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hypoglycemia presents with tachycardia, restlessness, con- extended period because the goal is not to achieve nor-
fusion, and irritability, accompanied by sweating, pallor, moglycemia instantly (which is not possible anyway, as the
and tremors. Severe hypoglycemia is marked by hypoten- number and sensitivity of insulin receptors are limited) .
29
sion and loss of consciousness. According to our National During DKA therapy, it's essential to frequently repeat la-
Guidelines for the Diagnosis and Treatment of Diabetes boratory tests, and monitoring of electrocardiogram (EKG)
Mellitus, for grades 1-2 (mild/moderate hypoglycemia), the is necessary if potassium levels are too low or too high (< 3
recommended treatment is to administer 2-4 glucose ta- mmol/L or > 6 mmol/L). Fractionated bolus doses of short-
blets or two teaspoons (10 g) of sugar, honey, or jam, or a acting insulin can be used in DKA therapy, but continuous
small bottle of juice containing sugar. For grades 3-4 (seve- intravenous infusion of this insulin is recommended. Bi-
re hypoglycemia), the recommended therapy is parenteral: carbonate replacement in DKA treatment should be very
slow intravenous bolus or infusion of glucose (25 mL of 50% cautious and limited to cases where metabolic acidosis is
or 100 mL of 20% solution). This therapy raises the blood su- severe (bicarbonate level < 8 mmol/L or pH < 7.0) . The fun-
8
gar level by 12.5 mmol/L within five minutes, making it the damental requirement for successful DKA treatment is con-
best way to manage severe hypoglycemia. However, cauti- tinuous monitoring and care of the patient during the first
on is needed as extravascular administration can cause ne- 24 hours of therapy.
crosis. An alternative to glucose is glucagon (1 mg = 1 unit),
which can be administered intravenously, intramuscularly, Certainly, the most important aspect is the prevention
or subcutaneously. However, this therapy may be ineffective of these complications, and in this context, as part of the
if the patient has been fasting or consuming alcohol for an pre-procedural preparation for dental interventions, pa-
extended period (as glycogen stores for glucose mobiliza- tients should receive advice on the importance of regular
tion may be depleted). Therefore, it is necessary for dental check-ups with an endocrinologist, maintaining a proper
offices to be equipped following the recommendations of dietary regimen, especially for particularly vulnerable cate-
the National Guide and to always have available (in addition gories of diabetic patients such as children, pregnant wo-
to the equipment for measuring blood glucose levels in ca- men, and elderly patients 38-40 .
pillary blood): a sugar cube or chocolate, fruit juice, or ano-
ther sweetened beverage, and a glucagon injection kit 8, 37 . It
is recommended that during dental procedures in patients
with diabetes, verbal contact should be maintained conti-
nuously, and if hypoglycemia has occurred (which has been
successfully managed), such patients should be monitored
in the dental office for at least another hour.

The therapy for DKA is complex. In cases of milder DKA
(conscious patient, good general condition), attempts can
be made with oral rehydration and subcutaneous injections
of regular or rapid-acting insulin. However, for severe forms
of DKA, therapy is exclusively parenteral (intravenous) and
requires laboratory and other monitoring, making it un-
suitable for administration in a dental office. Hospitalizati-
on is necessary in such cases. Therefore, it is important to
promptly suspect DKA in a dental to arrange for the patient's
transport to the hospital. Unfortunately, the symptoms and
signs of DKA are not particularly specific, necessitating la-
boratory confirmation. DKA presents with a sensation of
dryness in the mouth, thirst, general weakness, fatigue,
exhaustion, anorexia, decreased sweating, and possible na-
usea and vomiting. Various levels of consciousness distur-
bances may also occur, depending on the severity of DKA.
However, assessing the severity of DKA without laboratory
analysis, particularly gas analysis (blood pH and serum bi-
carbonate), is difficult. Therefore, the primary guide in the
clinical assessment of DKA severity is the patient's level of
consciousness 27, 29 .

The treatment for DKA, as per the National Guidelines,
involves rehydration, electrolyte replacement (primarily po-
tassium), insulin administration, and other measures . Fluid
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and electrolyte replacement must be done slowly over an

REVIEW PAPER Galenika Medical Journal, 2024; 3(9):69-75. 73