Diabetic Ketoacidosis

 

 

 

 

Diagnosis 

 

  • Glucose > 14

  • HCO3 < 18 

  • pH < 7.3

  • + ketones in urine/blood 

 

 

Considerations

 

  • Life threatening anion gap metabolic acidosis (ketoacidosis)

    • CNS: ↓ LOC (hypovolemia, cerebral edema)

    • Cardiovascular: cardiac arrythmias, congestive heart failure 

    • Hyperventilation (very high minute ventilation, caution with intubation & positive pressure ventilation)

  • Hypovolemia:

    • Osmotic diuresis (hyperglycemia)

    • Crystalloid volume replacement

  • Electrolyte abnormalities:

    • Depletion of potassium, phosphorus, magnesium

    • Hyponatremia (factitious hyponatremia)

  • Consequences of therapy:

    • Electrolyte abnormalities

    • Hypo/hyperkalemia, hypomagnesemia, hypophosphatemia 

    • Hypoglycemia

    • Cerebral edema, central pontine myelinolysis

  • Address underlying cause:

    • Infection, trauma, intoxication (cocaine), pancreatitis, acute coronary syndrome 

    • Medication noncompliance (insulin)

 


Conflicts

 

  • Resuscitation vs. emergency surgery

  • Severe metabolic acidosis vs. intubation/ventilation

  • Hypovolemia vs. aspiration risk (RSI)

 

 

Crises

 

  • Electrolyte abnormalities (hyper/hypokalemia, hypomagnesemia, hyponatremia) 

  • Hypoglycemia

  • Cerebral edema (glucose correction without correcting hyponatremia)

  • Central pontine myelinolysis (rapid serum sodium correction)

 

 

Management

 

  • Treat as per hospital protocol in consultation with endocrinology

  • For example, see BC Children's Hospital's DKA protocol:  

 

 

Goals

 

  • Normal anion gap (AG) 

  • pH > 7.2

  • Potassium > 3.5

  • Bicarbonate > 20

  • Glucose < 13

  • Urine output 1 ml/kg/hr 

  • Volume replacement: 

    • Normal saline to correct hypovolemia (3-5L deficit)

    • Then slow to maintenance (up to 500ml/hr)

    • Change to D5NS when glucose < 14

    • Add potassium to IV fluids once < 4.5 & urinating

  • Insulin R 

    • Start infusion at 0.14 u/kg/hr (10units/hr in 70kg male) OR give 0.1 u/kg bolus followed by infusion 0.1 u/kg/hr

    • DO NOT start insulin if potassium <3.3 

    • Glucose goal 10-15 mmol/L

    • When glucose <11: add D5W to solution 

  • Potassium management 

    • If < 3.3: DO NOT start insulin, give 20-30 meq/hr of potassium until K > 3.3  

    • If > 3.3 & < 5.3: give potassium 20meq/L of fluid 

    • If > 5.3: Do NOT give potassium 

  • Frequent monitoring: ABG, electrolytes (AG), BUN, creatinine, osmolality, plasma & urinary ketones, magnesium, phosphate, lactate

  • Consider sodium bicarbonate if pH < 7 & myocardial dysfunction or vasodilation or life-threatening hyperkalemia

 

 

Complications

 

  • Cerebral edema 

  • Pulmonary edema