Day 1 - Diabetic Ketoacidosis

Pillars of management:

  1. Volume resuscitation

  2. Insulin to correct anion gap

  3. Correction of electrolyte abnormalities

  4. Treatment of precipitating cause

Treatment:

  1. Potassium replacement - total body deficit despite normal or elevated serum K+

    1. Do NOT start insulin if less than 3.3 - replete K+ then proceed

    2. If patient is anuric, volume resuscitate and ensure urine output prior to K+ administration

  2. Volume resuscitation

    1. Severe volume depletion (6-8 L) given osmotic diuresis, vomiting and decreased oral intake

    2. Start by giving fluid boluses 1-2L for the first 1-2hrs followed by

    3. 500 mL/hr for 4 hours then decrease to 250 mL/hr thereafter

    4. *Ensure caution in patients with CHF or renal failure, and insert a urinary catheter to monitor accurate urine output

  3. Insulin infusion

    1. Insulin is used to stop ketone production & close anion gap, therefore infusion is adjusted to anion gap

    2. Start at 0.1units/kg/hr

      1. No need to use an insulin bolus, as this has not been shown to improve outcomes

      2. You only consider stopping the insulin infusion in cases where potassium is much less than 3.3 

      3. Avoid decreasing blood glucose by more than 5 mmol/L/hr, adjust insulin infusion accordingly

      4. Target glucose between 12-15 mmol/L

        1. If glucose drops below 15, add D5W to your fluids to compensate

        2. Never stop your insulin infusion because of drop in blood glucose. Instead add dextrose to your fluids

Diabetic Ketoacidosis (1).png

4. Serum osmolality - Cerebral edema is of concern if osmolality or sodium are corrected too quickly

  1. Avoid correcting glucose by more than 5mmol/L/hr or plasma osmolality faster than 3 mOSm/kg/h

  2. *Hyperglycemia can create pseudo-hyponatremia - correct Na by 3 mmol/L for every increase in glucose of 10 above 10 mmol/L

  3. If the patient has hypernatremia, drop the sodium content of your fluids by using 1/2NS instead

5. Sodium Bicarbonate

  1. May only be beneficial if the pH is less than 6.9

    1. In these cases, you can give 1 amp of sodium bicarbonate in 200 mL D5W over 1 hour and repeat every 2 hours until pH is more than 7

    2. Avoid giving bicarbonate if K is less than 3.3 as this can exacerbate hypokalemia

6. Precipitating factors

  1. Must be addressed for management to be successful

  2. Consider: insulin non-adherence (socioeconomic factors, sick day, etc), infection, myocardial infarction, stroke, intoxication, exogenous steroids, etc.

  3. Involve appropriate services, ie. surgical consultation, cardiology, when appropriate

7. Transition to subcutaneous insulin when:

  1. AG closes

  2. BG < 15mM

  3. Insulin requirements are 0.5-1 unit per hour or requiring near baseline insulin requirements

  4. Patient is hungry and tolerating PO intake

  5. Patient can be closely monitored during the transition

  6. Overlap IV insulin with subcutaneous rapid acting insulin for 1-2 hours before stopping your insulin infusion altogether

Investigations:

  • Glucose - capillary if accurate, but may require serum if severely elevated

    • *Consider euglycemic DKA in patients with anion gap but normal glucose - seen often in patients on SGLT2 inhibitors or presenting with starvation ketosis

  • Electrolytes & serum bicarbonate to calculate anion gap

    • AG = sodium - [chloride + bicarbonate]

  • Venous blood gas to assess for metabolic acidosis

  • β-hydroxybutarate

    • May be negative depending on assay and stage of metabolites

  • Identification of underlying cause

    • ECG & troponin

    • Chest x-ray

    • Blood cultures, urinalysis

    • Osmolar gap for co-ingestions

    • βHCG if childbearing age

The Intern at Work -