Management of diabetic ketoacidosis
Although the mortality of diabetic ketoacidosis (DKA) has decreased substantially in the developed world, high mortality rates still prevail in South Africa, thus making this an important condition to recognise early and manage well. This review discusses the treatment of DKA, with emphasis on the controversial aspect of initial fluid replacement therapy. Current guidelines recommend the use of normal saline. The concern is that normal saline, when used in large volumes, leads to the development of a hyperchloraemic metabolic acidosis which is of uncertain clinical significance. This hyperchloraemic acidosis is better quantified using Stewart’s model, as opposed to the “traditional” Henderson-Hasselbalch equation. Ringer’s lactate is an alternative choice for initial fluid resuscitation, but may exacerbate the high lactate to pyruvate ratio in patients in DKA, and may cause hyperkaleamia. Insulin therapy, prevention of electrolyte abnormalities, and the replacement of bicarbonate and phosphate, are other important considerations in the management of the patient with DKA.
Keywords: diabetic ketoacidosis, fluid replacement, normal saline, Ringer’s lactate, hyperchloraemic acidosis, insulin
Material submitted for publication in the Journal of Endocrinology, Metabolism and Diabetes of South Africa (JEMDSA) is accepted provided it has not been published elsewhere. JEMDSA reserves copyright of the material published. Neither JEMDSA nor the Publisher may be held responsible for statements made by the authors.