DKA

Question 1

History & Physical

Answer 1

Classic Triad:
Polyuria
Polydipsia
Polyphagia

A/w:
Weight loss
Secondary enuresis
Anorexia
Abdominal discomfort
AMS
Kussmail Breathing

Question 2

Diagnostic Criteria

Answer 2

Glucose > 13.9 mmol/L
pH < 7.3
Serum Bicarbonate < 15 mEq/L
Serum Ketones
Urine Ketones
Anion Gap > 17 mEq/L

Question 3

DDx

Answer 3

In adolescents without known diabetes:
Ethylene Glycol
Isopropyl Alcohol
Salicylates

Question 4

Management

Answer 4

Bolus isotonic crystalloid 10 ml / kg if stable, if shock or hypotension, 10 mg / kg, repeat until pressure normalized

Following initial bolus; Maintenance 4 cc / hr for 1st 10 kg, 2 cc / hr for 10-20 kg, 1 cc / hr per kg for every kg > 20 kg with NS at 1.5 maintenance rate

If initial [K] is <3.5 add 40 mEq [K]/L to each liter of maintenance fluid after the initial bolus

If [K] is between 3.5-5.5 mmol/L, add potassium at 30 mEq/L to each liter of maintenance fluid after the initial bolus

Supplement with potassium as needed to maintain a potassium level of at least 3.3 mmol/L before starting insulin infusion.

Regular Insulin infusion at 0.1 units/kg/h. Do not start until the potassium level is at least 3.3 mmol/L

If glucose drops below 13.9 mmol/L before correction of acidosis, add D5W to maintenance fluids.

Fingerstick glucose q 1 hr

Lytes q 2

Neuro checks q1-2 hrs assess acidosis, anion gap, and potassium

Continue insulin infusion until two of the following conditions are met:
Serum bicarbonate ≥15 mmol/L
pH >7.3
Anion gap ≤12 mmol/L

After resolution of DKA has been established according to repeat lab testing, give long-acting insulin, subcutaneously, 2 h before discontinuation of insulin infusion

Give sodium bicarbonate only if the patient has severe hyperkalemia, cardiac arrest, or profound shock from acidosis

Question 5

Management of Cerebral Edema

Answer 5

If AMS:

Mannitol 0.25 - 1 g / kg
OR
3% Saline 10 ml / kg over 30 min