Dka

Management of Diabetic Ketoacidosis

ObjectivesManagement of DKA:1) Fluids2) Insulin3) Electrolyte replacement

Management: FluidsGlucose osmotic diuresis causes dehydrationGive between 4-6 liters, then reassess (caution in CHF)Fluids help decrease the blood glucose levelsAlways start with NSBolus and then steady rate (i.e. 150cc/hr)Switch to 0.45% NS when corrected sodium within normal limitsAdd 1.6 mEq to sodium for every 100 glucose is above 100.Switch to D5 1/2NS when glucose between 200-250

Overall ManagementBe sure to check q1hour glucose checks and q2-4hrs bmp to monitor anion gap and acidosis

CASEA 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.

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 membranesCV: tachycardic, normal s1, s2. No murmursLung: CTABAbdomen: +bs, non distended, slight tenderness to deep palpation, no HSM no rebound or guardingExt: no cyanosis, clubbing or edema

What labs do you want to order?

CMPComplete blood count with differential Urinalysis and urine ketones by dipstickArterial blood gas

EKG sinus tachycardiaBMP:Na: 124K: 5.0Cl: 95CO2: 11BUN: 38Cr: 1.8 Glucose 450AST:40ALT:41Alk phos:67Arterial blood gas: pH 6.9, CO2 9, bicarb 10WBC 13K, Hb14.4 mg/dL, and Hct 43.5%.75% neutrophilsUA +glucose, +protein, -leuko esterase, -nitrite NO KETONES

Lab Results:

Serum ketones test ordered is positive for beta-hydroxybutyrate

What would you do next?

Bolus 10 units insulin, then start insulin dripBolus with normal saline, then start maintenceBlood cultures, chest x-ray to rule out other sources of infection Empiric antibiotics?Bicarbonate?

Q2 hour BMP checks:After 6 hours:Na: 139K: 2.5Cl: 108Co2: 13BUN 28Creatinine 1.4Glucose 280ABG:pH 7.2, CO2 of 18 and a bicarb of 12

What do you do next?

Switch to 0.45% saline with potassium supplementsRepeat BMP in 4 hours:Na: 142K: 4.5Cl: 110Co2: 15BUN 38Creatinine 1.2Glucose 230

Start on d5 NS with K supplementsContinue insulin drip

Repeat BMP in 4 hours:Na: 140K: 4.0Cl: 110Co2: 23BUN 28Creatinine 1.1Glucose 105

Continue insulin dripStart 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)

2 hours later

Stop drip (after 2 hours of starting the SQ insulin)!!Feed patient! If anion gap remains closed after meal can transfer to floor.

Key PointsClose 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

**It is important to switch to D51/2ns when glucose reached 200-250 as risk of hypoiglycemia is high. Caution boluses in CHF patients (check EF and clinical status)*Lispro is a great sliding scale insulin for patients with renal insufficiency as it does not stack like insulin and decreased risk of hypoglycemia.*Bicarbonate helps drive potassium into cells ( H/K atpase channels)UTD states only tx phos if