DKA

Question 1

How does DKA develop?

Answer 1

beta cells stop working–>insulin deficiency–>despite high serum glucose, intracellular glucose depletion–> increase in regulatory hormones to release more glucose into blood stream–>gluconeogenesis, breakdown of proteins and lipids–>even more hyperglycemia now with amino acids and fatty acids in blood stream–>derangement of fatty acids releases ketoacids into bloodstream–>
KETOACIDOSIS
HYPERGLYCEMIA (–>Glycosuria + OSMOTIC DIURESIS)

Question 2

What does DKA do to the body?

Answer 2

KETOACIDOSIS

HYPERGLYCEMIA (with Glycosuria + osmotic diuresis)

Question 3

clinical signs and symptoms: (4)

Answer 3

hyperglycemia (>180)
hypovolemia (5-10% fluid deficient w/ weight loss)
“fruity breath” (because acetoacetic acid turns to decarboxylate which turns to acetone)
hyperpnea with Kussmaul Breaths (as a פיצוי נשימתי לחמצת מטבולית)
(Abdomenal pain)

Question 4

Management Priorities in order: (9)

Answer 4

1. NEURO-RESP
2. CIRCULATORY/PERFUSION/HEMODYNAMICS
3. INSULIN admin
4. SODIUM correction
5. POTASSIUM and PHOSPHATE correction
6. continued אומדנים
7. Infection assessment
8. chronic hyperglycemia assessment
9. provide patient-family teaching (referals)

Question 5

What אומדנים are done and what order?

Answer 5

NEURO-RESP
CARDIO-VASC-URINE-WEIGHT+WEIGHT LOSS
GLUCOSE+ELECTROLYTE LEVELS+ACID/BASE 
INFECTION
MED HISTORY+SAMPLE

Question 6

What is the אומדן נוירולוגי/נשימתי for DKA? what is important to suspect?

Answer 6

FUNCTION–הכרה, GCS,אישונים, רפלקסים קרניאלים, התפתחות תקינה, שמירה על נתיב אוויר, חימצון
IMPORTANT TO SUSPECT CEREBRAL EDEMA

Question 7

What are the treatments of suspected Cerebral Edema in DKA? (2)

Answer 7

NACL 3% 10ML/KG over 30 min (PREFERRED cuz not diuretic)

MANNITOL 0.2-1gr/KG over 30-60 min

Question 8

What does the אומדן הימודינמי entail in DKA?

Answer 8

דופק
ל''ד
מילוי קפילרי
מתן שתן
חום פריפרי
צבע עור
משקל נוכחי

Question 9

What is the treatment for poor perfusion and hypovolemia in DKA?

Answer 9

הכנסת 2 עירויים עם עובי גדול
הכנסת AL
שוק: bolus NS 10-20ml/kg, can repeat, avoid>40ml/kg
ללא שוק: admin 5-20ml/kg over 1-2 hours

בשני מקרים: CALCULATE VOLUME DEFICIT and continue with maintinance+ [(deficit-minus previously given fluids) spread over 24-72 hrs]

at first give NS, when stable can move to 0.45%nacl

Question 10

What does the insulin treatment in DKA entail?

Answer 10

infusion of 0.05-0.1 units/kg/hr

במקביל נוזלים עם סוכר

Question 11

Should insulin be given in with העמסה?

Answer 11

לא, יגרום להיפוגליקמיה

Question 12

When should insulin be moved to SC?

Answer 12

כאשר כבר אין קטואצידוזיס

(עדות: אין קטונים בשתן או חמצת בדם

Question 13

When should insulin be reduced?

Answer 13

almost never–incrs glucose admin instead

Question 14

What are the poss AE’s of correcting with insulin?

Answer 14

hypoglycemia

hypokalemia

Question 15

How fast do we want the Glucose level to drop?

Answer 15

50-100 units/hr

Question 16

When do we add D10% to NS and when add D5% to NS?

Answer 16

if glucose levels<200 give D5%

if glucose levels<300 give D10%

Question 17

How often take מעקב סוכר?

Answer 17

כל שעה

Question 18

What other electrolytes must be corrected in DKA?

Answer 18

נתרן, אשלגן, פוספאט

Question 19

If we see Na<135, is it definitely hyponatremia? How do we calculate the true Na?

Answer 19

לא בהכרח
for every 100g/dL of glucose above 180, it “pushes” the Na 1.6meq/L below 135meq/L in the lab results (but is not really there). so must calculate the true Na value and correct according to that. if Na still below 135, correct with 2-4meq/kg of pt.

Question 20

If we see K>3.5 before treatment, is the patient still at risk for hypokalemia? why yes/no?

Answer 20

yes, because of dehydration, the K concentration can still be high, but the absolute K is quite low so especially when we start giving fluids and insulin, it can plummet.

Question 21

How do you correct potassium in DKA patient?

Answer 21

K<3.5 add 40meq/L in the NS
K תקין: add 30 meq/L in the NS
K>5.5: don’t give potassium addition

Question 22

Do we correct PO4-? If so, how and when?

Answer 22

if phosphate<3, then give the potassium via potassium phosphate and not potassium gluconate

Question 23

what are the risks in DKA regarding potassium levels?

Answer 23

cardiac arrythmias if hyperkalemia >7, if so give Calcium gluconate and weigh giving sodium bicarb

Question 24

How often do we do מעקב כימיה?

Answer 24

כל שעתיים

Question 25

What other tests must be performed in DKA patient?

Answer 25

אסטרופ עורקי
ספירה
HBA1C
קטונים בכל שתן
אומדני נוירו+נשימתי+קרדיווסק+ גלוקוז כל שעה
IN-OUT כל שעה