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Management of Diabetic Ketoacidosis

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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

  • EKG sinus tachycardiaBMP:Na: 124K: 5.0Cl: 95CO2: 11BUN: 38Cr: 1.8 Glucose 450AST:40ALT:41Alk phos:67Arterial blood gas: pH 6.9, CO2 9, bicarb 10WBC 13K, Hb14.4 mg/dL, and Hct 43.5%.75% neutrophilsUA +glucose, +protein, -leuko esterase, -nitrite NO KETONES

    Lab Results:

  • Serum ketones test ordered is positive for beta-hydroxybutyrate

  • What would you do next?

  • Bolus 10 units insulin, then start insulin dripBolus with normal saline, then start maintenceBlood cultures, chest x-ray to rule out other sources of infection Empiric antibiotics?Bicarbonate?

  • Q2 hour BMP checks:After 6 hours:Na: 139K: 2.5Cl: 108Co2: 13BUN 28Creatinine 1.4Glucose 280ABG:pH 7.2, CO2 of 18 and a bicarb of 12

  • What do you do next?

  • Switch to 0.45% saline with potassium supplementsRepeat BMP in 4 hours:Na: 142K: 4.5Cl: 110Co2: 15BUN 38Creatinine 1.2Glucose 230

  • Start on d5 NS with K supplementsContinue insulin drip

  • Repeat BMP in 4 hours:Na: 140K: 4.0Cl: 110Co2: 23BUN 28Creatinine 1.1Glucose 105

  • 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

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