Diabetes 1

Diabetic Ketoacidosis (DKA)

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Learning ObjectivesIdentify precipitating factors for the development of DKA

Outline steps needed to obtain accurate diagnosis of DKA

Implement strategies for the acute management of DKA

Explain methods that can be used to prevent recurrence of DKA2

Speaker Notes

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DKA Progression3Insulin DeficiencyIncreased Lipolysis Increased KetogenesisKetoacidosis DKA

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Overall Management Approach4

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Regulation of Ketogenesis and Glucose Metabolism 5KetogenesisGluconeogenesisGlycogenolysisGlycolysisGlycogen SynthesisInsulinGlucagonCortisolGrowth HormoneCatecholamines

From Kreisberg R. Diabetic ketoacidosis. In: Rifkin H, Porte D, eds. Diabetes mellitus: theory and practice, 4th ed. New York: Elsevier Science, 1990:591603.

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Precipitating Factors Inadequate insulin treatment

Infection (UTI, pneumonia, sepsis)

Myocardial infarction, stroke

Drugs

Pregnancy6

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Signs and SymptomsPolyuria, polydipsiaEnuresis

Dehydration/Volume DepletionTachycardiaOrthostasisReduced skin turgorDry mucus membranes

Abdominal painNauseaVomitingFruity breathAcetone

Kussmaul breathing

Mental status changesSomnolentCombativeDrunk

Coma

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Initial Evaluation of the Patient with Suspected DKAHistory of DM, hypoglycemic medication doses, and symptoms

History of DM-related complications

Medications

Social and medical history (including alcohol use)

Vomiting and ability to take fluids by mouth8

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Initial Evaluation of the Patient with Suspected DKA (contd)Plasma glucose

Attempt to identify precipitating event (e.g. infection, omission of insulin, myocardial infarction)

Assess volume status and degree of dehydration

Assess presence of ketonemia and acid-base disturbance9

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Laboratory Evaluation of the Patient with Suspected DKA (contd)Complete blood count (WBC often high; left shift suggests infection)

Serum glucose

Serum ketones

Calculate serum osmolality and anion gap

Measure osmolar gap if ingestion of osmotically active toxins suspected10

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Laboratory Evaluation of the Patient with Suspected DKA (contd)Urinalysis and urine culture

Consider blood culture

Consider chest radiograph

Consider measuring HCG

Acid-base assessment

HbA1c11

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Laboratory Values in DKADKAGlucose (mg/dL)250-600Sodium (meq/L)125-135Potassium (meq/L)Normal or increasedMagnesium Normal Chloride Normal Phosphate Decreased Creatinine (mg/dL)Increased

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Laboratory Values in DKA (contd)DKASerum Osmolality (mOsm/kg)300-320Serum -hydroxybutirat acid (mmol/L)>0.6Serum Bicarbonate (meq/L)250>250>250Effective serum osmolality (mOsm/kg)[*]VariableVariableVariableUrine or serum ketones (NP reaction)PositivePositivePositiveArterial pH7.25-7.307.00-7.2412>12Typical mental statusAlertDrowsyStupor or coma

14Modified from Kitabchi AE, Umpierrez G, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care 2001;24:131153. *Effective serum osmolality (mOsm/kg) = 2 [measured serum sodium (mEq/L)] + [serum glucose (mg/dL)/18]. Normal range = 285 5 mOsm/kg. Urea nitrogen is an ineffective osmole (i.e. it diffuses freely across compartments) and is therefore purposely excluded from this equation.

*Effective serum osmolality (mOsm/kg) = 2 [measured serum sodium (mEq/L)] + [serum glucose (mg/dL)/18]. Normal range = 285 5 mOsm/kg. Urea nitrogen is an ineffective osmole (i.e. it diffuses freely across compartments) and is therefore purposely excluded from this equation.

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Suggested Fluid ReplacementAdminister NS as indicated to maintain hemodynamic status, then follow general guidelines:NS for first 4 hoursConsider half NS thereafterChange to D5 half NS when blood glucose 250 mg/dL May need to adjust type and rate of fluid administration in the elderly and in patients with congestive heart failure or renal failure.

15HoursVolume0.5-11 L21 L3500 mL-1 L4500 mL-1 L5500 mL-1 LFirst 5 hours (total)3.5-5 L6-12200-500 mL/hour

NS, normal saline; D5, 5% dextrose in water

May need to adjust type and rate of fluid administration in the elderly and in patients with congestive heart failure or renal failure.

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Average Electrolyte Losses16 Sodium 500 mEq Chloride 350 mEq Potassium 300-1000 mEq Calcium 50-100 mmol Phosphate 50-100 mmol Magnesium 25-50 mmol

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Guidelines for Potassium ReplacementDo not administer potassium if serum potassium >5.5 mEq/L or if patient is anuric

Remember that normal or high serum potassium may mask total body depletion in setting of acidosis

Use KCI but alternate with KPO4 if there is severe phosphate depletion and patient is unable to take phosphate by mouth

Add IV potassium to each liter of fluid administered unless contraindicated17

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Guidelines for Potassium Replacement18Serum K+ (mEq/L)Additional K+ Required5.5Stop K or dont start infusion

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Guidelines for Insulin ManagementRegular insulin 0.15 U/kg IV (may not be needed)

Start regular insulin infusion 0.1 U/kg/hour or 5 U/hour

Increase insulin by 1 U/hour every 1-2 hours if 75 mg/dL/hour

Do not decrease insulin infusion to