. If the i.m. route is used, a priming dose of 10 units should be given at the outset and then 6-10 units hourly.

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