DKA

Diabetic Ketoacidosis (DKA) – Will Bassett

Background

  • Classically in type 1 diabetes but can also occur in insulin-dependent type 2 diabete
  • Definition: blood glucose (typically >350) w/ high anion gap and ketones in blood/urine
  • If glucose is significantly elevated but no ketones/anion gap present, you likely have HHS
    •   serum osm and BG > 600 commonly seen

 

Evaluation

  • Workup aimed at discovering the underlying cause (The "I’s"):
    • Infection/ Inflammation - CBC, CXR, UA/UCx, LFTs; consider BCx, lipase (pancreatitis). NB leukocytosis will be present in most DKA pts
    • Ischemia (MI, CVA, mesenteric ischemia) - EKG, Troponin, CT if clinical suspicion
    • Intoxication - Ethanol (can cause ketosis with or without acidosis)
    • Impregnation - Beta HCG if appropriate
    • Insulin-openia/Iatrogenic: steroids, other meds, insulin delivery failure (pump failure, insulin degraded by heat, etc)
  • ABG (for pH), serum osmolality
  • Check a phosphate at least once to ensure severe hypophosphatemia (<1mg/dL)
  • Remember to correct sodium for hyperglycemia (Na + 2.4 mEq * (BG-100))

 

Management

  • Initial monitoring: Q2h BMPs (monitor K closely), Q1h fingersticks
    • Can space less frequently once gap is closed x 2 and patient off insulin infusion
  • Ensure IV access and make NPO
  • Start IV fluids, insulin, and potassium as below
    • Lactated ringers’ preferred fluid if no contraindication
    • Dextrose gtt should be started when BG <200
    • Turn off insulin drip when anion gap is closed on 2 consecutive BMPs
  • Once BG<200 can start clear liquid diet and advance as tolerated. When pt is able to tolerate PO, dextrose infusion can stop
  • Consult endocrinology early, even though you’ve got it under control
  • Management algorithm on next page (Diabetes Care. 2009 Jul; 32(7): 1335–1343)

 

Additional Information

  • Patients on insulin drip can be admitted to stepdown (8MCE) with order set
  • “ADULT DKA RESUSCITATION ADMISSION ORDERS”
  • Start subcutaneous long-acting insulin as soon as insulin drip/IV insulin is started. Either home long-acting insulin (reduced for NPO if necessary) or, if insulin naive, Lantus 0.2-0.3 u/kg/day (0.1 if AKI in T1DM, 0.3 if obese-- can possibly take more but safe start)
  • Make sure PRN dextrose source is ordered for all patients on insulin drip
  • Pts are usually deficient in total body K+, even if serum [K+] is high