DKA Concepts and Management

8/7/2019 DKA Concepts and Management

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Dr Samreen Sheikh

MANAGEMENT OF

DIABETICKETOACIDOSIS


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Pathophysiology of DKA

A collection of severe and potentially life-

threatening metabolic disturbances: Hyperglycemia Osmotic diuresis

Urinary loss of fluids & electrolytes ECFv contraction

Depletion of total body K+ stores

(even though may be hyperkalemic 2 to cell

shift d/t insulin deficiency and acidosis)

Ketone production Metabolic acidosis

Compensatory Respiratory alkalosis (hopefully)

Uncontrolled lipolysis severe o TG


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DKA risk factors

Type 1 DM 1st presentation

Acute-illness

Insulin omission (inappropriate sick-day management,

noncompliance, Eating Disorders)

Type 2 DM During stress

Ethnicity: African-American, Hispanic

Extremes of age Poor glycemic control


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DKA: Precipitating Factors

Acute illness(MI, trauma,pancreatitis)

New-onset DM

Insulin omission

Infections

10-20%

5-39%

33%

20-38%


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DKA: Diagnosis

Symptoms & Signs: Polyuria, polydipsia

Fatigue

Nausea,vomitting, abdominal pain(may simulateacutevabdomen)

q ECFv(increase heart rate,hypotention,dry mucous membran

decrease skin turgor,

Kussmauls( deep) respiration, Acetone (fruity) breath, mild

impairment in cognition


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1st Step: Confirm diagnosis

Diabetes: RBS > 250 mg% (occasionally

normal or only mild o BS)

Ketones: Raised serum ketones (and urine

ketones)

Acidosis: pH < 7.3, serum HCO3 < 15mEq/L, AG > 14 mM


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2nd Step: Admit

Admit to hospital

Intensive-care setting may be necessaryfor frequent monitoring or if pH < 7.00 or

unconscious


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Goals of DKA Management

1. Replace Fluids

2. Halt Ketogenesis and Correct Acidosis

3. Maintain Acid-Base and Electrolyte

Balance

4. Identify & Treat Underlying Cause(s)

Note: Maintainance of euglycemia is not the

sole target of Insulin Infusion in DKA


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1st Goal ofManagement:

Repletion of ECV and ICV

Why?

There is Extracellular and Intracellularvolume loss due to Osmotic Diuresis


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1st Goal ofManagement:

Repletion of ECV and ICV

Choice of Fluids:

23 L of0.9% saline over first 13 h (1015

mL/kg per hour)

subsequently, 0.45% saline at 150300 mL/h

change to 5% glucose and 0.45% saline at

100200 mL/h when plasma glucose reaches

250 mg/dL (14 mmol/L).


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2nd Goal ofManagement:

Halt the Process of Ketosis; Roleof Insulin and Simultaneous

Dextrose Infusion

Administer short-acting insulin: IV (0.1 units/kg) or IM (0.3

units/kg)

Then 0.1 units/kg per hour by continuous IV infusion,

increase 2- to 3- fold if no response by 24 h

Adjust rate of Insulin to achieve 30 - 50 mg% / hour

decrase in RBS


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3rd Goal ofManagement:

Maintain Acid-Base and ElectrolyteBalance

Maintenance of Normokalemia Correction of Acidosis via Bicarbonate

Replacement


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Maintenance of Normokalemia

K+ defecit: 3-5 mEq/Kg (350 mEq for 70Kg)

Normal to high serum K+

K+

K+

H+ H+

Ketoacidosis

Insulin


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DKA: Potassium

Overall, K+ deficit 3-5 mEq/kg (350 mEq in 70kg)

Need K+ with initial IV fluid & insulin Rx unless:

Anuric

K > 5.5 mEq/L or hyperkalemic ECG changes

Initial [K] Replacement

>5.5 mEq/L nil (initially)

5.2-5.5 mEq/L 10 mEq/h4-5.2 mEq/L 20 mEq/h

3-4 mEq/L 30 mEq/h

< 3 mEq/L 40 mEq/h

>20 mEq/h:

With Cardiac monitor

Via Central line


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Additional electrolyte replasement

PHOSPHATE

Required only if phosphate


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Correction of Acidosis viaBicarbonate Replacement

The ADA advises bicarbonate [50 mmol/L (meq/L) ofsodium bicarbonate in 200 mL of sterile water with 10

meq/L KCl over 1 h if pH = 6.97.0

or 100 mmol/L (meq/L) of sodium bicarbonate in 400 mLof sterile water with 20 meq/L KCl over 2 h if pH < 6.9].


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Monitoring via Flow Chart

time VS UOP pH HcO

3

AG keto

nes

Glc K PO4 IVF insu

lin


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Transition from insulin infusion to

subcutaneous insulin Can consider switch to SC insulin when:

AG normalized

BS < 270 mg%

Insulin IV requirements < 2U/h Patient able to eat

Overlap insulin IV infusion with 1st SC insulin

by 2-4h to avoid recurrent ketosis

Type 2 DM patients with DKA: Dont necessarily have to be d/c on insulin SC (Type I

DM do require Insulin for life)

Once acute stress resolved, many do well on Oral Anti-

Diabetic medictaions


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4th Goal ofManagement:

Identify &T

reat UnderlyingCause(s)

Antibiotics for infection

Appropriate Cultures and Infection screen Look forOccult Abscess

Rule out ACS


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4th Goal ofManagement:

Identify &T

reat UnderlyingCause(s)

Counselling for:

Non-compliance Appropriate monitoring of blood glucose

during stress

Adequate increase in Insulin, if in any stress

Addressing cost issues

Proper storage and insulin administration

technique


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Thank You

Documents

DKA Concepts and Management