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 - PowerPoint PPT Presentation
Text of Management of Diabetic Ketoacidosis
Management of Diabetic Ketoacidosis
ObjectivesManagement of DKA:1) Fluids2) Insulin3) Electrolyte replacement
Management: FluidsGlucose osmotic diuresis causes dehydrationGive between 4-6 liters, then reassess (caution in CHF)Fluids help decrease the blood glucose levelsAlways start with NSBolus and then steady rate (i.e. 150cc/hr)Switch to 0.45% NS when corrected sodium within normal limitsAdd 1.6 mEq to sodium for every 100 glucose is above 100.Switch to D5 1/2NS when glucose between 200-250
Management: InsulinIV insulin dripbolus approx 10 units (or .1unit/kg), then initiate drip at 0.1 unit/kg/hrAvoid bolus if K
Management: Electrolyte ReplacementBicarbonate:If pH6 with ECG changesPotassium: If potassium
Overall ManagementBe sure to check q1hour glucose checks and q2-4hrs bmp to monitor anion gap and acidosis
CASEA 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 membranesCV: tachycardic, normal s1, s2. No murmursLung: CTABAbdomen: +bs, non distended, slight tenderness to deep palpation, no HSM no rebound or guardingExt: no cyanosis, clubbing or edema
What labs do you want to order?
CMPComplete blood count with differential Urinalysis and urine ketones by dipstickArterial blood gas
Continue insulin dripStart 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 PointsClose 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
**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)*Lispro is a great sliding scale insulin for patients with renal insufficiency as it does not stack like insulin and decreased risk of hypoglycemia.*Bicarbonate helps drive potassium into cells ( H/K atpase channels)UTD states only tx phos if