Insulin Treatment of Special
(DKA) is a life-threatening medical emer-gency caused by inadequate or absent
insulin replacement, which occurs in people with type 1 diabetes and
infrequently in those with type 2 diabetes. It typically occurs in newly
diagnosed type 1 patients or in those who have experienced interrupted insulin
replacement, and rarely in people with type 2 diabetes who have concurrent
unusually stressful conditions such as sepsis or pancreatitis or are on high-dose steroid
Signs and symp-toms
include nausea, vomiting, abdominal pain, deep slow (Kussmaul) breathing,
change in mental status, elevated blood and urinary ketones and glucose, an
arterial blood pH lower than 7.3, and low bicarbonate (< 15 mmol/L).
treatment for DKA includes aggressive intra-venous hydration and insulin
therapy and maintenance of potas-sium and other electrolyte levels. Fluid and
insulin therapy is based on the patient’s individual needs and requires
frequent reevaluation and modification. Close attention has to be given to
hydration and renal status, the sodium and potassium levels, and the rate of
correction of plasma glucose and plasma osmolality. Fluid therapy generally
begins with normal saline. Regular human insulin should be used for intravenous
therapy with a usual start-ing dose of about 0.1 IU/kg/h.
hyperglycemic syndrome (HHS) is diagnosed in per-sons with type 2 diabetes and
is characterized by profound hypergly-cemia and dehydration. It is associated
with inadequate oral hydration, especially in elderly patients, with other
illnesses, the use of medica-tion that elevates the blood sugar or causes
dehydration, such as phenytoin, steroids, diuretics, and β blockers,
and with peritoneal dialysis and hemodialysis. The diagnostic hallmarks are
declining mental status and even seizures, a plasma glucose of over 600 mg/dL,
and a calculated serum osmolality higher than 320 mmol/L. Persons with HHS are
not acidotic unless DKA is also present.
treatment of HHS centers around aggressive rehydration and restoration of
glucose and electrolyte homeostasis; the rate of correction of these variables
must be monitored closely. Low-dose insulin therapy may be required.