Editing Diabetic ketoacidosis (section)

==Management==
The main aim in the treatment of diabetic ketoacidosis is to replace the lost fluids and electrolytes while suppressing the high blood sugars and ketone production with insulin. Admission to an [[intensive care unit]] (ICU) or similar [[high dependency unit|high-dependency area or ward]] for close observation may be necessary.<ref name=JBDS/>

===Fluid replacement===
The amount of fluid replaced depends on the estimated degree of dehydration. If dehydration is so severe as to cause [[Shock (circulatory)|shock]] (severely decreased [[blood pressure]] with insufficient blood supply to the body's organs), or a depressed level of consciousness, rapid infusion of [[saline (medicine)|saline]] (1&nbsp;liter for adults, 10&nbsp;mL/kg in repeated doses for children) is recommended to restore circulating volume.<ref name=ADA2009/><ref name=BSPED>{{cite web | vauthors = Edge J | title=BSPED Recommended DKA Guidelines 2009 | publisher=British Society for Paediatric Endocrinology and Diabetes | date=May 2009 | url=https://www.bsped.org.uk/professional/guidelines/docs/DKAGuideline.pdf | access-date=2009-07-12 | url-status=dead | archive-url=https://web.archive.org/web/20111027082817/http://www.bsped.org.uk/professional/guidelines/docs/DKAGuideline.pdf | archive-date=2011-10-27 }}</ref> Slower rehydration based on calculated water and sodium shortage may be possible if the dehydration is moderate, and again saline is the recommended fluid.<ref name=NICE2015>{{cite web|title=Type 1 diabetes in adults: diagnosis and management|url=http://www.nice.org.uk/guidance/ng17|publisher=National Institute for Health and Care Excellence|access-date=10 February 2016|date=August 2015|url-status=live|archive-url=https://web.archive.org/web/20160809065421/https://www.nice.org.uk/guidance/NG17|archive-date=9 August 2016}}</ref><ref name=BSPED/> Very mild ketoacidosis with no associated vomiting and mild dehydration may be treated with oral rehydration and subcutaneous rather than intravenous insulin under observation for signs of deterioration.<ref name=BSPED/>

[[Normal saline]] (0.9% saline) has generally been the fluid of choice.<ref name=Jay2019>{{cite journal | vauthors = Jayashree M, Williams V, Iyer R | title = Fluid Therapy For Pediatric Patients With Diabetic Ketoacidosis: Current Perspectives | journal =  Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy| volume = 12 | pages = 2355–2361 | date = 2019 | pmid = 31814748 | pmc = 6858801 | doi = 10.2147/DMSO.S194944 | doi-access = free }}</ref> There have been a few small trials looking at balanced fluids with few differences.<ref name=Jay2019/>

A special but unusual consideration is [[cardiogenic shock]], where the blood pressure is decreased not due to dehydration but due to the inability of the heart to pump blood through the blood vessels. This situation requires ICU admission, monitoring of the [[central venous pressure]] (which requires the insertion of a [[central venous catheter]] in a large upper body vein), and the administration of [[inotrope|medication that increases the heart pumping action]] and blood pressure.<ref name=ADA2009/>

===Insulin===
Some guidelines recommend a bolus (initial large dose) of insulin of 0.1&nbsp;units of insulin per kilogram of body weight. This can be administered immediately after the potassium level is known to be higher than 3.3&nbsp;mmol/L; if the level is any lower, administering insulin could lead to a dangerously low potassium level (see below).<ref name=ADA2009/> Other guidelines recommend a bolus given intramuscularly if there is a delay in commencing an intravenous infusion of insulin,<ref name=JBDS/> whereas guidelines for the management of pediatric DKA recommend delaying the initiation of insulin until fluids have been administered.<ref name=BSPED/> It is possible to use rapid acting [[insulin analog]]s [[Subcutaneous injection|injections under the skin]] for mild or moderate cases.<ref>{{cite journal | vauthors = Andrade-Castellanos CA, Colunga-Lozano LE, Delgado-Figueroa N, Gonzalez-Padilla DA | title = Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis | journal = The Cochrane Database of Systematic Reviews | volume = 1 | issue = 1 | pages = CD011281 | date = January 2016 | pmid = 26798030 | pmc = 8829395 | doi = 10.1002/14651858.CD011281.pub2 }}</ref>

In general, insulin is given at 0.1&nbsp;units/kg per hour to reduce blood sugars and suppress ketone production. Guidelines differ as to which dose to use when blood sugar levels start falling; American guidelines recommend reducing the dose of insulin once glucose falls below 16.6&nbsp;mmol/L (300&nbsp;mg/dL)<ref name=ADA2009/> and UK guidelines at 14&nbsp;mmol/L (253&nbsp;mg/dL).<ref name=JBDS/> Others recommend infusing glucose in addition to saline to allow for ongoing infusion of higher doses of insulin.<ref name=NICE2015/><ref name=BSPED/>

===Potassium===
Potassium levels can fluctuate severely during the treatment of DKA, because insulin decreases potassium levels in the blood by redistributing it into [[Cell (biology)|cells]] via increased sodium-potassium pump activity. A large part of the shifted extracellular potassium would have been lost in urine because of osmotic diuresis. [[Hypokalemia]] (low blood potassium concentration) often follows treatment. This increases the risk of [[cardiac arrhythmia|dangerous irregularities in the heart rate]]. Therefore, continuous observation of the heart rate is recommended,<ref name=JBDS/><ref name=BSPED/> as well as repeated measurement of the potassium levels and addition of potassium to the intravenous fluids once levels fall below 5.3&nbsp;mmol/L. If potassium levels fall below 3.3&nbsp;mmol/L, insulin administration may need to be interrupted to allow correction of the hypokalemia.<ref name=ADA2009/>

===Sodium bicarbonate===
The administration of [[sodium bicarbonate]] solution to rapidly improve the acid levels in the blood is controversial. There is little evidence that it improves outcomes beyond standard therapy, and indeed some evidence that while it may improve the acidity of the blood, it may actually worsen acidity inside the body's cells and increase the risk of certain complications. Its use is therefore discouraged,<ref name=JBDS/><ref name=ESPE/><ref name=NICE2015/> although some guidelines recommend it for extreme acidosis (pH<6.9), and smaller amounts for severe acidosis (pH&nbsp;6.9–7.0).<ref name=ADA2009/>

===Cerebral edema===
Cerebral edema, if associated with coma, often necessitates admission to intensive care, [[artificial ventilation]], and close observation. The administration of fluids is slowed. The ideal treatment of cerebral edema in DKA is not established, but intravenous [[mannitol]] and [[Saline (medicine)#Hypertonic saline|hypertonic saline]] (3%) are used—as in some other forms of cerebral edema—in an attempt to reduce the swelling.<ref name=ESPE/> Cerebral edema is unusual in adults.<ref name=JBDS/>

===Resolution===
Resolution of DKA is defined as the general improvement in the symptoms, such as the ability to tolerate oral nutrition and fluids, normalization of blood acidity (pH>7.3), and absence of ketones in the blood (<1&nbsp;mmol/L) or urine. Once this has been achieved, insulin may be switched to the usual subcutaneously administered regimen, one hour after which the intravenous administration can be discontinued.<ref name=JBDS/><ref name=BSPED/>

In people with suspected ketosis-prone type 2 diabetes, determination of antibodies against [[glutamic acid decarboxylase]] and [[islets of Langerhans|islet cells]] may aid in the decision whether to continue insulin administration long-term (if antibodies are detected), or whether to withdraw insulin and attempt treatment with oral medication as in type 2 diabetes.<ref name=Umpierrez2006/> Generally speaking, routine measurement of [[C-peptide]] as a measure of insulin production is not recommended unless there is genuine doubt as to whether someone has type 1 or type 2 diabetes.<ref name=NICE2015/>