DKA Management Summary for Dept

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DKA Management Summary for Dept

  1. 1. DKA summary for dept<br />Dr G R Letchuman<br />
  2. 2. Blood ketone testing> urine<br />ADA. Tests of glycaemia. Diabetes Care 2003:26(supp.1)S106-8<br />> sensitive than urine ketone<br />Assist in decision making for admission and discharge.<br />S. Beta-hydroxybutyrate ≥ 3.8mmol/l maybe superior than HCO3Diabetes Care 31:643-647,2008<br />When glucose ≥16.7<br />
  3. 3. sodium<br />Na+ = 127<br />(+1.6 for every 5.5mmol rise above 5.5) <br />Corrected Na+ = 127 + (30.3-5.5)/5.5 X 1.6 = 134 mmol/l<br />What about serum osmolality?<br />
  4. 4. Serum osmolality<br />Osmolality = 2(Na+ + K+) + glucose + urea<br />This patient = 2(134 + 3.3) + 30.3 + 6.9 = 311.8<br />
  5. 5. Coma in HHS/DKA<br />Conscious level correlates to serum osmolality. Diabetes Care 3:53-56,1980, Arch Intern Med 157:669-675,1997<br />If osmolality < 320, look for other causes.<br />
  6. 6. Therapy :<br />Fluid<br />Insulin<br />Potassium<br />Underlying precipitating factor<br /><ul><li>MONITORING!</li></li></ul><li>ADA:Fluid therapy :<br />1st hour : 0.9% NaCl 15-20ml/kg (50kg~1L)<br />Then : 0.45% NaCl 4-14ml/kg/hr (50kg~500mls/hr) if corrected S. Na+ is normal or high<br />Use 0.9% NaCl if corrected S Na+ is low<br />Beware in renal or cardiac failures<br />
  7. 7. ADA: Insulin therapy<br />Once hypokalemia K+ < 3.3 is ruled out,<br />Bolus I/V S. insulin 0.1/kg *<br />Then S. insulin infusion 0.1/kg/hr<br />Glucose reduction - 3-4 mmol/l per hour<br />If above not achieved, increase every hour <br />
  8. 8. ADA: Potassium<br />Total body depletion<br />Insulin, correction of acidosis & volume expansion decreases potassium<br />Start K+ when serum < 5.3 & adequate urine output ~50ml/hr.<br />Generally 1.0 – 1.5 g KCL in 500 mls.<br />If first K+<3.3, Correct with K+ & fluids. Delay insulin therapy until K+>3.3 <br />Check electrolytes every 2 -4 hours<br />
  9. 9. ADA :Bicarbonate <br />Bicarbonate therapy did not alter recovery outcomes in adults with moderate DKA (pH 6.9-7.14). Kitabchi, Abbas E.; Umpierrez, Guillermo E.; Fisher, Joseph N.; Murphy, Mary Beth; Stentz, Frankie B.<br />< 6.9 prudent to treat but be careful of hypokalemia.<br />100 mmol sodium bicarbonate in 400 ml an isotonic solution with 20 mEq KCl administered at a rate of 200 ml/h for 2 h until the venous pH is >7.0. <br />
  10. 10. ADA: Glucose < 11mmol/l :<br />5%DW +/- 0.45%NaCl at 150-250ml/hr (~500mls every 2 -3 hrs)<br />Insulin 0.05-0.1/kg/hr (2-5 unit per hour)<br />KCL in drip as previous<br />Keep glucose 8-11mmol/l<br />Monitor BUSE & glucose 2-4 hourly until stable<br />
  11. 11. Once patient able to eat…<br />Change to basal bolus regime<br />Dose will depend on previous dose required.<br /> Continue insulin infusion for 1-2 hours after s/c insulin. (consider s/c basal early)<br />
  12. 12. Complications:<br />hypoglycemia and hypokalemia due to overzealous treatment with insulin<br />Cerebral edema is a rare but frequently fatal complication of DKA <br />noncardiogenic pulmonary edema <br />
  13. 13. Key points:<br />Infection (30-40 percent)<br />Effective Posm = [2 x Na (mmol/L)] + glucose (mmol/L)<br />Water loss =100ml/kg<br />
  14. 14. New in NICE <br />Measurement of blood ketones, venous (not arterial) pH and bicarbonate and their use as treatment markers<br />Replacing ‘sliding scale’ insulin with weight-based fixed rate intravenous insulin infusion i.e. 0.1Units /kg IVII)<br />Monitoring of electrolytes on the blood gas analyser with intermittent laboratory confirmation<br />Continuation of long acting insulin analogues (Lantus® or Levemir®) as normal<br />Do not use a priming dose (bolus) of insulin<br />
  15. 15. New in NICE -Metabolic treatment targets<br />Reduction of the blood ketone concentration by 0.5 mmol/L/hour<br />Increase the venous bicarbonate by 3 mmol/L/hour<br />Reduce capillary blood glucose by 3 mmol/L/hour<br />Potassium should be maintained between 4.0 and<br />5.0 mmol/L<br />0.9% sodium chloride solution is the recommended fluid of choice<br />Subcutaneous long-acting analogue insulin should be continued<br />
  16. 16. Accurate fluid balance chart, minimum urine output 0.5ml/kg/hr<br />Give low molecular weight heparin<br />Continue fixed rate IVII until ketones less than 0.3 mmol/L, venous pH over 7.3 and/or venous bicarbonate over 18mmol/L<br />
  17. 17. Severe DKA :<br />Blood ketones over 6 mmol/L<br />Bicarbonate level below 5 mmol/L<br />Venous/arterial pH below 7.1<br />Hypokalaemia on admission (under 3.5 mmol/L)<br />GCS less than 12<br />Oxygen saturation below 92% on air (assuming normal baseline respiratory function)<br />• Systolic BP below 90 mmHg<br />• Pulse over 100 or below 60 bpm<br />• Anion gap above16 [Anion Gap = (Na+ + K+) – (Cl- + HCO3-) ]<br />
  18. 18. Pitfalls:<br />Delay in tracing electrolytes & hence K+ replacement<br />Inadequate fluids<br />Not correcting Na+<br />Dependence on sliding scale<br />Non overlap of insulin infusion & S/C insulin<br />Inadequate intensive MONITORING<br />

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