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Sargent noon conference 072618
- 1. Noon Conference Jonathon Sargent, MD Internal Medicine, R3
- 2. © 2016 Virginia Mason Medical Center 2 Objectives DKA • clinical presentation • Pathophysiology • precipitants • diagnostic testing • illness script • Treatment • protips
- 3. © 2016 Virginia Mason Medical Center 3 Objectives DKA • clinical presentation • Pathophysiology • precipitants • diagnostic testing • illness script • Treatment • Pro tips
- 4. © 2016 Virginia Mason Medical Center Clinical presentation 4 • Pt with type I DM • Acute onset (<24 hrs) • Polyuria, polydipsia, polyphagia • Abdominal pain • Nausea, vomiting • Fatigue, headache, confusion, lethargy, persistent vomiting
- 5. © 2016 Virginia Mason Medical Center Clinical presentation 5 • Dehydration • Tachycardia • Hypotension • Kussmaul respiration • Fruity odor on breath
- 6. © 2016 Virginia Mason Medical Center Pathophysiology 6 • Reduced insulin, elevation of counter regulatory hormones → • Accelerated gluconeogenesis and glycogenolysis → • ↑ serum osmolality → dehydration • ↑ Free fatty acids →ketones which creates metabolic derangements • Increase in proinflammatory cytokines and procoagulation factor levels.
- 7. © 2016 Virginia Mason Medical Center Pathophysiology 7 • Insulin does 2 things: 1. Lowers serum glucose 1. Stops hepatic glucose production (main) 2. ↑ peripheral utilization (minor) 2. Stops ketone production 1. ↓ lipolysis 2. Stops glucagon
- 8. © 2016 Virginia Mason Medical Center Precipitants 8 • New onset type I DM • Infection (pna, uti) • Reduced insulin intake, pump failure • Alcohol • MI • Pregnancy • Change in eating patterns • Pancreatitis • Psychological stress
- 9. © 2016 Virginia Mason Medical Center Evaluation • BMP or CMP • CBC • Serum ketones, urine ketones • BUN • Electrolytes (phos, mg) • HbA1c • UA • ABG or VBG • ECG, CXR • cultures 9
- 10. © 2016 Virginia Mason Medical Center Diagnostic tests • Serum glucose > 250 mg/dL • Serum bicarb < 18 • Serum pH < 7.3 • Anion Gap > 10 • Elevated urine and serum ketones • Dehydration • Hypokalemia, hypokalemia 10
- 11. © 2016 Virginia Mason Medical Center Diagnostic tests • Serum glucose > 250 mg/dL • Serum bicarb < 18 • Serum pH < 7.3 • Anion Gap > 10 • Elevated urine and serum ketones • Dehydration • Hypokalemia, hyperkalemia 11
- 12. © 2016 Virginia Mason Medical Center Our patient 12
- 13. © 2016 Virginia Mason Medical Center Illness Scripts 13 DKA HHS Pathophysiology Actual or relative insulin deficiency Lack of insulin leads to lipolysis and oxidation of FA Sufficient insulin to block lipolysis and oxidation of FA, but not enough to prevent hyperglycemia Epidemiology Type I DM Type II DM Time course Acute (24 hrs) Days to weeks Clinical presentation Polyuria, polydipsia, weight loss, vomiting, weakness, mental status changes (↓ in DKA) Polyuria, polydipsia, weight loss, vomiting, weakness, mental status changes (↑ in HHS) Diagnostics Plasma glucose: 250 - 800, wide range pos. Bicarb < 18 pH < 7.3 AG >10 Elevated serum and urine ketones dehydration Plasma glucose 800-1200 mg/dL Urine or serum ketones – wnl or small Serum osms > 320 mOsm/kg Serum bicarb > 18 mEq/L Therapeutics IVF K Insulin Electrolytes IVF K Insulin electrolytes
- 14. © 2016 Virginia Mason Medical Center Treatment • ICU • Severe dka • Hypotension, anasarca, other comorbid critical illness • Floor • Mild-mod dka • Use the dka orderset! 14
- 15. © 2016 Virginia Mason Medical Center Treatment Volume • NS (1-1.5 L/hr) ± K (20-30 mEq/L) • 1/2NS (250-500 mls/hr) ± K • D5, 1/2NS at 200 mls/hr once glucose < 200 15
- 16. © 2016 Virginia Mason Medical Center Treatment Potassium • UOP ok? (50 mls/hr) • If K < 3.3 DO NOT give insulin, give IV K via central line until K>3.3. • Then put 20-30 mEq/L of IVF • If K>5.2, do not replete • Check K and electrolytes frequently 16
- 17. © 2016 Virginia Mason Medical Center Treatment Insulin (regular=short acting) • 0.1 U/kg IV bolus • 0.1 U/kg/hr gtt • Goal is to drop glucose by 10% in 1 hr – monitor with labs closely • Insulin pumps are like insulin gtt, give sq bolus of basal 1-2 hr before turning off. 17
- 18. © 2016 Virginia Mason Medical Center Treatment Electrolytes • If Mg<1.2, replete with 8-12gIV in first 24 hrs, then 4-6g/day for 3-4 days • Conisder K repletion with Kphos if phosphate<1 (weak recommendation) 18
- 19. © 2016 Virginia Mason Medical Center Treatment Acidosis • If pH < 6.9, give sodium bicarb 100 mmol in 400 ml water over 2 hours • No bicarb if pH > 6.9 19
- 20. © 2016 Virginia Mason Medical Center Follow up • Check glucose 1 hour after insulin to ensure 10% decrease • Check BMP and venous pH every 2-4 hours until stable • Resolution of ketoacidosis takes longer than resolution of hyperglycemia 20
- 21. © 2016 Virginia Mason Medical Center Pro tips • 2 methods for measuring serum ketones: • Semi-quant – misses beta-hydroxybutyrate • measures acetoacetate and acetone. • May underestimate DKA severity • Quant – measures beta-hydroxybutyrate • Negative urine ketones likely excludes DKA • Potassium – beware the shift • Hyper K, but total body K depleted • Low-normal K – severe total body depletion • Replete if < 5.2 • Leukocytosis > 25,000 suggests infection • VBG = ABG for sn and sp • If DKA and ESRD, insulin is sufficient for treating hyperK 21
- 22. © 2016 Virginia Mason Medical Center References • Acad Emerg Med 2011 Oct;18(10): 1105 • BMJ 1998 Oct 31;317 (7167):1213 • Ann Emerg Med 1999 Sep:34 (3):342 • Dynamed plus – diabetic ketoacidosis in adults, updated Aug 23, 2017. • Kirsch, IB, Emmett, M - Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults, UpToDate, last updated Jan 13, 2017. • Phillips, BD, et al. A novel approach to preventing diabetic ketoacidosis in a patient treated with an insulin pump. Diabetes Care 2003 Oct; 26(10): 2960-2961 • Masters, Philip A. Endocrinology and Metabolism, MKSAP 17. American College of Physicians, 2017. 22
Editor's Notes
- 10-30% of patients in DKA are DMII. What are you worried about with the neurological symptoms? Cerebral edema
- 10-30% of patients in DKA are DMII.
- 10-30% of patients in DKA are DMII.
- Stopping ketone production takes less insulin than lowering serum glucose, which explains the difference between HHS and DKA.
- 10-30% of patients in DKA are DMII.
- Get these frequently, every 1-4 hours as needed. This is something to monitor closely until resolved. Why was serum ketones negative but urine ketones positive? wrong diagnosis Test doesn’t’ measure betahydroxybutyrate Serum ketones resolved, but urine ketones stay in bladder
- DKA severity index
- Pts are severely dehydrated due to osmotic diuresis. IVF helps correct acidosis and makes pts more responsive to insulin and other therapies. Remember, K is osmotically active, and dka and hhs usually have a increased serum osmolality. Therfore adding K to ivf increases their tonicity. Adding K to ½ NS makes it more like ¾ NS.
- Hypo K for 2 reasons: loss during osmotic diuresis and from hyperaldosteronism