Management of Diabetic Ketoacidosis

Objectives Management of DKA: Control of precipitating cause 1) Fluids 2) Insulin 3) Electrolyte replacement Control of precipitating cause How to discharge the patient?

Management: Fluids Switch to D5 1/2NS when glucose between 200-250 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 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)

Management: Insulin IV insulin dripbolus 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 Lispro is a great sliding scale insulin for patients with renal insufficiency as it does not “stack” like insulin and decreased risk of hypoglycemia.

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 Bicarbonate helps drive potassium into cells ( H/K atpase channels) UTD states only tx phos if <1 or symptomatic.

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. Kussmaul: deep, labored breathing, form of hyperventilation(compensation for metabolic acidosis)-RR32 Often 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.

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-Comprehensive Metabolic Panel Sodium. Potassium. Calcium. Chloride. Carbon Dioxide (Bicarbonate). Glucose. Blood Urea Nitrogen (BUN). Creatinine. Total Protein. Albumin. Total Bilirubin. Alkaline Phosphatase (ALP). Aspartate Aminotransferase (AST). Alanine Aminotransferase (ALT). Complete blood count with differential Urinalysis and urine ketones by dipstick Arterial blood gas

Lab Results: EKG sinus tachycardia CMP: 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 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 bicarb WBC=inflammatory response BUT need to rule out infection as it is a precipitating factor U/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.

Serum ketones test ordered is positive for beta-hydroxybutyrate U/a does not show ketones!!! IF SUSPECT ORDER serum ketones (nitroprusside urine test does not test for betahydroxybutyrate in urine)

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? 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 infection Ph 6.9 indication for bicarbonate use

Q2 hour Basic Metabolic Pannel 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 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

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

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 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

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

Go to uptodate for reference table

Thank you.