DKA

1
DKA

• Carolyn Stickney
• July 10, 2008

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DKA Defined

• Diabetic glucose gt250 mg/dL
• Keto ketones produced
• Acidosis anion gap metabolic acidosis HCO3-
  lt15, pHlt7.30

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Why does it happen?

• elevation of counter-regulatory hormones with
  concomitant reduction of insulins effective
  action
• hormones induce
• hepatic/renal glucose production and impaired
  peripheral utilization ? hyperglycemia
• lipolysis and fatty acid oxidation ? ketone
  bodies

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Yeah, but why does it happen?

• non-compliance/iatrogenic insulinopenia
• infection, infection, infection
• pneumonia, UTI, gastroenteritis
• thromboembolic phenomena MI, CVA, etc.
• new-onset disease
• pancreatitis
• trauma or alcohol abuse

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DKA isnt going to be their chief complaint,
right?

• nausea/vomiting
• abdominal pain
• lethargy or fatigue
• polyuria/polydipsia and subjective dehydration
• symptoms of precipitating event

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Lab Evaluation(or, what the ER should have sent)
first! finger-stick glucose
urinalysis, arterial blood gas, serum ketones,
Ca, Mg, Phos
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Your chance to think

• cultures urine, blood, sputum, etc.
• chest X-ray
• cardiac enzymes, EKG
• LFTs, amylase/lipase
• ß-HCG
• other imaging given clinical suspicions

Dont forget to treat the precipitating event
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While youre waiting

• FLUIDS!
• total deficit on presentation commonly 5-10 L
• start with NS resuscitation
• even after restoration of adequate circulation,
  high rates of IVF infusion
• further osmotic diuresis will occur
• will help decrease serum glucose

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Diabetics need insulin

• initial bolus of IV insulin 0.1-0.15 units/kg
• continuous infusion 0.1 units/kg/hr
• goal decrease blood sugar 50-75 mg/dL/hr
• titrate insulin based on finger sticks, but

DONT TURN OFF THE DRIP!
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When the glucose falls

• once chem sticks fall below 200-250 mg/dL, add
  dextrose to fluids
• fixing the sugar isnt the endgame
• need to keep glucose 200 mg/dL until youve
  closed the gap Na - (Cl- HCO3-) lt12
• this means monitoring chemistries frequently
  (renal panel a good choice)

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Osmotic diuresis electrolyte depletion

• urine losses are free water gtgt sodium
• serum sodium usually low to normal beware of
  pseudohyponatremia
• remember correction factor (1.6 mEq/100 mg/dL
  glucose above 100)
• potassium hyperkalemia can be deceiving
• once adequate urine output ensured, add KCl to
  IVF (20-40 mEq/L)

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Electrolytes under debate

• hypophosphatemia is common as well
• no evidence that routine supplementation
  indicated in adults
• follow levels on renal panels
• bicarbonate drips dont seem to affect outcome
  with pH 6.9-7.1
• that said, drips are often used when pHlt6.9 given
  risk of vascular compromise

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When the gap closes

• think can they eat yet?
• if no, continue insulin and dextrose infusions
• if yes, restart home regimen give subcutaneous,
  turn off drip about an hour later
• dont forget to order a diet!
• if new diagnosis, design an initial regimen and
  titrate as necessary (total insulin requirements
  0.5-0.8 units/kg/day)

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What can go wrong

• majority of morbidity and mortality is from
  precipitating events
• hypoglycemia
• hyperglycemia
• hypokalemia, hypophosphatemia
• noncardiogenic pulmonary edema
• cerebral edema (young patients)

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Bottom line necessities

• fluids be aggressive
• insulin monitor hourly glucose levels, watch
  for closure of AG
• electrolytes frequent renal panels
• precipitating event treat the infection or MI

AND

• a big cup of coffee for you