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DKA: Management and Pitfalls

DKA: Management and Pitfalls. Justin Bright, M.D. Emergency Physicians of NW Ohio February 20, 2013. Goals For Today. Definitions and characteristics of DKA Appropriate workup Treatment modalities Identify pitfalls and complications Discuss difference in adult vs. pediatric population

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DKA: Management and Pitfalls

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  1. DKA: Management and Pitfalls Justin Bright, M.D. Emergency Physicians of NW Ohio February 20, 2013

  2. Goals For Today • Definitions and characteristics of DKA • Appropriate workup • Treatment modalities • Identify pitfalls and complications • Discuss difference in adult vs. pediatric population • Management of DKA here at Henry Ford

  3. What Is DKA? • State of insulin deficiency (absolute or relative) causing dehydration, acidosis, and metabolic derangement • By blood work • Anion gap metabolic acidosis • BHOB > 5 mEq/L • Blood glucose > 250 mg/dL • pH < 7.3 • HCO3 < 18 mEq/L

  4. The Stats • DKA is reason for 50% of diabetic admissions • Tends to occur in patients less than 19 yo • Type 1 DM > Type 2 DM • Death occurs in 2% of presenting patients

  5. Causes of DKA? • Underlying Infection (40%) • Non-compliance with insulin regimen (25%) • New onset diabetes (15%) • Medical or surgical stress (20%) • AMI • Sepsis • “weak and dizzy” • Syncope • Altered mental status

  6. What Is Insulin? • Anabolic regulatory hormone • Released by pancreas (or administered as supplemental medication) in response to elevated blood sugar • Causes blood sugar to be utilized for fuel, with excess stored as muscle and fat • Inhibits release of glucagon • Inhibits gluconeogenesis and glycogenolysis

  7. Pathophysiology • Insulin deficiency • Hepatic gluconeogenesis and glycogenolysis • Fatty acid break down  ketogenesis • Byproducts: ketones (acetone, BHOB, acetoacetate) • Excess blood glucose  osmotic diuresis • BHOB induces vomiting  more dehydration • Rising acidosis  potassium shift and osmotic loss

  8. What Does DKA Look Like? • Insidious onset • Polydypsia, polyuria • Weakness, fatigue, malaise • Abdominal pain and vomiting as BOHB increases • Altered level of consciousness • May present with symptoms of their concurrent illness that triggered DKA

  9. A Case • 19 yo female in Room 115.5 • Known Hx of diabetes • CC: “One Touch Hi” • Reports being out of her insulin x 1 week • Mother reports patient is more confused and has been vomiting for 2 days

  10. What Do You Want To Know?

  11. ROS & PE • Review of Systems • Confusion • Vomiting • Frequent urination • LMP 5 weeks ago • Systems otherwise neg • Physical Exam • Tc 37.2, HR 115, BP 108/50, RR 28, SaO2 98 • Patient appears pale • Tachypneic, but not in distress • Poor skin turgor and capillary refill • No focal deficits, A/O x 3, but intermittently sleepy during questioning

  12. What Should We Order? • Diagnostics • One touch • CBC • Lytes • UA, urine preg • ABG w/ lactate • Serum Osm • B-Hob • LFTs • Lipase • EKG • ?? Imaging • Therapeutics • IVF Fluids (how much?) • Insulin (how much? Do you want to wait?) • Other meds?

  13. Labs Are Back! • WBC 14 • Na 126 • Cl 92 • HCO3 8 • BUN 30 • Cr 1.3 • K 3.7 • Glucose 786 • pH 7.12 • CO2 23 • Lactate 4.2 • B-Hob 6.2 • Osm 306 • Gap 26 • UA: large ketones and glucose • Ucg neg

  14. What Do You Think Of The Labs? • Na of 126 corrected  137 • K 3.7 (actually much lower intracellularly) • ABG  anion gap metabolic acidosis with incomplete respiratory compensation • Acute kidney injury (pre-renal dehydration) • Lots of serum B-Hob  persistent vomiting

  15. So Now What Do We Do?

  16. Treatment of DKA • ABC’s • IV, O2, Monitor • Fluids • Insulin • Correction of other electrolytes

  17. IV Fluids in DKA • Start with .9NS • If hypotensive  rapid infusion of .9NS until SBP > 80 • If normotensive  1L of .9NS in first 30 minutes, another 1L within subsequent 1 hour • Change to ½ NS • Start at 250 cc/hr and titrate to urine output of 1-2 ml/kg/hr • Change to D5 ½ NS when blood sugar is < 250 but hydration still needed

  18. Saline vs. Ringers • Must really think about patient’s electrolyte status and composition of the fluids you’re giving • Normal Saline  154 mmol/L Na; 154 mmol/L Cl- • Chloride can contribute to worsening acidosis • ½ NS has 77 mmol/L • Ringers  130 mmol/L Na; 109 mmol/L of Cl • Less Cl to contribute to acidosis • LR also promotes HCO3 formation  helps further counter acidosis

  19. Insulin Administration • Use regular (Novalin) Insulin  IV • Bolus of 10U IV prior to drip is controversial • Insulin Drip • 0.1 U/kg/hr • Stop the drip when blood glucose is 250 or lower • Goal drop in glucose is 50-100 per hr

  20. Electrolytes • Potassium • Need to watch the K levels!!!! • Patient’s are relatively K depleted • Insulin dramatically reduces K levels • Sodium • Remember that Na levels are deceptive because they are skewed by glucose levels • Bicarb • Use is controversial • Generally not indicated with pH > 7.0 • In peds patients  use is associated with higher incidence of cerebral edema

  21. More on Potassium • Beware of the “warning colors” on Careplus • If K > 6  don’t give more • If K 4.5-6  consider 10 mEq infusion with fluids • If K 3-4.5  give 20 mEq infusion with fluids • If K < 3  give K before giving insulin

  22. Why Do DKA Patients Die?

  23. Because We Kill Them!

  24. How Do We Kill DKA Patients? • Cerebral Edema • Poor ventilator management • Not respecting the K levels • Not monitoring glucose levels enough • CHF from over-aggressive fluid administration

  25. Cerebral Edema in DKA • Occurs almost exclusively in patients < 20 yo • Mortality approaches 40% • Correlation with HCO3 administration • Causes paradoxical cerebral acidosis as lipid soluble CO2 crosses blood-brain barrier • Initial symptom is headache • Onset 12-24 hrs from treatment onset • Rapid deterioration of mental status

  26. What Do You About It? • Manage airway • Immediate head CT • Neurosurg consult • Do whatever you can to prevent herniation • mannitol • Pray!

  27. Ventilator Management • Must communicate with the RT about vent settings! • Keep in mind patient’s metabolic status • If RR set to low  will develop worsening acidosis • Must try to set RR to match their natural compensatory mechanisms

  28. How Do We Prevent Electrolyte Catastrophes? • Hourly one touches • Frequent rechecks of lytes and ABG • Utilize the DKA protocol tab on our order set

  29. Disposition • In a perfect world  all patients go to MICU • In our world • Boarding patients for excessive periods of time • May do a much larger portion of the acute/critical management than in other EDs • How do we know who can go to floor? • Closure of anion gap • Persistent glycemic control • K corrected • Mental status normal • Tolerating PO

  30. Pediatric Considerations • Literature suggests 10 cc/kg boluses instead of 20 cc/kg • Cerebral edema is more likely to occur • More likely to have DKA as initial presentation of their diabetes

  31. Milwaukee Formula • 1st hour • 10 – 20 cc/kg bolus of NS • Monitor neuro status • Insulin drip 0.05-0.1 U/kg/hr • 2nd hr – resolution • ½ NS (85 ml/kg + maintenance) – initial bolus over next 23 hrs • Continue insulin drip until BS < 250 • Potassium supplementation

  32. Moral of the Story • You will see a lot of DKA patients at HF • You may be in charge of their management for a long period of time • You don’t have to rapidly correct the metabolic derangements • Beware of changes in glucose and K levels • Fear cerebral edema • Beware of ventilator induced death

  33. Questions/Comments? Thank You!

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