The treatment of severely uncontrolled diabetes mellitus

Patients with severely uncontrolled diabetes mellitus must be cared for by physicians and nurses who understand the pathophysiology of ketoacidosis and nonketotic hyperglycemia, who carefully seek and treat precipitating or underlying illnesses, and who can provide the patients with continuous clinical attention and laboratory monitoring. Most patients with diabetic ketoacidosis survive the acute metabolic disorder; the infrequent deaths are usually due to serious underlying illnesses. The latter are more common in patients with nonketotic hyperglycemia, who are usually older than those with ketoacidosis and who usually also have serious underlying chronic diseases. The essential features of treatment for either of the foregoing acute metabolic disorders are administration of insulin (especially gingerly in the older patients with nonketotic hyperglycemia, despite their commonly remarkable hyperglycemia); rehydration with NaCl solutions; and IV administration of K+, usually not until after a few hours of treatment with insulin and NaCl solutions. Administration of NaHCO3 is usually not necessary except in patients with a blood pH less than 7.1. Administration of phosphate has been recommended as part of the treatment for ketoacidosis, but its need is uncertain. Although patients with nonketotic hyperglycemia are often more severely dehydrated and hyperglycemic than those with ketoacidosis, they usually should be given smaller amounts of insulin, NaCl solutions, and K+, and less rapidly.