1. Management of Diabetic Ketoacidosis

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

3. 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
It is important to switch to D51/2ns when glucose reached as risk of hypoiglycemia is high.
Caution boluses in CHF patients (check EF and clinical status)

4. 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.

5. 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

6. 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.

7. 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.

8. 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

9. What labs do you want to order?

10. 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

11. 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 (3.5). Need to start normal saline.

12. 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)

13. What would you do next?

14. 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

15. 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

16. What do you do next?

17. 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

18. Start on d5 ½ NS with K supplements
Continue insulin drip

19. 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

20. 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

21. 2 hours later…

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

23. 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.

24. Go to uptodate for reference table

25. Thank you.