Dka fss

Management of Diabetic Ketoacidosis

SAMIR EL ANSARY

Objectives

•Management of DKA:

•1) Fluids

•2) Insulin•3) Electrolyte replacement

Management: Fluids

• Glucose osmotic diuresis causes dehydration

• Give between 4-6 liters, then reassess (caution in CHF)• Fluids help decrease the blood glucose levels

• Always start with NS• Bolus and then steady rate (i.e. 150cc/hr)

Management: Fluids

• Switch to 0.45% NS when “corrected” sodium within normal limits•Add 1.6 mEq to sodium for every 100 glucose is above 100.

• Switch to D5 1/2NS when glucose between 200-250

It is important to switch to D51/2ns when glucose reached 200-250 as risk of hypoglycemia is high.

Caution boluses in CHF patients (check EF and clinical status)

Management: Insulin

• IV insulin dripbolus approx 10 units (or .1unit/kg), then initiate drip at 0.1 unit/kg/hr

• Avoid bolus if K<3.3

• Replete K before starting drip

• Insulin drives potassium into the cells so if potassium starts off very low can make hypokalemia life threatening.

• Switch to SC insulin when anion gap closed signifying acidosis cleared.

Management: Insulin

• SC insulin must overlap with insulin drip over 2 hours.

• Use patient’s outpatient insulin dose OR

• In insulin-naive patients, a multi-dose insulin regimen should be started at a dose of 0.5 to 0.8 U/kg per day, including bolus and basal insulin until an optimal dose is established OR

Management: Insulin

Calculate 24 hour insulin requirements and use 50% as long acting

•Once the AG closes, can feed the patient.

•Remember to add sliding scale insulin (preferably lispro) with meals in addition to basal SC insulin dose.

Lispro is a great sliding scale insulin for patients with renal insufficiency

as it does not “stack” like insulin and decreased risk of hypoglycemia.

Management: Electrolyte Replacement

• Bicarbonate:

• If pH<6.9 (controversial) or K>6 with ECG changes

• Potassium:

• If potassium <5.3

•20-60 meq/L of ½ NS given when K <5.3 with severe acidosis

Bicarbonate helps drive potassium into cells ( H/K atpase channels)

Management: Electrolyte Replacement

• Phosphate:

•If phos <1, especially if muscle weakness

•When needed 20-30mEQ/L of potassium phosphate can be added to replacement fluids

Overall Management

•Be sure to check q1hour glucose checks

•and q 2-4hrs to monitor anion gap and acidosis

CASE• A 24 year old female with past medical

history of diabetes mellitus I is brought to the ER by her mother with complaints of fatigue and increased thirst and urination.

• Of note patient states she ran out of her insulin last week.

• She also has had a runny nose and cough for the past week.

• She noticed her glucose levels have been running “very high” and got concerned.

CASE

• On Exam: • BP 101/72; heart rate: 113; respirations: 32;

Temperature: 36.8 °C; pulse oximetry: 100% on room air.

• General: No apparent distress, AA and Ox3. • HEENT: dry mucous membranes• CV: tachycardic, normal s1, s2. No murmurs• Lung: CTAB• Abdomen: +bs, non distended, slight tenderness to

deep palpation, no HSM no rebound or guarding

• Ext: no cyanosis, clubbing or edema

Kussmaul: deep, labored breathing, form of hyperventilation(compensation for metabolic acidosis)- RR 32Often times they have abdominal pain (ileus from electrolyte abnormalities) and are very dehydrated

Patient does have tachycardia and slightly lower blood pressure indicating dehydration. Non compliance is one of the main reasons pts go into DKA. Also new onset type II diabetics present this way too.

•CMP

•Complete blood count with differential

•Urinalysis and urine ketones by dipstick

•Arterial blood gas

What labs do you want to order

Lab Results:• Glucose 450

• AST:40

• ALT:41

• Alk phos:67

• Arterial blood gas:

pH 6.9, CO2 9, bicarb 10

• WBC 13K, Hb14.4 mg/dL,

• and Hct 43.5%.

• 75% neutrophils

• UA +glucose, +protein, -leuko esterase, -nitrite NO KETONES

• EKG sinus tachycardia

• BMP:

• Na: 124

• K: 5.0

• Cl: 95

• CO2: 11

• BUN: 38

• Cr: 1.8

Anion gap (124- (95+11)= 18 Patient also has acute kidney injury secondary to dehydration will resolve with fluids (pre-renal)Ph<6.9 should start bicarbWBC=inflammatory response BUT need to rule out infection as it is a precipitating factorU/a does not show ketones!!! IF SUSPECT ORDER serum ketones (nitroprusside urine test does not test for betahydroxybutyrate in urine)Patient with hyponatremia after correction 124 +1.6 (3.5). Need to start normal saline.

• U/a does not show ketones!!! IF SUSPECT ORDER serum ketones (nitroprusside urine test does not test for betahydroxybutyrate in urine)

• Bolus 10 units insulin, then start insulin drip

• Bolus with normal saline, then start maintence

• Blood cultures, chest x-ray to rule out other sources of infection

• Empiric antibiotics?

• Bicarbonate?

• What would you do next?

Leukocytosis likely inflammatory response..need to look for other sources of infection, chest x-ray, blood cultures etc..No need to start antibiotics unless highly suspicious of infectionPh 6.9 indication for bicarbonate use

•BUN 28

•Creatinine 1.4

•Glucose 280

• ABG:

•pH 7.2, CO2 of 18 and a bicarb of 12

• Q 2 hour BMP checks:

• After 6 hours:

•Na: 139

•K: 2.5

•Cl: 108

•Co2: 13

AG= 139- (108+12)= 19, sodium normal range, can now switch to ½ normal saline so pts don’t have iatrogenic hypernatremia.Creatinine slowly improving with fluids

• Switch to 0.45% saline with potassium supplements

• Repeat BMP in 4 hours:

• Na: 142

• K: 4.5

• Cl: 110

• Co2: 15

• BUN 38

• Creatinine 1.2

• Glucose 230

•What do you do next?

Glucose <250 so will switch to D51/2Ns on next slide, Ag still open at 17

• Repeat BMP in 4 hours:

• Na: 140

• K: 4.0

• Cl: 110

• Co2: 23

• BUN 28

• Creatinine 1.1

• Glucose 105

• Start on d5 ½ NS with K supplements

• Continue insulin drip

Anion gap closed! (140-(110+23)= 7

•Continue insulin drip

•Start patient on home regimen of SQ insulin

•or calculate last 24 hour total dose and give 50% in form of long acting (i.e lantus)

Need to emphasize leaving drip on for 2 hours after starting SQ insulin as gap can open. Can ask students why do we keep drip on for 2 hours after gap already closed?

It is important to have patient eat a meal in ICU first before transferring to floor and monitoring their anion gap

•Stop drip (after 2 hours of starting the SQ insulin)!!

•Feed patient!

• If anion gap remains closed after meal can transfer to floor.

Key Points• Close monitoring is crucial with glucose

checks and bmps as electrolytes respond quickly and management depends on these numbers

• Early fluid resuscitation is important

• Insulin gtt must overlap SQ insulin for 2 hours prior to discontinuation of the drip

Pts often very dehydrated (glucose osmotic effect). Think of it like sepsis and that you need to give fluids early.

GOOD LUCK

SAMIR EL ANSARY