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Diabetic Ketoacidosis
Myths, Misconceptions, and Mismanagement
Justin Hensley, MD
Assistant Professor of Emergency Medicine
Texas A&M Health Science Center/CHRISTUS Spohn
Disclosures None
What is DKA?
Excess insulin antagonism Insulin deficiency
Lipolysis Hyperglycemia
Ketogenesis
Acidosis
Dehydration
Electrolyte abnormalities
deVeciana M. Diabetes ketoacidosis in pregnancy. Semin Perinatol. 2013 Aug;37(4):267-73.
Levels
Mild
 pH >7.25
 HCO3 15-18
Moderate
 pH 7-7.24
 HCO3 10-15
Severe
 pH <7
 HCO3 <10
KitabchiAE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. DiabetesCare 2009;32:1335–43.
deVeciana M. Diabetes ketoacidosis in pregnancy. Semin Perinatol. 2013 Aug;37(4):267-73.
Workup
Glucose
Ketones
pH
Identify stressor
Glucose
>250 mg/dL
>600 mg/dL
 HHS
Ketones
Qualitative or Quantitative
β-hydroxybutyrate (ß -OHB)
Acetoacetate
1:1-10:1
pH
VBG>ABG
CBG
Venous pH
Stressors
Infections
Inflammatory conditions
Catecholamine surges
 Cardiac events
 Cocaine
Medications
Stressors
Infection
Noncompliance
New onset
KitabchiAE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al. Management of hyperglycemic crises in patients with diabetes. DiabetesCare 2001;24:131–53.
Treatment
Don’t just do something
Stand there
What not to do
Treatments
Strategy
Initial
 0.9% Normal Saline
 LR
Hypernatremia or hyperosmolarity?
 0.45% NS
Glucose <250mg/dL
 Dextrose containing fluids
v
Treatments
Plan
Check level
Replete if below 5.2 mEq/dL
Do not start insulin until above 3.5 mEq/dL
Potassium
Prospective study
82% normal or high K
63% became hypoK during therapy
Significant repletion
 145 mEq (59-239 mEq)
Martin HE, Smith K,Wilson ML.The fluid and electrolyte therapy of severe diabetic acidosis and ketosis; a study of twenty-nine episodes (twenty-six patients).Am J Med 1958;24:376–89.
Strategy
20-40 mEq/L in crystalloid
Most as KCl
 Rest as KPO4 or K Acetate
Treatments
Bolus?
Pediatrics?
 NO!
Adults?
 Maybe
Lindsay R, Bolte RG. The use of an insulin bolus in low-dose insulin infusion for pediatric diabetic ketoacidosis. Pediatr Emerg Care. 1989 Jun;5(2):77-9.
Strategy
0.14 units/kg/hr
0.1 units/kg bolus
 0.1 units/kg/hr
Glucose 10% in first hour
 0.1-0.14 units/kg bolus, continue drip
Glucose 50 mg/dL/hr
Glucose 250 mg/dL
 drip to 0.02-0.05 units/kg/hr
KitabchiAE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. DiabetesCare 2009;32:1335–43.
Subcutaneous? 0.3 units/kg bolus
0.1 units/kg/hr
No difference in time to resolution
39% cost savings
UmpierrezGE, Latif K, Stoever J, Cuervo R, Park L, FreireAX, et al.The efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for treatment of diabetic
ketoacidosis.Am J Med 2004;117:291–6.
Ersöz HO, Ukinc K, Köse M, Erem C, Gunduz A, Hacihasanoglu AB, Karti SS Subcutaneous lispro and intravenous regular insulin treatments are equally effective and safe for the treatment of
mild and moderate diabetic ketoacidosis in adult patients. Int J Clin Pract. 2006 Apr;60(4):429-33.
Glucose
KHCO3pH
OsmolalityBHB
Subcutaneous
Treatments
Sodium
Bicarbonate
No data to suggest beneficial for acidosis
 May delay resolution of ketone bodies
Associated with cerebral edema in children
Hyperkalemia with ECG changes?
Morris LR, Murphy MB, KitabchiAE. Bicarbonate therapy in severe diabetic ketoacidosis.Ann Intern Med 1986;105:836–40.
ViallonA, Zeni F, Lafond P,Venet C,Tardy B, PageY, et al. Does bicarbonate therapy improve the management of severe diabetic ketoacidosis? Crit Care Med 1999;27:2690–3.
Hale PJ, Crase J, Nattrass M. Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis. Br Med J (Clin Res Ed) 1984;289:1035–8.
Glaser N, Barnett P, McCaslin I, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. N Engl J Med. 2001;344:264–9.
Treatments
Phosphorus Only if <1 mg/dL
Tattersall RB.The history of diabetes mellitus. In: Holt RIG, Cockram CS, FlyvbergA,Goldstein BJ, editors.Textbook of diabetes. 4th ed.,West Sussex, UK:Wiley-Blackwell; 2010. p. 3–23.
KitabchiAE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al. Management of hyperglycemic crises in patients with diabetes. DiabetesCare 2001;24:131–53.
Treatments
Magnesium
Generally low
Normalizes with standard treatment
Some words
about cerebral
edema
Vasogenic edema secondary to reperfusion
Subclinically present in many children with DKA
Can happen at any time
 Even before treatment
Mannitol or 3% NS
Octreotide
GlasgowAM. Devastating cerebral edema in diabetic ketoacidosis before therapy. DiabetesCare. 1991;14:77–8.
Curtis JR, Bohn D, Daneman D. Use of hypertonic saline in the treatment of cerebral edema in diabetic ketoacidosis (DKA). Pediatr Diabetes. 2001;2:191–4.
SeewiO,VierzigA, Roth B, Schonau E. Symptomatic cerebral oedema during treatment of diabetic ketoacidosis: effect of adjuvant octreotide infusion. Diabetol Metab Syndr. 2010;2:56.
Bosnak M, Dikici B, Dogru O, Davutoglu M, Haspolat K. Somatostatin therapy in the management of resistant diabetic ketoacidosis. Diabetes Care. 2002;25:629–30.
Disposition
ICU
Manage in ED then admit to floor
Floor with subcutaneous
Summary
Diagnose
 W
Treat
 Hydrate
 K
 Insulin
Watch for cerebral edema
Questions?

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Diabetic Ketoacidosis

  • 1. Diabetic Ketoacidosis Myths, Misconceptions, and Mismanagement Justin Hensley, MD Assistant Professor of Emergency Medicine Texas A&M Health Science Center/CHRISTUS Spohn
  • 3. What is DKA? Excess insulin antagonism Insulin deficiency Lipolysis Hyperglycemia Ketogenesis Acidosis Dehydration Electrolyte abnormalities deVeciana M. Diabetes ketoacidosis in pregnancy. Semin Perinatol. 2013 Aug;37(4):267-73.
  • 4. Levels Mild  pH >7.25  HCO3 15-18 Moderate  pH 7-7.24  HCO3 10-15 Severe  pH <7  HCO3 <10 KitabchiAE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. DiabetesCare 2009;32:1335–43.
  • 5. deVeciana M. Diabetes ketoacidosis in pregnancy. Semin Perinatol. 2013 Aug;37(4):267-73.
  • 8. Ketones Qualitative or Quantitative β-hydroxybutyrate (ß -OHB) Acetoacetate 1:1-10:1
  • 11. Stressors Infection Noncompliance New onset KitabchiAE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al. Management of hyperglycemic crises in patients with diabetes. DiabetesCare 2001;24:131–53.
  • 12. Treatment Don’t just do something Stand there
  • 15. Strategy Initial  0.9% Normal Saline  LR Hypernatremia or hyperosmolarity?  0.45% NS Glucose <250mg/dL  Dextrose containing fluids
  • 16. v
  • 18. Plan Check level Replete if below 5.2 mEq/dL Do not start insulin until above 3.5 mEq/dL
  • 19. Potassium Prospective study 82% normal or high K 63% became hypoK during therapy Significant repletion  145 mEq (59-239 mEq) Martin HE, Smith K,Wilson ML.The fluid and electrolyte therapy of severe diabetic acidosis and ketosis; a study of twenty-nine episodes (twenty-six patients).Am J Med 1958;24:376–89.
  • 20. Strategy 20-40 mEq/L in crystalloid Most as KCl  Rest as KPO4 or K Acetate
  • 22. Bolus? Pediatrics?  NO! Adults?  Maybe Lindsay R, Bolte RG. The use of an insulin bolus in low-dose insulin infusion for pediatric diabetic ketoacidosis. Pediatr Emerg Care. 1989 Jun;5(2):77-9.
  • 23. Strategy 0.14 units/kg/hr 0.1 units/kg bolus  0.1 units/kg/hr Glucose 10% in first hour  0.1-0.14 units/kg bolus, continue drip Glucose 50 mg/dL/hr Glucose 250 mg/dL  drip to 0.02-0.05 units/kg/hr KitabchiAE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. DiabetesCare 2009;32:1335–43.
  • 24. Subcutaneous? 0.3 units/kg bolus 0.1 units/kg/hr No difference in time to resolution 39% cost savings UmpierrezGE, Latif K, Stoever J, Cuervo R, Park L, FreireAX, et al.The efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for treatment of diabetic ketoacidosis.Am J Med 2004;117:291–6.
  • 25. Ersöz HO, Ukinc K, Köse M, Erem C, Gunduz A, Hacihasanoglu AB, Karti SS Subcutaneous lispro and intravenous regular insulin treatments are equally effective and safe for the treatment of mild and moderate diabetic ketoacidosis in adult patients. Int J Clin Pract. 2006 Apr;60(4):429-33. Glucose KHCO3pH OsmolalityBHB Subcutaneous
  • 27. Sodium Bicarbonate No data to suggest beneficial for acidosis  May delay resolution of ketone bodies Associated with cerebral edema in children Hyperkalemia with ECG changes? Morris LR, Murphy MB, KitabchiAE. Bicarbonate therapy in severe diabetic ketoacidosis.Ann Intern Med 1986;105:836–40. ViallonA, Zeni F, Lafond P,Venet C,Tardy B, PageY, et al. Does bicarbonate therapy improve the management of severe diabetic ketoacidosis? Crit Care Med 1999;27:2690–3. Hale PJ, Crase J, Nattrass M. Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis. Br Med J (Clin Res Ed) 1984;289:1035–8. Glaser N, Barnett P, McCaslin I, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. N Engl J Med. 2001;344:264–9.
  • 29. Phosphorus Only if <1 mg/dL Tattersall RB.The history of diabetes mellitus. In: Holt RIG, Cockram CS, FlyvbergA,Goldstein BJ, editors.Textbook of diabetes. 4th ed.,West Sussex, UK:Wiley-Blackwell; 2010. p. 3–23. KitabchiAE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al. Management of hyperglycemic crises in patients with diabetes. DiabetesCare 2001;24:131–53.
  • 32. Some words about cerebral edema Vasogenic edema secondary to reperfusion Subclinically present in many children with DKA Can happen at any time  Even before treatment Mannitol or 3% NS Octreotide GlasgowAM. Devastating cerebral edema in diabetic ketoacidosis before therapy. DiabetesCare. 1991;14:77–8. Curtis JR, Bohn D, Daneman D. Use of hypertonic saline in the treatment of cerebral edema in diabetic ketoacidosis (DKA). Pediatr Diabetes. 2001;2:191–4. SeewiO,VierzigA, Roth B, Schonau E. Symptomatic cerebral oedema during treatment of diabetic ketoacidosis: effect of adjuvant octreotide infusion. Diabetol Metab Syndr. 2010;2:56. Bosnak M, Dikici B, Dogru O, Davutoglu M, Haspolat K. Somatostatin therapy in the management of resistant diabetic ketoacidosis. Diabetes Care. 2002;25:629–30.
  • 33. Disposition ICU Manage in ED then admit to floor Floor with subcutaneous
  • 34. Summary Diagnose  W Treat  Hydrate  K  Insulin Watch for cerebral edema

Editor's Notes

  1. Nitroprusside tests for AcAc, not BOHB
  2. Fluid deficit 3-6L on average
  3. Vasopressor dependent sepsis, 53000 pts, 3365 LR, matched 1:! With NS, 19.6% mortality vs 22.8%, NNT=31LR had higher bicarb, lower chloride, 45 ptsThose with NS had longer insulin drips, 0.45% had hyponatremia
  4. Max oral dose recommended is 40 mEq at a time, and 100 mEq/dayIV 10mEq/hr peripherally, 20 mEq/hr central
  5. Mechanism unclear, may be IGF-1 related, may be glucagon related, may be both
  6. They can eat once pH&gt;7.3, HCO3&gt;18, and tolerating PO