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Diabetic Ketoacidosis
- 1. Diabetic Ketoacidosis Myths, Misconceptions, and Mismanagement Justin Hensley, MD Assistant Professor of Emergency Medicine Texas A&M Health Science Center/CHRISTUS Spohn
- 3. What is DKA? Excess insulin antagonism Insulin deficiency Lipolysis Hyperglycemia Ketogenesis Acidosis Dehydration Electrolyte abnormalities deVeciana M. Diabetes ketoacidosis in pregnancy. Semin Perinatol. 2013 Aug;37(4):267-73.
- 4. Levels Mild pH >7.25 HCO3 15-18 Moderate pH 7-7.24 HCO3 10-15 Severe pH <7 HCO3 <10 KitabchiAE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. DiabetesCare 2009;32:1335–43.
- 5. deVeciana M. Diabetes ketoacidosis in pregnancy. Semin Perinatol. 2013 Aug;37(4):267-73.
- 8. Ketones Qualitative or Quantitative β-hydroxybutyrate (ß -OHB) Acetoacetate 1:1-10:1
- 10. Stressors Infections Inflammatory conditions Catecholamine surges Cardiac events Cocaine Medications
- 11. Stressors Infection Noncompliance New onset KitabchiAE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al. Management of hyperglycemic crises in patients with diabetes. DiabetesCare 2001;24:131–53.
- 12. Treatment Don’t just do something Stand there
- 13. What not to do
- 14. Treatments
- 15. Strategy Initial 0.9% Normal Saline LR Hypernatremia or hyperosmolarity? 0.45% NS Glucose <250mg/dL Dextrose containing fluids
- 16. v
- 17. Treatments
- 18. Plan Check level Replete if below 5.2 mEq/dL Do not start insulin until above 3.5 mEq/dL
- 19. Potassium Prospective study 82% normal or high K 63% became hypoK during therapy Significant repletion 145 mEq (59-239 mEq) Martin HE, Smith K,Wilson ML.The fluid and electrolyte therapy of severe diabetic acidosis and ketosis; a study of twenty-nine episodes (twenty-six patients).Am J Med 1958;24:376–89.
- 20. Strategy 20-40 mEq/L in crystalloid Most as KCl Rest as KPO4 or K Acetate
- 21. Treatments
- 22. Bolus? Pediatrics? NO! Adults? Maybe Lindsay R, Bolte RG. The use of an insulin bolus in low-dose insulin infusion for pediatric diabetic ketoacidosis. Pediatr Emerg Care. 1989 Jun;5(2):77-9.
- 23. Strategy 0.14 units/kg/hr 0.1 units/kg bolus 0.1 units/kg/hr Glucose 10% in first hour 0.1-0.14 units/kg bolus, continue drip Glucose 50 mg/dL/hr Glucose 250 mg/dL drip to 0.02-0.05 units/kg/hr KitabchiAE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. DiabetesCare 2009;32:1335–43.
- 24. Subcutaneous? 0.3 units/kg bolus 0.1 units/kg/hr No difference in time to resolution 39% cost savings UmpierrezGE, Latif K, Stoever J, Cuervo R, Park L, FreireAX, et al.The efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for treatment of diabetic ketoacidosis.Am J Med 2004;117:291–6.
- 25. Ersöz HO, Ukinc K, Köse M, Erem C, Gunduz A, Hacihasanoglu AB, Karti SS Subcutaneous lispro and intravenous regular insulin treatments are equally effective and safe for the treatment of mild and moderate diabetic ketoacidosis in adult patients. Int J Clin Pract. 2006 Apr;60(4):429-33. Glucose KHCO3pH OsmolalityBHB Subcutaneous
- 26. Treatments
- 27. Sodium Bicarbonate No data to suggest beneficial for acidosis May delay resolution of ketone bodies Associated with cerebral edema in children Hyperkalemia with ECG changes? Morris LR, Murphy MB, KitabchiAE. Bicarbonate therapy in severe diabetic ketoacidosis.Ann Intern Med 1986;105:836–40. ViallonA, Zeni F, Lafond P,Venet C,Tardy B, PageY, et al. Does bicarbonate therapy improve the management of severe diabetic ketoacidosis? Crit Care Med 1999;27:2690–3. Hale PJ, Crase J, Nattrass M. Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis. Br Med J (Clin Res Ed) 1984;289:1035–8. Glaser N, Barnett P, McCaslin I, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. N Engl J Med. 2001;344:264–9.
- 28. Treatments
- 29. Phosphorus Only if <1 mg/dL Tattersall RB.The history of diabetes mellitus. In: Holt RIG, Cockram CS, FlyvbergA,Goldstein BJ, editors.Textbook of diabetes. 4th ed.,West Sussex, UK:Wiley-Blackwell; 2010. p. 3–23. KitabchiAE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al. Management of hyperglycemic crises in patients with diabetes. DiabetesCare 2001;24:131–53.
- 30. Treatments
- 31. Magnesium Generally low Normalizes with standard treatment
- 32. Some words about cerebral edema Vasogenic edema secondary to reperfusion Subclinically present in many children with DKA Can happen at any time Even before treatment Mannitol or 3% NS Octreotide GlasgowAM. Devastating cerebral edema in diabetic ketoacidosis before therapy. DiabetesCare. 1991;14:77–8. Curtis JR, Bohn D, Daneman D. Use of hypertonic saline in the treatment of cerebral edema in diabetic ketoacidosis (DKA). Pediatr Diabetes. 2001;2:191–4. SeewiO,VierzigA, Roth B, Schonau E. Symptomatic cerebral oedema during treatment of diabetic ketoacidosis: effect of adjuvant octreotide infusion. Diabetol Metab Syndr. 2010;2:56. Bosnak M, Dikici B, Dogru O, Davutoglu M, Haspolat K. Somatostatin therapy in the management of resistant diabetic ketoacidosis. Diabetes Care. 2002;25:629–30.
- 33. Disposition ICU Manage in ED then admit to floor Floor with subcutaneous
- 34. Summary Diagnose W Treat Hydrate K Insulin Watch for cerebral edema
- 35. Questions?
Hinweis der Redaktion
- Nitroprusside tests for AcAc, not BOHB
- Fluid deficit 3-6L on average
- Vasopressor dependent sepsis, 53000 pts, 3365 LR, matched 1:! With NS, 19.6% mortality vs 22.8%, NNT=31LR had higher bicarb, lower chloride, 45 ptsThose with NS had longer insulin drips, 0.45% had hyponatremia
- Max oral dose recommended is 40 mEq at a time, and 100 mEq/dayIV 10mEq/hr peripherally, 20 mEq/hr central
- Mechanism unclear, may be IGF-1 related, may be glucagon related, may be both
- They can eat once pH>7.3, HCO3>18, and tolerating PO