DKA Treatment Flashcards
Goals of therapy (5)
- Volume repletion
- Reversal of metabolic consequences of insulin insufficiency
- Corection of electrolyte and acid-base imbalances
- Recognition and treatment of precipitating causes
- Avoidance of complications
ORDER OF PRIORITY:
1. VOLUME
2. K DEFICIT
3. INSULIN
Specific goals of treatment
BG <200mg/dl
HCO3 > or = 18mEqs/L
Venous pH >7.3
Fluid of choice
Normal saline
LR
Balance crystalloid
16 or 18G
IVF 1: PNSS or LR or Balanced
IVF 2: 0.45 PNSS
Rate of fluid given initially
Fluid bolus at 15-20ml/kg/hr during the 1st hr
Based on clnical suspicion alone
rate depends on stability, hydration, urine output, electrolytes
After initial fluid bolus, what is the fluid regimen?
NS at 250-500ml/hr in HYPOnatremic patients
0.45NS 250-500ml/hr in Eunatremic and HYPERnatremic patients
General fluid regimen in DKA
First 2L administered rapidly over 0-2hrs
Next 2L over 4-6hrs
Additional 2L over 6-12 hrs
Once BG is at 250mg/dl, shift to 5% dextrose + 0.45% NS
in patients without severe depletion, 250 to 500ml over 4 hours may be done
Reversal of metabolic consequences in DKA should be done in what timeframe
24 to 36 hours
monitor q2
For each __ decrease in pH, Serum potassium rises ___ meqs/L
0.1 decrease in pH
0.5 meqs/L increase in K
Rises due to acidosis (hydrogen exchange, total body fluid deficit, diminished renal function)
Initial hypokalemia indicates?
Severe total body potassium deficits
requirement of a large amount of replacement in the 1st 24 to 36hrs
HypoK during treatment:
primarily occurs due to inslin promoting entry into cells
secondary: dilution of ECF, correction of acidosis, urinary losses
Most severe life threatening electrolyte derangement during DKA treatment
Rapid development of severe hypokalemia
Initial K 3.3-5.2mEqs/L
Add 20 to 30mEqs/L K to PNSS for 4 hrs
Initial K <3.3mEqs/L
20 to 30mEqs/h K and HOLD insulin
resume once K > or equal to 3.5
Hold or decrease K replacement if oliguric or w renal insufficiency
use of potassium phosphate may induce
hypocalemia and precipitation of calcium phosphate in tissues
Rate of K correction
NO FASTER THAN
10 meqs/hr via peripheral line
20meqs/hr via central line
during the 1st 24 hours 100 to200 mEqs of KCl is usually required
Dose of K2PO4 replacement
2.5 - 5mg/kg
Started only once <1mg/dl
Complications: Hyperphosphatemia, Hypernatremia Hypocalcemia, Hypomagnesemia, Metastatic soft tissue calcification, Volume loss
HypoP most severe 24-48 hrs after insulin initiation
Hypomagnesemia inhibits PTH secretion and results to
Hypocalcemia
Hyperphosphatemia
if <2.0mEq/L (<1.0mmol/L) give 2g TIV over 1 hr
Insulin infusion dose
Once Hypokalemia is excluded
0.1 to 0.14u/kg/hr
then reduce to 0.02 to 0.05 u/kg/hr
Alt: 0.1u/kg IM if no IV line followed by 0.1u/kg/hr
HL: 4-5mins
Tissue HL: 20-30mins
Expected drop of blood glucose when on infusion
50-75mg/dl/h
If no decrease by 10% 1 hr after therapy, or 3mmol/L/h, give 0.14u/kg bolus then resume drip OR increase rate by 1u/hr
what to give in severe acidosis with pH <6.9
100meqs of NaHCO3 in 400ml of water with 20mEqs of KCL at 200ml/hr for 2 hrs until pH 7.0
Pros: improved contractiliy, increased vfib threshold, improved catecholamine tissue response, decreased work of breathing
Cons: Hypokalemia, CNS acidosis, Intracellular acidosis, Impaired shift to the left oxyhemoglobin dissociation, hypertonicity, Na overload, Delayed recovery from ketosis, elevated lactate, cerebral edema
What is done to avoid relapse of hyperglyecemia and DKA?
Initiate SC insulin 2-4 hrs before discontinuing IV infusion
Give 50% of long acting 2hrs prior stopping infusion
new DM dose: 0.5 to 0.8 u/kg
Can SC Insulin be used in DKA?
Yes for mild to moderate uncomplicated DKA
SC lispro: 0.3 u/kg then 0.1u/kg q1
OR
0.3u/kg then 0.2u/kg q2 until BG <250mg/dl
subsequent doses are decreased by half and given q1-2 until DKA resolved
Main contributors to mortality
Infection and myocardial infarction
moratality is mainly from sepsis or cardiopulmonary complications in elderly
Most common and feared cause of mortality in children, adolescents, and newly diagnosed DM
Cerebral edema
develops in 4-12 hrs, present in 24-48 hrs
(+) AMS early in TX : give mannitol 1-2/kg or HTS 3% 5 to 10ml/kg over 30 mins
Major trigger for recurrent DKA
Insulin non-compliance
