7 - DKA Flashcards
patient population for DKA?
Molsty DM 1
10-30% are new DM2
Pathophys of DKA?
Absence of insulin and excess counter-regulatory hormones result in
- hyperglycemia,
- osmotic diuresis,
- preenteral azotemia
- Worseing hyperglycemia
- Ketone formation
- Wide-anion-gap metabolic acidosis
What are counter-regulatory hormones?
Glucagon
Catecholamines
Cortisol
Growth hormone
Causes of DKA?
Often idiopathic but…
- stopping insulin
- infection
- pregnancy
- hyperthyroid/pheo/cushing
- cocaine
- meds (steroids, thiazides, antipsychotics)
- heat injury
- cerebrovascular accident
- GI hemorrhage
- myocardial infarction
- PE
- pancreatitis
- maj trauma
- surgery
Clinical manifestations of DKA are related to?
Hyperglycemia
Volume depletion
Acidosis
Symptoms of DKA?
Polydipsia Polyuria Ketones in urine Increased ventilation (acidosis) Prostaglandin - N/V - Abd pain Altered mental Fruity breath Hypothermia
What condition can be hard to distinguish from DKA?>
Pancreatitis
- both have abdominal pain and elevated serum amylase or lipase
Diagnostic criteria for DKA?
Glucose >250 Anion gap >10 Bicarb <15 pH <7.3 Ketonuria Ketonemia
Euglycemic ketoacidosis?
Glucose <300
DDX for DKA?
Alcoholic ketoacidosis
Starvation ketoacidosis
Renal failure
Lactic acidosis
Ingestion of
- salicylate
- ethylene glycol
- methanol
Lab testing for DKA?
Rapid bedside glucose Venous blood gas (VBG) CMP CBC calculated anion gap (AG) ABG Ketones Potassium ECG
What effect does DKA have on potassium?
Low potassium from renal losses
Can be normal or High sometimes b/c
- extracellular shift
- increased intravascular osmolarity
ECG changes from DKA?
Hyperkalemia or hypokalemia
Also signs of ischemia
- b/c MI may precipitate DKA
If you suspect DKA at triage you should?
Aggressive fluid therapy should be initiated
Order of therapeutic priorities for DKA?
Volume first and foremost Then Correction of K+ Then Insulin administration
Treatment of metabolic disturbances?
Corrected at approximate rate of occurrence
Or
Over 24-36hrs
Monitoring every 2hrs of electrolyes, vital signs, mental status, and volume
Numeric volume goals of treatment?
Glucose <200mg/dL
Bicarbonate >/= 18mEq/L
Venous pH >7.3
Most important factor in treating DKA?
Why?
IV fluid administration
Restores IV volume and tonicity Perfuses vital organs Improves GFR Lowers serum glucose Lowers ketone levels
What fluids do you treat DKA with?
NS initially
Once corrected then change to 0.45%NS
1st - 2 L in 2 hrs
2nd - 2L in 2-6hrs
When glucose is 250mg
- switch to 5% dextrose in 0.45% NS
What is potentially the most life-threatening electrolyte derangement during treatment of DKA?
Rapid development of severe hypokalemia
If initial serum potassium level is
> 3.3mEq/L
but
<5.2 mEq/L
you should?
Administer IV K+ at 20-30mEq/L/hr x 4 hrs
What does K >5.2 reflect?
More profound acidemia and volume depletion or renal insufficiency
Insulin administration for DKA?
After bolus NS
0.1-0.14 unit/kg/h (once hypokalemia is excluded)
Once glucose is 200mg/dL addd dextrose to IV
Reduce insulin to 0.02 to 0.05 unit/kg/h
Continue insulin infusion until?
Glucose <200 and 2 of the following
Bicarb >15mEq/L
Venous pH >7.2
Normal calculated anion gap
K+ >3.3 - < 5.2mEq/L
Give IV fluid
Give IV K
Give IV insulin
K+ <3.3mEq/L
Give IV fluid
Give IV K
Hold insulin
K >5.2mEq/L
Give IV fluids
Hold K+
Give Insulin
Complications of acute DKA?
Loss of airway
Sepsis
MI
Hypovolemic shock
Complications of DKA related to therapy?
Hypokalemia Hypophosphatemia ARDS Cerebral Edema Hypoglycemia
Complications of DKA late complications?
Recurrent anion gap metabolic acidosis
Non-anion gap metabolic acidosis
Vascular thrombosis
Mucormycosis
Where do DKA pts get admitted to?
ICU if critical
General med/surg if:
- anion gap <25
- glucose < 600mg/dL
- no comorbidities
Leading cause of fetal loss?
DKA, fetal mortality rate of 30%
Colonel: You write “born to kill” on your helmet, and you wear a peace button. What’s that supposed to be, some kind of sick joke?
Joker: No, sir.
