Diabetic Ketoacidosis

Diabetic Diabetic KetoacidosisKetoacidosis

April CopeApril Cope

PharmD candidatePharmD candidate

Presentation at SUNY Presentation at SUNY DownstateDownstate

ObjectivesObjectives

Physiology and pathophysiology Physiology and pathophysiology overviewoverview

Diagnosis of diabetesDiagnosis of diabetes Types of diabetes Types of diabetes Treatment options for diabetes Treatment options for diabetes Complications of diabetesComplications of diabetes Type 1 Diabetes in detailType 1 Diabetes in detail Diabetic KetoacidosisDiabetic Ketoacidosis Patient CasePatient Case

Physiology OverviewPhysiology Overview



Diagnosis of DiabetesDiagnosis of Diabetes

Any one of the followingAny one of the following Symptoms plus RBG > 200 mg/dLSymptoms plus RBG > 200 mg/dL FPG > 126 mg/dLFPG > 126 mg/dL Two hour plasma glucose >200 mg/dL Two hour plasma glucose >200 mg/dL

during OGTduring OGT Pre-diabetesPre-diabetes

Impaired Fasting Glucose (IFG)Impaired Fasting Glucose (IFG) Impaired Glucose Tolerance (IGT)Impaired Glucose Tolerance (IGT)

Must be confirmed on a later dateMust be confirmed on a later date

Types of DiabetesTypes of Diabetes

Type 1 DiabetesType 1 Diabetes


Other Specific TypesOther Specific Types

Gestational DiabetesGestational Diabetes


EpidemiologyEpidemiology

PathophysiologyPathophysiology

Characteristics Characteristics

ScreeningScreening

Other Specific TypesOther Specific Types

Genetic DefectsGenetic Defects Beta cell functionBeta cell function Insulin actionInsulin action

DiseasesDiseases Drug/Chemical InducedDrug/Chemical Induced Infection InducedInfection Induced Immune MediatedImmune Mediated Genetic Syndromes associated with Genetic Syndromes associated with

diabetesdiabetes

Gestational DiabetesGestational Diabetes

High Risk PatientsHigh Risk Patients

Low Risk PatientsLow Risk Patients

TestingTesting

Treatment and GoalsTreatment and Goals

Treatment OptionsTreatment Options

Non-pharmacological TreatmentsNon-pharmacological Treatments

Oral medicationsOral medications

Exogenous InsulinExogenous Insulin

Non-Pharmacological Non-Pharmacological TreatmentsTreatments

Medical Nutrition TherapyMedical Nutrition Therapy

ExerciseExercise

Proper MonitoringProper Monitoring

EducationEducation

Oral MedicationsOral Medications

SulfonylureasSulfonylureas Alpha-Glucosidase InhibitorsAlpha-Glucosidase Inhibitors MeglitinidesMeglitinides ThiazolidinedionesThiazolidinediones BiguanidesBiguanides

SulfonylureasSulfonylureas

Mechanism of ActionMechanism of Action Medications AvailableMedications Available IndicationsIndications ContraindicationsContraindications Adverse EffectsAdverse Effects

Alpha-Glucosidase Alpha-Glucosidase InhibitorsInhibitors


MeglitinidesMeglitinides


ThiazolidinedionesThiazolidinediones


BiguanidesBiguanides


Exogenous InsulinExogenous Insulin

Rapid ActingRapid Acting Short ActingShort Acting Intermediate ActingIntermediate Acting Long ActingLong Acting Mixed InsulinsMixed Insulins Future PossibilitiesFuture Possibilities

Complications of Complications of DiabetesDiabetes

NeuropathyNeuropathy RetinopathyRetinopathy NephropathyNephropathy Infection and Impaired healingInfection and Impaired healing AmputationsAmputations Cardiovascular EventCardiovascular Event

NeuropathyNeuropathy

Types of NeuropathyTypes of Neuropathy Peripheral sensory neuropathyPeripheral sensory neuropathy Motor neuropathyMotor neuropathy Autonomic neuropathyAutonomic neuropathy

PathophysiologyPathophysiology Signs and SymptomsSigns and Symptoms TreatmentTreatment

RetinopathyRetinopathy

Microvascular diseaseMicrovascular disease Types of RetinopathyTypes of Retinopathy

NonproliferativeNonproliferative ProliferativeProliferative

TreatmentTreatment

NephropathyNephropathy

EpidemiologyEpidemiology Signs and SymptomsSigns and Symptoms Nephrotic SyndromeNephrotic Syndrome Further ComplicationsFurther Complications Treatment Treatment

Infection and Impaired Infection and Impaired HealingHealing

Increased InfectionsIncreased Infections

Unusual InfectionsUnusual Infections

Impaired HealingImpaired Healing

TreatmentsTreatments

AmputationsAmputations

EpidemiologyEpidemiology

PathophysiologyPathophysiology

GoalsGoals

PrognosisPrognosis

Cardiovascular EventsCardiovascular Events

AtherosclerosisAtherosclerosis Heart DiseaseHeart Disease

Heart FailureHeart Failure Myocardial InfarctionMyocardial Infarction

Peripheral Vascular DiseasePeripheral Vascular Disease Cerebral Vascular AccidentCerebral Vascular Accident


EpidemiologyEpidemiology PathophysiologyPathophysiology CharacteristicsCharacteristics ScreeningScreening TreatmentTreatment

Diabetic KetoacidosisDiabetic Ketoacidosis

PathophysiologyPathophysiology Signs and SymptomsSigns and Symptoms DiagnosisDiagnosis ComplicationsComplications TreatmentTreatment

DKA Signs and DKA Signs and SymptomsSymptoms

Clinical PresentationClinical Presentation

Laboratory DataLaboratory Data

OtherOther

DKA ComplicationsDKA Complications

Complications of associated illnessComplications of associated illness HypokalemiaHypokalemia HypoglycemiaHypoglycemia Acute pulmonary edemaAcute pulmonary edema Other complicationsOther complications

DKA Treatment DKA Treatment

Fluid AdministrationFluid Administration InsulinInsulin PotassiumPotassium Other ElectrolytesOther Electrolytes Other MedicationsOther Medications

Patient CasePatient Case

V.H. is an 18 yo BF presented to the ER on V.H. is an 18 yo BF presented to the ER on 6/29/05 with:6/29/05 with:

CC: “My stomach and back hurt”CC: “My stomach and back hurt” HPI: Abdomen & back pain x 1 day, HPI: Abdomen & back pain x 1 day,

vomiting since 12 AMvomiting since 12 AM PMH: Type 1 Diabetes Mellitus, diagnosed PMH: Type 1 Diabetes Mellitus, diagnosed

13 years ago13 years ago Family History: Non-ContributoryFamily History: Non-Contributory Social History: Non-smoker, no alcohol use, Social History: Non-smoker, no alcohol use,

no IVDA, lives with motherno IVDA, lives with mother


Allergies: NKDAAllergies: NKDA Past Medication History:Past Medication History:

Novolin R 12 units AM, 12 units PMNovolin R 12 units AM, 12 units PM

Novolin 16 units AM, 16 units PMNovolin 16 units AM, 16 units PM Vital SignsVital Signs

BP: 155/101 T: 97.7 RR: 20 P: 126BP: 155/101 T: 97.7 RR: 20 P: 126

Ht: 5’5” Wt: 125 lbs. CrCl: Ht: 5’5” Wt: 125 lbs. CrCl: 81.82 81.82

Patient CasePatient Case PE: facial grimace, dry oral mucosa, tachycardicPE: facial grimace, dry oral mucosa, tachycardic HEENT: eyes nml, ENT nml, pharynx nml, dry HEENT: eyes nml, ENT nml, pharynx nml, dry

oral mucosaoral mucosa Neck: supple, nml inspectionNeck: supple, nml inspection Resp: breath sounds nml, no respiratory distressResp: breath sounds nml, no respiratory distress CVS: RRR, heart sounds nml, tachycardiaCVS: RRR, heart sounds nml, tachycardia Abd: soft, no tenderness, nml BS, no distentionAbd: soft, no tenderness, nml BS, no distention Ext: non-tender, nml ROM, no pedal edemaExt: non-tender, nml ROM, no pedal edema Neuro: A&O x 3, mood/affect nml, CNs nml as Neuro: A&O x 3, mood/affect nml, CNs nml as

tested, no motor/sensory deficittested, no motor/sensory deficit Pain scale: 5/10, patient describes a dull, Pain scale: 5/10, patient describes a dull,

constant acheconstant ache


Lab DataLab Data

Radiologic DataRadiologic Data EKG showed sinus tachycardiaEKG showed sinus tachycardia

Patient ProblemPatient Problem

Diabetic Ketoacidosis due to urosepsisDiabetic Ketoacidosis due to urosepsis Objective dataObjective data

arterial pH = 7.324 Cl = 109 CO2= 11 arterial pH = 7.324 Cl = 109 CO2= 11

anion gap = 25 RBG = 217 K+ = 4.1anion gap = 25 RBG = 217 K+ = 4.1

arterial pCO2 = 23 UA = arterial pCO2 = 23 UA = ketones/protein/glucoseketones/protein/glucose

WBC = 14.8 ANC = 1364 EKG= sinus WBC = 14.8 ANC = 1364 EKG= sinus tachytachy

Subjective dataSubjective data

N/V, abdominal pain, normal tempN/V, abdominal pain, normal temp

Pharmacotherapeutic Pharmacotherapeutic GoalGoal

Correct anion gapCorrect anion gap Correct acidosisCorrect acidosis Prevent further production of Prevent further production of

ketonesketones Normalize lab valuesNormalize lab values Prevent complicationsPrevent complications Reduce morbidity and mortalityReduce morbidity and mortality Increase quality of lifeIncrease quality of life

Recommendations for Recommendations for TherapyTherapy

NS 1 Liter IV wide open, then 1 liter at NS 1 Liter IV wide open, then 1 liter at 125cc/hr125cc/hr

Reglan 10 mg IVPBReglan 10 mg IVPB Pepcid 20 mg IVPBPepcid 20 mg IVPB Regular Insulin 100 units in 100 mL NS, Regular Insulin 100 units in 100 mL NS,

start at 5cc/hr (0.1 units/kg/hr)start at 5cc/hr (0.1 units/kg/hr) Levofloxacin 500 mg IVPB Levofloxacin 500 mg IVPB Admit to MICU, continue IVF: D51/2NS at Admit to MICU, continue IVF: D51/2NS at

150 cc/hr, if BG <90, give D50 1 amp, do not 150 cc/hr, if BG <90, give D50 1 amp, do not stop infusion until anion gap normalizes.stop infusion until anion gap normalizes.

Recommendations for Recommendations for TherapyTherapy

6/30/05: anion gap normalized, d/c 6/30/05: anion gap normalized, d/c insulin infusion, begin subcutaneous insulin infusion, begin subcutaneous injections: NPH/regular 70/30 28 injections: NPH/regular 70/30 28 units AM and 20 units PMunits AM and 20 units PM

6/30/05: K+ = 2.5/2.8. Begin: 6/30/05: K+ = 2.5/2.8. Begin: KCl 20 mEq in 100 cc NS IVPB x 2 KCl 20 mEq in 100 cc NS IVPB x 2

doses at 2 hours apartdoses at 2 hours apart KCl 40 mEq p.o. x 2 doses at 1 hour KCl 40 mEq p.o. x 2 doses at 1 hour

apartapart

Specific Desired Specific Desired EndpointEndpoint

No anion gapNo anion gap No ketonemia or ketonuriaNo ketonemia or ketonuria No proteinuriaNo proteinuria No metabolic acidosis or respiratory No metabolic acidosis or respiratory

alkalosisalkalosis Resolution of infectionResolution of infection K+ = 3.5 – 5.0K+ = 3.5 – 5.0 Cl = 98 – 107Cl = 98 – 107 CO2 = 22 – 31CO2 = 22 – 31 FPG < 126FPG < 126 WBC = 4.8 – 10.8WBC = 4.8 – 10.8

Specific Desired Specific Desired EndpointEndpoint

Adherence with medicationsAdherence with medications Regular self-glucose monitoringRegular self-glucose monitoring No complicationsNo complications No ADRsNo ADRs Increased quality of lifeIncreased quality of life

Monitoring Parameters & Monitoring Parameters & FrequencyFrequency

ParametersParameters Blood GlucoseBlood Glucose

ElectrolytesElectrolytes

CBC w/ diffCBC w/ diff Blood GasesBlood Gases UAUA Signs & SymptomsSigns & Symptoms

FrequencyFrequency Every hour until Every hour until

controlled, then controlled, then three times dailythree times daily

Twice daily until Twice daily until normal, then once normal, then once dailydaily

Once dailyOnce daily Twice daily until Twice daily until

normal, then once normal, then once dailydaily

Once dailyOnce daily ContinuouslyContinuously

Patient CounselingPatient Counseling

Importance of medication adherenceImportance of medication adherence Proper injection techniqueProper injection technique Re-teach self-glucose monitoringRe-teach self-glucose monitoring Educate patient and family about Educate patient and family about

complicationscomplications Importance of regular MD appointmentsImportance of regular MD appointments Ways to prevent UTIsWays to prevent UTIs Q&A with patient and familyQ&A with patient and family

ReferencesReferences Julie C. Oki, William L. Isley “Diabetes Julie C. Oki, William L. Isley “Diabetes

Mellitus” Mellitus” Pharmacotherapy A Pathophysiologic Pharmacotherapy A Pathophysiologic Approach.Approach. Ed. Joseph T. Dipiro, New York, Ed. Joseph T. Dipiro, New York, McGraw Hill. Fifth Edition: 1335-1358McGraw Hill. Fifth Edition: 1335-1358

Stephen N. Davis, Daryl K. Granner “Insulin, Stephen N. Davis, Daryl K. Granner “Insulin, Oral Hypoglycemic Agents, and the Oral Hypoglycemic Agents, and the Pharmacology of the Endocrine Pancreas” Pharmacology of the Endocrine Pancreas” The The Pharmacological Basis of TherapeuticsPharmacological Basis of Therapeutics. Ed. . Ed. Alfred Goodman Gilman, New York, McGraw Alfred Goodman Gilman, New York, McGraw Hill. Tenth Edition: 1679-1714Hill. Tenth Edition: 1679-1714

www.harrisonsonline.comwww.harrisonsonline.com. July 2005. Accessed . July 2005. Accessed July 6-10, 2005July 6-10, 2005

ReferencesReferences

www.crlonline.comwww.crlonline.com. July 2005. Accessed July . July 2005. Accessed July 6-10, 20056-10, 2005

www.guidelines.govwww.guidelines.gov. July 2005. Accessed July . July 2005. Accessed July 9, 20059, 2005

www.efactsonline.comwww.efactsonline.com. July 2005. Accessed . July 2005. Accessed July 6-9, 2005July 6-9, 2005

www.cdc.govwww.cdc.gov. July 2005. Accessed July 9, 2005. July 2005. Accessed July 9, 2005 ““Management of Diabetes Mellitus” by Dr. Management of Diabetes Mellitus” by Dr.

Elaena Quattrocchi (Supplemental Lecture to Elaena Quattrocchi (Supplemental Lecture to Pharmacotherapeutics IV, Fall 2004)Pharmacotherapeutics IV, Fall 2004)

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Diabetic Ketoacidosis