Volume 03 Issue 11-2023
96
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
11
P
AGES
:
96-102
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
ABSTRACT
The aim of our work was to develop a comprehensive, pathogenetic substantiated intensive care in patients with
diabetic ketoacidosis who are in critical condition. The development of complex pathogenetic substantiated intensive
care in patients with diabetic ketoacidosis who are in critical condition is one of the urgent problems of intensive care.
It should be noted that the proposed intensive care with solutions containing succinate and potassium in the complex
intensive care of diabetic ketoacidosis is one of the promising directions for optimizing the treatment of patients. The
intensive care option we proposed contributed over 3 days in 95% of patients to the elimination of diabetic
hyperglycemic ketoacidosis.
KEYWORDS
Diabetes, diabetic ketoacidosis, intensive care, succinate.
INTRODUCTION
Research Article
SOME FEATURES OF INTENSIVE THERAPY FOR DIABETIC KETOACIDOSIS
Submission Date:
November 18, 2023,
Accepted Date:
November 23, 2023,
Published Date:
November 28, 2023
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume03Issue11-10
Dadajonov Sh.N.
Main Medical Directorate Under The Administration Of The President Of The Republic Of Uzbekistan, Central
Clinical Hospital N. 2, Tashkent, Uzbekistan
Usmanov Z.H.
Main Medical Directorate Under The Administration Of The President Of The Republic Of Uzbekistan, Central
Clinical Hospital N. 2, Tashkent, Uzbekistan
Quziev Z.N.
Main Medical Directorate Under The Administration Of The President Of The Republic Of Uzbekistan, Central
Clinical Hospital N. 2, Tashkent, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 03 Issue 11-2023
97
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
11
P
AGES
:
96-102
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
Diabetes mellitus (DM) is one of the most common
endocrine diseases worldwide. One of the severe
complications of diabetes mellitus is diabetic
ketoacidosis and hyperglycemic ketoacidotic coma,
which require a special approach, both due to the
severity of the course and due to high mortality. High
mortality in hyperglycemic ketoacidotic coma is
associated with insulin insufficiency (1,4,6), tissue
hypoxia, endogenous intoxication, water-electrolyte
imbalance, metabolic disorders, multiple organ
dysfunction (2,3,5). Most clinicians distinguish
hypovolemia and concomitant systemic hypoperfusion
as one of the leading links in the pathogenesis of
systemic and organ insufficiency in patients with
diabetic ketoacidosis and hyperglycemic ketoacidotic
coma (2,6).
The leading role in the correction of hypovolemia is
played by infusion therapy aimed at a rapid increase in
the volume of circulating blood, cardiac output,
oxygen delivery and its consumption by div tissues.
Its optimal choice, along with insulin therapy and other
means of pharmacological correction, can prevent the
development of a critical condition and multiple organ
dysfunction in patients with diabetic ketoacidosis and
hyperglycemic ketoacidotic coma. All of the above
indicates the relevance and clinical significance of the
problem under consideration, since timely diagnosis
and adequate intensive therapy of diabetic
ketoacidosis and hyperglycemic ketoacidotic coma can
not only significantly improve the results of treatment,
but also the outcome of the disease as a whole. The
aim of our work is to develop a comprehensive, well-
founded intensive therapy in patients with diabetes
mellitus complicated by diabetic ketoacidosis and
ketoacidotic coma.
Materials and methods of research. 65 patients with
diabetes mellitus, in critical condition, complicated by
diabetic ketoacidosis and hyperglycemic ketoacidotic
coma, who underwent inpatient treatment in the
intensive care unit, were examined. The study included
patients aged 35 to 60 years (average age 55 + 1.2
years). Of these, 37 female and 28 male patients. The
duration of the disease ranged from 3 to 15 years. To
determine the severity of the patients' condition, the
parameters of the central hemodynamics of volemic
parameters (Heart rate, Systemic Scleroderma, Stroke
Volume (SV), Cardiac index CI, Volume of circulating
blood VCB, volume of circulating plasma (VCP) and
volume of circulating erythrocytes (VCE) were studied.
To optimize infusion therapy, the main and control
groups of patients were formed. In the main group, in
accordance with the severity of the patients' condition
(n=35), pathogenetic-based infusion programs were
used, balanced in qualitative and quantitative
composition. The volume and optimal ratio of saline,
salt-free and colloidal solutions calculated according to
the clinical severity of the condition and the div
weight of patients were selected. In patients of the
Volume 03 Issue 11-2023
98
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
11
P
AGES
:
96-102
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
control group (n=30), a generally accepted classical
infusion program was used as part of infusion therapy.
All clinical and laboratory studies were carried out at
the following stages before the start of therapy, after
2 hours, 6 hours, on the 2nd, 3rd day.
Results of research patients with diabetes mellitus in
critical condition complicated by diabetic ketoacidosis
and hyperglycemic ketoacidotic coma revealed
changes in central hemodynamics, indicating a
breakdown of compensatory mechanisms of the
circulatory system, a sharp increase in cardiovascular
insufficiency due to a combination of low cardiac
output, hypovolemia and dehydration. Tachycardia
was observed in patients with stable arterial pressure,
with an average intake of 90.2+1.2 beats/min, ADP
(average dynamic pressure) 110 + 1.7 mmHg, CI (cardiac
index) 24.4+1.2 ml x m, SI (cardiac index) 3.0+0.8 l l x
min. In 97% of patients, there was a decrease in the
volume of circulating blood (VCB) due to a decrease in
the volume of circulating plasma (VCP) and a decrease
in the volume of circulating erythrocytes (VCE).
A significant decrease in VCB was observed by 45.7%
(p<0.05). When patients breathed, the smell of
acetone was clearly detected, hard breathing without
wheezing. In 59% (38) of patients with palpation of the
abdomen, pain was observed during palpation. The
urine test for acetone in all patients was positive and
sharply positive. Decompensated metabolic acidosis
was detected in all patients, with an average blood pH
of 7.22 +0.3 in all patients. Modern intensive therapy
for diabetes mellitus in a critical condition complicated
by
diabetic
ketoacidosis
and
hyperglycemic
ketoacidotic
coma
includes
two
mandatory
components. This is a subsidy of fluid with
compensation for its deficiency and correction of
current pathological losses of the water-electrolyte
composition of the blood, as well as insulin therapy
(Alexandrovich Yu.S.). Patients of the main and control
groups underwent standard insulin therapy to correct
blood glycemia. The dose of insulin and the rate of its
administration are selected in such a way that the rate
of glucose reduction does not exceed 3.5-5.5 mmol / l /
hour or 10% of the initial values. Rehydration therapy
with salt and salt-free solutions is carried out strictly
under the control of CVP and hourly diuresis. Patients
of the control group received standard infusion
therapy with saline solutions: 0.9% sodium chloride
solution or Ringer's solution, 0.45% sodium chloride
solution were used. The concentration of sodium
chloride (0.9 or 0.45%) was selected depending on the
concentration of sodium in the blood plasma. With
normonatremia,
0.9%
are
used,
and
with
hypernatremia, 0.45%.
It was mandatory in infusion therapy to pay attention
to the correction of potassium deficiency, since its
deficiency can lead to the development of cardiac
arrhythmias. Correction of potassium deficiency was
carried out by intravenous drip administration of
Volume 03 Issue 11-2023
99
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
11
P
AGES
:
96-102
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
potassium chloride solution. Polycomponent and
multifunctional crystalloid Succinasol solution was
used in patients of the main group in the intensive care
complex in order to correct acidosis and detoxification.
Succinasol is based on sodium succinate, which
supplies succinic acid anion - a substrate of the Krebs
cycle and a supplier of energy-rich compounds, with a
pH of 6.97. Its main property is the ability to influence
the electrolyte composition and volume of the
extracellular and intracellular fluid, as well as the acid-
base state (ABS). This solution is able to have an effect
on not only hemodynamics, water-electrolyte
composition and ABS, but also improves blood
microcirculation,
activates
energy
metabolism,
improves the function of the heart muscle increases
energy production by including fumarate ion in the
Krebs cycle. To correct severe hypovolemia, we
prescribed this solution 200-400 ml, 1-2 times a day.
One of the problems in the correction of diabetic
ketoacidosis is the stabilization of blood levels of
potassium and glucose. After lowering blood glucose
to 14-16 mmol / l, Cadence solution was included in the
infusion in order to provide parenteral carbohydrate
nutrition and regulation of salt balance with the
addition of short-acting insulin (SAI) against the
background of insulin therapy. Since potassium
deficiency occurs especially in diabetes mellitus
complicated
by
diabetic
ketoacidosis
and
hyperglycemic ketoacidotic coma. The use of ready-
made potassium solutions reduces the likelihood of
errors in the dosage of potassium, which can be
observed when preparing solutions from ampoule and
pharmacy concentrates, thereby preventing the risk of
potassium overdose and the development of
hyperkalemia. The ability of this infusion drug to
increase potassium levels without the risk of
hyperkalemia distinguishes it from other potassium-
containing drugs. Dosage: 10-20 mmol of potassium
(0.5-1.0 L), administered within 1-3 hours. The dosage
of Cadence solution depends on the age, div weight,
severity of the clinical condition of the patient and the
indications of laboratory tests. When conducting a
rehydration program in patients in the main group, an
improvement in the indicators of the water-electrolyte
balance of the blood was revealed. As can be seen from
the table, patients of the main group had an increase in
the Na+ content in blood plasma by 3.6% on day 1, and
by 6.5% on day 2. No change in Na+ was observed in
blood plasma in patients of the control group on days
1 and 2. Such normalization of the electrolyte
composition of the blood in patients of the main group
led to an improvement in the indicators of central
hemodynamics.
In the main group, the values of the parameters of
central hemodynamics improved in the first days. This
was confirmed by a significant decrease in heart rate
by 5% after 1 day, SSD by 13%, an increase in CI by 24%,
SV by 14%. It should be noted that the Specific
peripheral resistance SPR decreased by 50%. On the
Volume 03 Issue 11-2023
100
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
11
P
AGES
:
96-102
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
second day of observation, there was an improvement
in CG indicators, which are reflected in the table. In
patients of the control group, against the background
of treatment according to the standard algorithm, the
parameters of the CI, SV did not differ significantly
from the initial values. The heart rate remained at the
same level. The indicators of the study results
presented in Table c show that, in the control group,
against the background of traditional infusion therapy,
achieving the target level of glycaemia was
accompanied by a significant decrease in this indicator
on day 1 to 52.4%, and on day 2 to 48.8%. In patients of
the main group, patients have a smooth decrease in
glycaemia, by 60 and 68%. According to the data
obtained, patients with hyperglycemic ketoacidosis in
critical condition have volemic disorders associated
with a decrease in VCB, VCP and a decrease in VCE.
Despite the therapy, during rehydration therapy, the
control group patients showed an increase in VCB by
only 15%, VCP by 24%, and VCE did not undergo
significant changes. In the patients of the main group,
there was an increase in VCB by 39% on day 1, and on
day 2 by 60%, while the increase in VCP by 2 times,
respectively by 54.5% and 71%, indicating the
effectiveness of the therapy. This allowed to correct
the VCB deficiency, stabilize blood circulation, creating
optimal conditions for circulation.
It should be noted that the recovery of pH was observed on the 2nd day of treatment, in 42% of patients of the main
group, this indicator began to increase. And on the 2nd day of treatment, 89% began to meet the norm. There was a
connection between changes in the pH of blood and urine during treatment. Elimination of diabetic hyperglycemic
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Na+,
mmol/l
К+,
mmol/l
Glucose,
mmol/l
Heart
rate,
min"1
SV,
mmHg.
CI, ml x
m"2
CI, l x
min"1
х
m"2
SPR,
din/s
х
sm"5
х
m"2
VCB,
ml/kg
VCP,
ml/kg
VCE,
ml/kg
Hemodynamic parameters in patients in the control
group
Control group In admission
Control group After 24 hours
Control group After 48 hours
Volume 03 Issue 11-2023
101
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
11
P
AGES
:
96-102
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
ketoacidosis was observed in all patients of the main group within 3 days. 5% of patients in the main group had a
relapse of diabetic ketoacidosis.
The cause was chronic renal failure, pneumonia was
observed in 7% of patients. Mortality of patients in the
main group was not observed. All patients of the main
group were transferred to the endocrinological and
therapeutic departments. The average duration of stay
of patients of the main group in the ICU was 2.65 ± 0.12
days, in patients of the control group 3.45 ± 0.18 days.
Thus, based on the above, it can be assumed that the
developed intensive therapy of solutions containing
succinate and Cadence in the complex therapy of
diabetic ketoacidosis is one of the promising directions
for optimizing the treatment of patients. And also
significantly contribute to reducing the length of stay
of patients in the ICU and reducing the mortality rate.
REFERENCES
1.
Aleksandrovich YU.S. Intensivnaya terapiya
diabeticheskogo ketoatsidoza u detey. /
YU.S.Aleksandrovich
K.V.
Pshenisnov.//
Rossiyskiy
vestnik
detskoy
khirurgii,
anesteziologi,
reanimatologi.-2012.-T.2.-
№2.
-
S.92-99. Aleksandrovich Yu.S. Intensive care of
diabetic ketoacidosis in children. / Yu.S.
Aleksandrovich K.V. Pshenisnov.// Russian
Bulletin of Pediatric Surgery, anesthesiologists,
resuscitators.-2012.-T.2.-No.2.-S.92-99
2.
Kriticheskiye
sostoyaniya
v
klinicheskoy
praktike. // S. A. Rumyantseva, V. A. Stupin,V. V.
Afanas'yev, A. I. Fedin, Ye. V. Silina
—
M.: MIG
«Meditsinskaya kniga»;2010.
—
640 s. Critical
0%
20%
40%
60%
80%
100%
Na+, mmol/l
Glucose, mmol/l
SV, mmHg.
CI, l x min"1
х
m"2
VCB, ml/kg
VCE, ml/kg
Hemodynamic parameters in patients of the
main group
Main group In admision
Main group After 24 hours
Main group After 48 hours
Volume 03 Issue 11-2023
102
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
11
P
AGES
:
96-102
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
conditions in clinical practice. // S. A.
Rumyantseva, V. A. Stupin, V. V. Afanasiev, A. I.
Fedin, E. V. Silina - M .: MIG "Medical Book";
2010.
—
640 p.
3.
Potemkin, V.V.3. Diabeticheskiy ketoatsidoz /
V.V. Potemkin, Ye.G. Starostina // Neotlozhnaya
endokrinologiya: rukovodstvo dlya vrachey.
—
M.:
Meditsinskoye
informatsionnoye
agentstvo, 2008.
—
S.11
—
125, 365
—
387.
Potemkin, V.V.3. Diabetic ketoacidosis / V.V.
Potemkin,
E.G.
Starostina
//
Urgent
endocrinology: a guide for physicians. - M .:
Medical Information Agency, 2008. - P. 11-125,
365-387.
4.
Rabochaya gruppa po diabetu i SSZ
Yevropeyskogo obshchestva kardiologov i
Yevropeyskoy assotsiatsii po izucheniyu
sakharnogo diabeta, 2007 g. Rekomendatsii po
lecheniyu sakharnogo diabeta, prediabeta i
serdechno-sosudistykh
zabolevaniy
//
Sakharnyy diabet, 2008. №1. S. 86
-92. Diabetes
and CVD Working Group of the European
Society of Cardiology and the European
Association for the Study of Diabetes Mellitus,
2007. Recommendations for the treatment of
diabetes
mellitus,
prediabetes
and
cardiovascular diseases // Diabetes mellitus,
2008. No. 1. pp. 86-92.
5.
Brown, T.B.4. Cerebral oedema in childhood
diabetic ketoacidosis: Is treatment a factor? /
T.B. Brown // Emerg. Med. J.
—
2004.
—
№ 21.
—
Р.141—
144.
6.
Wolfsdorf, J.5. Diabetic ketoacidosis in infants,
children and adolescents: A consensus
statement from the American Diabetes
Association / J. Wolfsdorf, N. Glazer, M.A.
Sperling // Diabetes Care.
—
2006.
—
№ 29. —
Р.1150—
1159.
