Signs of advanced cerebral edema include obtundation, papilledema, pupillary dilation or inequality, hypertension, bradycardia, and apnea. Treatment involves the rapid use of IV mannitol, endotracheal intubation, and ventilation and may require the use of a subdural bolt. Other complications of DKA are intracranial thrombosis or infarction, acute tubular necrosis with acute renal failure caused by severe dehydration, pancreatitis, arrhythmias caused by electrolyte abnormalities, pulmonary edema, and bowel ischemia. Peripheral edema occurs commonly 24 to 48 hours after therapy is initiated and may be related to residual elevations in antidiuretic hormone and aldosterone.
Transition to Outpatient Management
When the acidosis has been corrected and the patient tolerates oral feedings, the IV insulin infusion can be discontinued, and a regimen of subcutaneous (SC) insulin injections can be initiated. The first SC insulin dose should be given 30 to 45 minutes before discontinuation of the IV insulin infusion. Further adjustment of the insulin dose should be made over the following 2 to 3 days. A patient already diagnosed with DM1 may be restarted on the prior doses if they were adequate. For a patient with new-onset DM1, typical starting total daily doses are approximately 0.5 to 0.7 U/kg/24 hours for prepubertal patients and approximately 0.7 to 1 U/kg/24 hours for adolescents, using any number of the available insulin combinations. The best and most common choice for making the transition to SC insulin is to begin by giving injections of fast-acting (bolus) insulin (lispro, aspart, or glulisine insulin) with each meal and long-acting (basal) insulin (glargine or detemir) at bedtime. This regimen of multiple daily injections provides the most flexibility but requires the patient to administer many injections per day and to count carbohydrates in food. An alternative is a fixed mixed split dosing regimen (neutral protamine Hagedorn [NPH] and fasting-acting insulin) with two daily injections.
Externally worn pumps that provide a continuous SC infusion of fast-acting insulin are available, although not usually used at the very onset of DM1. Insulin pumps provide fast-acting insulin in small basal amounts continuously every hour and will provide bolus insulin when instructed. Insulin pumps may be used by all age groups who are highly motivated to achieve tight control. The absence of SC depot insulin (glargine or detemir) can increase the risk of DKA.
Serum glucose concentrations should be assessed before each meal, at bedtime, and periodically at 2 to 3 am to provide information for adjustment of the regimen. Patients and their families should begin learning the principles of diabetes care as soon as possible. Demonstration of the ability to administer insulin injections and test glucose concentrations using a glucose meter is necessary before discharge, as is knowledge of hypoglycemia management. Meal planning is crucial to control glucose in DM1. Nutrition services must be part of the care delivered to the families from diagnosis.
In some patients with new onset of DM1, the beta cell mass has not been completely destroyed. The remaining functionalbeta cells seem to recover function with insulin treatment. When this occurs, exogenous insulin requirements decrease.This is a period of stable blood glucose control, often with nearly normal glucose concentrations. This phase of the disease, known as the honeymoon period, usually starts in thefirst weeks of therapy, often continues for 3 to 6 months, andcan last 2 years.