Diabetic Ketoacidosis

Walt Lubbers MD Summary of DKA Management

Fluid: Giving fluid is super important- a bolus of 1-2 L followed by putting them on a rate of 1.5x maintenance is a pretty safe way to start and pound for pound about the best thing you can do.  If you have to do one thing, it’s give them fluid.  

When the Glucose Drops (around 300): Giving the patient glucose instead of turning off the insulin when the sugar drops is kinda confusing to people but I think it’s really important to hammer that in: don’t stop the insulin.  Even if the glucose is better, the insulin is there to correct the bad stuff that’s going on otherwise.
 
The problem is not so much the elevated glucose, the problem is the body’s inability to use the glucose it has.  The osmotic diuresis is does some bad stuff, but once you replete the fluid deficit the simple presence of the glucose isn’t that big a deal any more, but the fact that you are still unable to use glucose and still making ketones is the bad thing.  So you keep the insulin going until the ketones have cleared signaling metabolism has been restored, the acidosis has resolved, and the anion gap has closed.  If you turn off the insulin without giving it in some other way like subQ, you are just letting them start to produce ketones again and setting them back because they still don’t have adequate insulin to get glucose into their cells. It’s equivalent to throwing a drowning man a life preserver, then pulling it away once he catches his because his oxygen sat is OK- he still has the same primary problem.  So don’t turn off the insulin outside the hospital.  You can turn it down a touch if you just can’t maintain the glucose, or you can give more glucose, but don’t turn it off.  FYI While IV insulin is often used, there’s something to be said in many adults for doing just fluid replacement, electrolyte repletion, and giving subQ insulin and avoiding the drip altogether.  

Potassium Replacement:
1) don’t give insulin until you know the K
2) if K is elevated, give insulin and IVF
3) If K is “normal” give K, IVF, and insulin
4) If K is measured low, don’t give insulin.  Give IVF and K until the K is normal and then give insulin.  

On Treating High Potassium: One other thing on the K- resist the temptation and don’t treat it if it’s high.  It may be high, but you’re going to give them fluids, insulin and glucose, correct their acidosis, etc. in just a minute – don’t be in a super big rush to give them something for their elevated K specifically.  If they are unstable and bradycardic with wide complex QRS then OK, give them some calcium while you’re getting the fluid and insulin ready, but don’t panic if they have an elevated K if they have a little peaked T wave- you’re going to fix it in a minute.  They either get calcium for their wide complex  or you forget about the elevated K for now and watch it resolve as you treat everything else.

On Cerebral Edema: Probably happens when we try to fix stuff too fast- if your shriveled up brain all of a sudden gets tossed in a bunch of free water, and you drop the glucose concentration from syrup down to crystal light, the brain soaks up all that free water and if it does so really fast.  There’s probably a large proportion of kids especially who get a subclinical amount of cerebral edema with correction even at moderate speed.  That’s some of why most of the DKA protocols have you giving NS specifically rather than LR to avoid the hypotonicity of LR.

Useful Algorithms

ISPAD DKA Algorithm (Pediatrics)

Source: “The Internet Book of Critical Care”, by @Pulmcrit

And the podcast:

References

AX, U. (2019). Abdominal pain in patients with hyperglycemic crises. – PubMed – NCBI. Retrieved 29 September 2019, from https://www.ncbi.nlm.nih.gov/pubmed/12040551

Farkas, J. (2016). Anatomy of a DKA Resuscitation. Retrieved 29 September 2019, from https://emcrit.org/ibcc/dka/

Hirsch MD. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment. Post TW, ed. UpToDate. Waltham, MA:
UpToDate Inc. https://www.uptodate.com (Accessed on September 15, 2019)

ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. (2019). Retrieved 29 September 2019, from

Walls, R., Hockberger, R., & Gausche-Hill, M. Rosen’s emergency medicine.

Curbside to Bedside

Curbside to Bedside is a blogcast created by front line EMS Clinicians to provide simple and relevant initial and continuing prehospital EMS education.

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