Diabetic Ketoacidosis Flashcards
Schafer
DKA Severity Level: Mild
Arterial pH: 7.25-7.3
Serum bicarb: 15-18 mEq/L
Anion Gap > 10
Mental status: alert
DKA Severity Level: Moderate
Arterial pH: 7.00-7.24
Serum bicarb: 10-14 mEq/L
Anion Gap > 12
Mental status: alert/drowsy
DKA Severity Level: Severe
Arterial pH < 7.00
Serum bicarb < 10 mEq/L
Anion Gap > 12
Mental status: stupor/coma
What is consistent across all severity levels of DKA
Urine ketones: +
Serum ketones: +
What are key areas of management for DKA tx?
fluids
electrolyte management
insulin
What are the guideline recs for initial fluids for uncontrolled diabetes in DKA patients
ADA: 1-1.5 L 0.9% NaCl over first hour
JBDS: 1 L 0.9% NaCl over first hour
When and why would you add dextrose back into fluid bag?
Once BG < 250, start maintenance fluid w dextrose (½ NS + D5W) to ensure we are not causing hypoglycemia with the drip
What are the guideline recs for fluids after labs for uncontrolled diabetes in DKA patients
Determined by sodium level
ADA: Na level normal to high – 0.45% NaCl (250-500 mL/hr)
JBDS: 0.9% NaCl (500 mL/hr)
What are the guideline recs for potassium for uncontrolled diabetes in DKA patients
Determined by potassium level
ADA: 20-30 mEq/L IV fluid
JBDS: 40 mEq/L IV fluid
Why do we need to add potassium into the fluid bag?
Because the insulin will drive the serum potassium down which is problematic for the heart
What are the guideline recs for insulin infusion for uncontrolled diabetes in DKA patients
ADA:
0.1 unit/kg as IV bolus + 0.1 unit/kg/hr IV infusion
0.14 unit/kg/hr IV infusion
JBDS: 0.1 unit/kg/hr regular insulin
Continuous infusion at 0.1 units/kg REGULAR insulin/hour
When and how to do transition from insulin infusion to SQ insulin according to guideline recs?
ADA: if BG < 200 and meet two of the following: serum bicarb ≥ 15 mEq/L, venous pH > 7.3, and/or anion gap ≤ 12 mEq/L
- Reduce regular insulin infusion to 0.02-0.0.5 units/kg/hr OR rapid acting insulin at 0.1 units/kg SQ every 2 hours
JBDS: if BG < 250, consider reducing regular insulin infusion to 0.05 units/kg/hr OR assess for rapid acting insulin conversion
Continue insulin infusion for 2 hours after first dose of SQ insulin
What is the conversion to rapid acting insulin (insulin naive)
TDD: 0.5 units x weight (kg)
Insulin glargine once daily (50% TDD)
Insulin aspart (25% of TDD divided over 3 meals)
Additional correction factor using insulin aspart
Round to patient friendly numbers
What monitoring do you want to perform for a DKA patient ? (diabetes related)
Blood Glucose
– Hourly point of care testing (performed by nursing)
– If CGM: cannot wear CGM w imaging- removed inpatient and therefore unreliable for data collection (high cost to keep reapplying as well)
Beta hydroxybutyrate (ketone levels)
Serum bicarb
Potassium
Phosphorus
Magnesium
Venous blood gas
A1c (once)
What are some concerns with SGLT2 (empagliflozin) in new DKA dx patients?
Increases risk for euglycemic DKA
If patient experiences another DKA episode, often avoid in the future
Do not re-initiate SGLT2 inhibitor w hx of DKA episode
