You’re TOO Sweet! DKA Emergency w/Marc Probst, MD

youre too sweet

“I find it very gratifying to treat because you can see the effects of your treatment right in front of your eyes. And your patients can go from very sick to well within a matter of hours.” – Marc Probst, MD

Who is Marc Probst, MD?

Bio Pic
Courtesy of Marc Probst, MD

Marc Probst, MD, MS is an Academic Emergency Physician at The Mount Sinai Hospital in New York City.

Dr. Probst is funded by a career development grant from the National Institutes of Health (NIH).

His interests include syncope, shared decision-making, and Halloween.

Twitter @probstMD

 

Diabetic Ketoacidosis (DKA)

Biochemical Findings

  • Hyperglycemia
  • Ketosis
  • (High anion gap) Metabolic Acidosis

Parameters to treat DKA

  • Blood glucose >250mg/dL
  • Elevated anion gap w/albumin adjustment >10
  • Serum bicarbonate <18mEq/L
  • *Positive serum/urine ketones
  • pH <7.3

Causes

  • Lack of insulin
    • Poorly controlled DM
      • Barriers include access, insurance, expensive, etc.
    • Undiagnosed DM
    • Disasters
  • Infection
    • Mesenteric Ischemia
  • Cardiac (MI)
  • Intoxication (cocaine, ETOH)
  • Iatrogenic (steroids, HCTZ, SGLT2, antipsychotics)
  • CVA
  • Pregnancy
  • Hyperthyroidism
  • Click here for a nice review at emdocs

Ketosis vs. DKA

  • Pt can have an elevated blood glucose but not in DKA
  • See if they really are acedotic first – check for ketones
    • Ex: blood glucose 500+, pH 7.4, no ketones in serum/urine
  • Look at baseline labs (compare history)
    • Ex: Renal failure patients can live in a lower pH

Euglycemic DKA

  • Normal blood glucose
  • Has Anion gap

What’s the worse that can happen?

  • Cerebral Edema (documented in Pediatrics)
  • Death
    • 1% mortality rate and a 5% mortality rate for elderly

Symptoms

  • Nausea/Vomiting (can cause mixed acid-base disorder)
    • Combination of metabolic acidosis and metabolic alkalosis
  • Abdominal Pain
  • Altered Mental Status/Confusion
  • Frequent Urination
  • Excessive Thirst
  • Weakness/Fatigue
  • Respiratory Status – Kussmal respirations (fruity breath)- tachypnea to blow off CO2
    • Mental status
    • If they are intubated, want to match RR to pre-intubation status
  • Bipap? -Consider High flow nasal cannula to maximize “blowing off CO2.”
    • Look at respiratory drive to determine airway intervention
  • Dehydration
    • Dehydration & electrolyte imbalances due to osmotic diuresis
    • Glucose-mediated osmotic diuresis
    • Nausea and vomiting
    • Poor PO intake.

Work-Up

POCT Blood Glucose
POCT Urinalysis
Labs
  • VBG
    • ABGs are unnecessary
    • VBGs are a more accurate representation of what is going on in the tissues
  • Chemistry Panel including Mg & P
  • Urinalysis
Add. Labs/Diagnostics if you suspect underlying cause, etc.
  • Serum ketones (suspect/known anuria secondary to dehydration or renal failure)
  • Troponin
  • EKG
  • Blood/Urine Cultures (suspect infection)
  • Lactate Level (suspect infection)

Anion Gap

  • What is an Anion Gap?
    • Too many unmeasured anions causes metabolic acidosis.
    • Etiologies of increase organic acids:
      • MUDPILES: methanol, metformin, uremia, diabetic ketoacidosis, ethylene glycol, salicylates, and starvation.
      • ESKD
  • What’s a normal anion gap?
    • 3-11mEq/L
  • Hypoalbuminemia affecting anion gap calculation – adjust for albumin
    • Albumin is a major source of unmeasured anions and clinically significant for treatment
    • A drop in albumin by 10 g/L will cause the anion gap to fall ~ 2.5mEq/L at constant pH

Management –  Lots of Nursing (Step-down or ICU)

  • Telemonitoring
  • Hourly fingersticks
  • VBG/BMP every 1-2 hours
    • In my own clinical practice I don’t find hourly labs to be useful
  • Mental Status & Respiratory status
  • Adjust Insulin Drip
  • Watch out for Hypokalemia and Hypoglycemia (Clinical Pearl!)

Management = Fluids, Insulin, Electrolytes

Fluids

  • How much Fluids? How aggressive? What’s the concern? (Controversial in Pediatrics!)
  • IV fluids
    • NS 0.9% saline, 1L/hr for the first 2 hours
    • If hypernatremic, switch to NS 0.45% saline at 250-500mL/hr
      • Trend Na+
    • When BG falls to 250mg/dL, D5 1/2 NS at 100-250mL/hr
  • Renal Failure patients will still need fluids but be careful on how much you’re giving to prevent fluid overloading esp. with pts who don’t produce urine anymore.
  • Some argue that Plasmalyte is the fluid of choice over Normal Saline.

Insulin

Do NOT start an insulin drip without first confirming Potassium (K) level! (Clinical Pearl!)

K 3.3 or higher before starting an insulin drip. (Clinical Pearl!)

Insulin drip

  • No insulin bolus is needed prior to starting insulin drip (not really controversial)
    • Currently against ADA recommendation in Adults
    • Studies have shown there’s no additional benefit with insulin bolus
  • ADA does not recommend insulin bolus for pediatric population
    • Concern that serum glucose will drop too quickly
  • Click here for more nerdy information about this at REBEL EM
  • Insulin Drip Goals
    • Keep BG 150-200 and close anion gap
    • Go slowly – too fast of a correction can cause complications
    • 50-75 mg/dL per hour
  • Dosage
    • 0.1 U/kg/hr continuous infusion
    • Increase dosage if you are not achieving a drop between 50-75mg/dL per hour
    • Increase to 0.14-2 U/kg/hr

How to transition off insulin drip

  • Targets:
    • Anion Gap normalizes 12 or less
    • Serum glucose <200mg/dL
  • Unreliable Targets:
    • pH > 7.3
    • Serum bicarbonate >16-18mEq/L
  • Administer:

Complications while on insulin drip:

  • Hypoglycemia (Keep BG 150-200)
  • Hypokalemia (insulin pushes potassium into cells)
    • See below on how to prevent hypokalemia while on insulin drip
    • Replete potassium

Electrolytes

Potassium
  • Check K level prior to insulin drip administration – correct hypokalemia prior to administering insulin drip
    • K 3.3 or higher needed to start an insulin drip
  • Potassium Replacement
    • Serum K <3.5 give 40mEq in next hour
    • Serum K 3.5-5.0 give 20mEq in next hour
    • Serum K >5.0 no K replacement
    • Consider the route! There is a limit on how much potassium you can infuse/administer per hour based on route.
      • PO 40mEq/hour
      • Peripheral IV 10mEq/hour
      • Central Line 20mEq/hour
      • *Know your institution’s policies
    • I like Sal’s easy chart in REBEL EM here!
    • You can give both PO and IV at the same time if needed.
    • *Renal Failure Patients don’t need K replacements.
  • Preventing hypokalemia while on insulin drip
    • Give K replacement when starting drip and monitor serum potassium first 4-6 hours of therapy
  • Thoughts:
    • Check Renal Function (BUN, Creatinine)
    • Is this a known renal failure patient? On HD? Last HD?
      • Are we doing anything differently in these patients?
        • Don’t need K replacement
        • Watch amount of fluid
        • Consider dialysis
Hyponatremia
  • Already correcting w/fluids
  • Add 2 mmol/L for every 100 over 100 glucose. Was 1.6. Now using 2.4 as correction factor.
    • Ex: Sodium is 130. The glucose is 500. What is corrected sodium? 130 + 8 =138.
Magnesium
  • Generally low
  • Helps kidney retains potassium
  • Marc Probst, MD likes to give 2gm right off the bat
Phosphate
  • Generally not corrected in the ED
Sodium Bicarbonate Drip (VERY controversial!)

Expected Outcomes

  • Mental status (should improve)
  • Respirations (should improve)
  • Abnormal lab values (should improve)

When can my patient eat?

  • Once DKA has resolved
  • On insulin sliding scale

Cerebral Edema

Symptoms

  • Headache
  • Altered Mental Status
  • Lethargy
  • Seizures

Treatment

  • Hob elevated to 30 degrees
  • Mannitol
  • Intubation if airway is a concern
  • CT Scan/MRI

Disposition/ED Throughput

These patients are admitted to a step-down or an ICU unit for the amount of nursing required. Once the anion gap has closed and remains closed, and your patient is STILL in the ED – talk to the provider and consider changing the bed assignment (Med Surg) if you’re still boarding this patient.

Final Thoughts

  • Know your institution’s protocol.
  • If you don’t have one, consider developing one!
  • DKA treatment protocol have shown to have better patient outcomes.
References:
Books
Journals/Research
  • http://cjasn.asnjournals.org/content/2/1/162.full
  • https://www.ncbi.nlm.nih.gov/pubmed/11369334
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