Management of Diabetic Ketoacidosis

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)

• 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

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 drive s 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.

• 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

• 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.

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

• 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 q2-4hrs bmp 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.

• 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

• What labs do you want to order?

• CMP

• Complete blood count with differential

• Urinalysis and urine ketones by dipstick

• Arterial blood gas

• EKG sinus tachycardia

• BMP:

• Na: 124

• K: 5.0

• Cl: 95

• CO2: 11

• BUN: 38

• Cr: 1.8

• 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

Lab Results:

• Serum ketones test ordered is positive for beta-hydroxybutyrate

• What would you do next?

• 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?

• Q2 hour BMP checks:

• After 6 hours:• Na: 139

• K: 2.5

• Cl: 108

• Co2: 13

• BUN 28

• Creatinine 1.4

• Glucose 280

• ABG:• pH 7.2, CO2 of 18 and a bicarb of 12

• What do you do next?

• 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

• Start on d5 ½ NS with K supplements

• Continue insulin drip

• Repeat BMP in 4 hours:• Na: 140

• K: 4.0

• Cl: 110

• Co2: 23

• BUN 28

• Creatinine 1.1

• Glucose 105

• 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)

• 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 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