“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?

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

• VBG
  • ABGs are unnecessary
  • VBGs are a more accurate representation of what is going on in the tissues
• Chemistry Panel including Mg & P
• Urinalysis

• Serum ketones (suspect/known anuria secondary to dehydration or renal failure)
• Troponin
• EKG
• Blood/Urine Cultures (suspect infection)
• Lactate Level (suspect infection)

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!)
  • New RCT trial coming out comparing aggressive vs. gentle fluid resuscitation in Pediatric population w/DKA.
  • Nathan Kuppermann from UC-Davis is the PI on that study.
  • Concern for Cerebral Edema
  • Not an issue in Adult population. Aggressive fluid resuscitation is OK in adults.
• 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.
  • It’s more expensive than using NS
  • If you have a good DKA protocol using NS and insulin – most of your patients will benefit just fine.
  • Click here to read Josh Farkas of PulmCrit’s argument

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:
  • Keep blood glucose between 150-200mg/dL
  • Decrease insulin drip 50% when BG 250
    • 0.5 U/kg/hr
  • IV fluids w/dextrose
  • Long acting Insulin subcutaneous: Overlap 1-2 hours w/drip and then stop drip once the anion gap closes (Clinical Pearl!)
  • Click here for more nerdy stuff on transitioning off insulin drips at the Daily Bolus
  • Why is this important?
    • Pt can go back into DKA

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

• 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

• 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.

• Generally low
• Helps kidney retains potassium
• Marc Probst, MD likes to give 2gm right off the bat

• Generally not corrected in the ED

• When should we be using a bicarb drip?
  • ADA recommends to start a bicarb drip when pH <7.0
• Personally, I’m NOT a fan of sodium bicarbonate drips to treat ketoacidosis (Against ADA recommendation). Here’s why:
  • Bicarb not routinely recommended for DKA regardless of severity of acedemia
    • No real benefit in treating DKA
    • No significant rise in pH
    • Potential for harm
  • Bicarb drip associated with cerebral edema in pediatric population
  • Use as last ditch effort because pH is in the toilet?! Yes, fine. At this point, pH 6.8/6.7 – it’s crappy – ok to hang the drip!
    • MD will probably order it.
    • Anticipate infusing.
    • No good studies for very low pH and bicarb drip.
    • Remember! There may be an underlying cause that may benefit from a bicarb drip.
  • ALWAYS treat underlying cause.
• Click here to read more on REBEL EM’s take on sodium bicarbonate drips and DKA?
• Click here for Anand Swaminathan “Swami’s” take
• Click here for Josh Farkas of Pulm Crit’s application of sodium bicarbonate drip (but not what you think)

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

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

• Marino, P. L., & Gast, P. (2014). The ICU book. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
• Nyce AL, Lubkin CL, Chansky ME. Diabetic Ketoacidosis. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109443771.

Journals/Research

• https://clinicaltrials.gov/ct2/show/NCT00629707?cond=pediatric+dka&rank=1
  • Nathan Kuppermann from UC-Davis is the PI on that study.

FOAMed

• https://www.mdcalc.com/anion-gap
• https://lifeinthefastlane.com/ccc/anion-gap/
• http://rebelem.com/benefit-initial-insulin-bolus-diabetic-ketoacidosis/
• http://rebelem.com/benefit-sodium-bicarbonate-dka/
• http://www.emdocs.net/myths-dka-management/
• https://thedailybolus.com/2017/07/11/transitioning-off-insulin-infusions-in-patients-with-dka/
• http://www.emdocs.net/myths-dka-management/
• https://emcrit.org/pulmcrit/four-dka-pearls/
• http://www.emdocs.net/diabetic-ketoacidosis-sneaky-triggers-clinical-pearls/

Now Listen to the Episode…

Cite this post as:

Podcast: Play in new window | Download

Subscribe: RSS