DKA

[see Pedi DKA]
Initial Orders:
1.  NPO, CBC, CMP, ABG, Serum Ketones, UA w/ C+S, Blood Culture, CE & EKG, Amylase, Lipase CXR, Head CT ?
     Look for possible source of infection (UTI, Pneumonia, Skin infection...)
     NOTE: Ketones found in high ratio (1:36) means worse DKA
2.  CBG & K+  q2h
3.  NS 1 L/hr x 2-5 hours (or more)
4.  Add K+ after first void.
    - 1/2 NS + KCL 40 mEq/L 100-250 cc/hr
5.  K+ will bottom out. (monitor q2h)
6.  Change to D5 1/2 NS when CBG is 250
7.  IV Insulin: (Humalin R, Novolin R)
        - 0.05 - 0.1 U/kg of Regular insulin bolus, then 0.1 U/kg/hr infusion until anion gap closed (DKA resolved)
8.  Monitor patient closely:
  • Urine Output
    • Normal : 1 - 2.4 L/Day -OR-  0.5 mL/kg/hr
      •  Oliguric < 30cc/hr
      • Monitor with Foley.
    • Remove ASAP to prevent CAUTI
  • Monitor serum osmolality.
9.  Consider ABX, find the infection.
 

Summary/Overview:

  Dx Criteria Resolution Criteria What to do next? How to start Insulin?
Glucose Elevated < 200 (for DKA)
< 300
for HHS
Transition to D5W 1/2 NS (Acidosis is still not resolved)
1 U/kg/day
      OR
TDD x 0.8
1/2 Bolus 1/3 with breakfast NovoLOG
1/3 with lunch
1/3 with dinner
1/2 Basal 1/2 in AM Levemir
1/2 in PM
Anion Gap:  > 12   12 Can START SQ Insulin (overlap w/ IV x2hr).
Advance diet when Gap Normalized
HCO3:  < 15 15  
pH: < 7.30 >7.30  
Symptoms Nausea/ Vomiting Ability to eat (N/V resolved) Can Stop D5W
Advance diet when Gap Normalized
Mental Status Altered Normal  

NOTE: For initial insulin dose, the following formula is suggested:

  • TDD (Total Daily Dose) x 0.8 = ___ Units of estimated SQ insulin.
  • Administer first dose of basal insulin Levemir 2 hr prior to discontinuing IV infusion.
  • The maintenance fluids should either be discontinued or changed to remove Dextrose when pt transitions to regular diet.

 

Dx Criteria

Diagnostic criteria for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)

 

DKA

HHS

Mild Moderate Severe
Plasma Glucose >250 >250 >250 >600
Arterial PH 7.25 - 7.30 7.00 - 7.24 <7.00 >7.30
Serum HCO3 15-18 10 to <15 <10 >18
Urine Ketones* (+) (+) (+) (-) or small
Serum Ketones* (+) (+) (+) (-) or small
Effective Serum Osm. Variable Variable Variable >320
Anion gap Δ >10 >12 >12 Variable (<12)
Alteration in sensoria or mental obtundation Alert Alert
Drowsy
Stupor
Coma
Lethargy
Stupor
Coma
 

 

Resolution Criteria

Glucose: < 200 (for DKA), < 300 for HHS Transition to D5W 1/2 NS
Anion Gap: 12 Can START SQ Insulin (overlap w/ IV x2hr).
Advance diet when Gap Normalized
HCO3: 15  
pH: >7.30  
Ability to eat (No N/V) Can Stop D5W
Advance diet when Gap Normalized
Normal Mental Status  

NOTE: For initial insulin dose, the following formula is suggested:

  • TDD (Total Daily Dose) x 0.8 = ___ Units of estimated SQ insulin.
  • Administer first dose of basal insulin Levemir 2 hr prior to discontinuing IV infusion.
  • The maintenance fluids should either be discontinued or changed to remove Dextrose when pt transitions to regular diet.

 

Clinical Features

Clinical features
DKA usually evolves rapidly over a 24-hour period.
Common, early signs of ketoacidosis include nausea, vomiting, abdominal pain, and hyperventilation. The earliest symptoms of marked hyperglycemia are polyuria, polydipsia, and weight loss.
As hyperglycemia worsens, neurologic symptoms appear, and may progress to include lethargy, focal deficits, obtundation, seizure, and coma.
Common causes of DKA include: infection; noncompliance, inappropriate adjustment, or cessation of insulin; new onset diabetes mellitus; and myocardial ischemia.

 

Evaluation & Lab Findings

Evaluation and laboratory findings
Assess vital signs, cardiorespiratory status, and mental status.
Assess volume status: vital signs, skin turgor, mucosa, urine output.
Obtain the following studies: serum glucose, urinalysis and urine ketones, serum electrolytes, BUN and creatinine, plasma osmolality, mixed venous blood gas, electrocardiogram; add serum ketones if urine ketones present.
Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, an elevated anion gap metabolic acidosis, and ketonemia. Dehydration and potassium deficits are often severe.
Serum glucose is usually > 250 mg/dL (13.9 mmol/L) and < 800 mg/dL (44.4 mmol/L). In certain instances (eg, insulin given prior to ED arrival), the glucose may be only mildly elevated.
Additional testing is obtained based on clinical circumstances and may include: blood or urine cultures, lipase, chest x-ray.

 
 

Management

Management: (uptodate.com)
- Stabilize the patient's airway, breathing, and circulation.
- Obtain large bore IV (≥16 gauge) access; monitor using a cardiac monitor, capnography, and pulse oximetry.

- Monitor
:
  • Vitals: q1h x 6h, then q2h x6h, then q4h until stable
  • CBG q1h
  • BMP, Mg, PO4, (+/- Plasma osmolality & pH)  q4h x 24h.
  • K+  q2h x 6h

- Determine and treat any underlying cause of DKA (eg, pneumonia or urinary infection, myocardial ischemia). 

Fluid Replacement:
(+) Signs of Shock:
  • Give Several liters of isotonic (0.9 %) saline as rapidly as possible.

(-) signs of Shock, (-) Cardiac Compromise:

  • Give NS at 20 cc/kg/hr for the first few hours to hypovolemic patients w/o shock.
  • After IV volume is restored:
    • If Corrected Na is normal or :
      • 1/2 NS (0.45 %) at 4 to 14 cc/kg/hr.
    • If Corrected serum Na is reduced:
      • NS is continued.
Switch 0.9 % NS  to  D5 1/2 NS + Current KCL when the serum glucose reaches 200 (for DKA), 300 for HHS. 
Replete potassium (K+) deficits:
- Regardless of the initial measured K+, patients with DKA have a large total body potassium deficit.

- If initial serum K+ is < 3.3 mEq/L:
  - HOLD insulin
  - Give K+ 20 mEq/hour IV until K+ > 3.3 mEq/L.

- If initial serum K+ is 3.5 and 4.0 mEq/L:
  - Give K+ 20 mEq/L IV fluid

- If initial serum K+ is 4.1 and 5.0 mEq/L:
  - Give K+ 40 mEq/L IV fluid

- If initial serum K+ is > 5.3 mEq/L
  - DO NOT
give K+;

- Maintain K+ between 4 to 5 mEq/L.

 Check K+ q 2 hrs
.
Give insulin: (IV forms: Humalin R, Novolin R)
- DO NOT give insulin if initial  K+ is < 3.3 mEq/L; Replete K+ first.

- Regular Insulin to all patients with K+ > 3.3 mEq/L. Either of two regimens can be used:
  • 0.1 units/kg IV bolus, then start a continuous IV infusion 0.1 units/kg/hr;
    --OR --
  • Do not give bolus  and  start a continuous IV infusion at a rate of 0.14 units/kg/hr.

- Continue insulin infusion until:

  • Ketoacidosis is resolved,
  • Serum glucose is < 200 mg/dL
  • Subcutaneous insulin is begun x 2hrs.
  • Serum anion gap <12 meq/L (or less than the upper limit of normal for the local laboratory)
  • Serum bicarbonate ≥18 meq/L
  • Venous pH >7.30
 pH < 7.00 =  Give NaHCO3
- Arterial pH between 6.90 - 7.00:
  • Give 50 mEq of NaHCO plus 10 mEq of KCL in 200 mL of sterile water over 2hr.

- Arterial pH < 6.90:

  • give 100 mEq of NaHCO plus 20 mEq of KCL in 400 mL sterile water over 2 hr.

 

Insulin Dose

(0.5-0.8 U/kg/day)
1 U/kg/day
      OR
TDD x 0.8
1/2 Bolus 1/3 with breakfast
1/3 with lunch
1/3 with dinner
1/2 Basal 1/2 in AM
1/2 in PM

 


 

Admit Orders: DKA

1. Admit to:  ICU
2. Diagnosis:
 Diabetic ketoacidosis
3. Condition:
4. Vital Signs:
 q1-4h. Call physician if BP >160/90, <90/60; P >140, <50; R >30, <10; T >38.5°C; or urine output <20 mL/hr for more than 2 hours.
5. Activity:
 Bed rest with bedside commode.
6. Nursing:
 Inputs and outputs. Foley to closed drainage. Record labs on flow sheet.
7. Diet:
 NPO for 12 hours, then clear liquids as tolerated.
8. IV Fluids:

  500 mL NS IV boluses; report until blood pressure is >100/60 mmHg, then change to 0.45% saline at 125-150 cc/hr; keep urine output >30-60 mL/h.
  Add KCL when serum potassium is <5.0 mEq/L.
  Concentration.......20-40 mEq KCL/L
  Use K phosphate, 20-40 mEq/L, in place of KCL if hypophosphatemic.
  Change to 5% dextrose in 0.45% saline with 20-40 mEq KCL/liter when blood glucose is 250-300 mg/dL.


9. Special Medications:

  -Oxygen at 2 L/min by NC.
  -Insulin regular (Humulin) 7-10 U/h IV infusion (0.1 U/kg/h); 50 U in 250 mL of 0.9% saline; flush IV tubing with 20 mL of insulin solution. Titrate. Adjust insulin to decrease serum glucose by 100 mg/dL per hour.
  -When bicarbonate level is >16 mEq/L and the anion gap is <16 mEq/L, decrease insulin infusion rate by half.
  -Start subcutaneous insulin when the anion gap has cleared; discontinue insulin infusion 1-2h after subcutaneous dose.


10. Symptomatic Medications:

  -Famotidine (Pepcid) 20 mg IV q12h.
  -Docusate sodium (Colace) 100 mg PO qhs.
  -Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache.
  -Zofran 4 mg IV q4h

11. Extras: Portable CXR, ECG.
12. Labs:
 Fingerstick glucose q1-2h.  CBC, CMP, then BMP q4-6h. HCO3, Mg, phosphate, hemoglobin A1c; Anion gap, Serum lactate, Serum amylase/lipase, Serum Osmolality, Blood/Urine/Sputum cultures, Cardiac enzymes, ABG. UA, beta-HCG, serum ketones, Acetones.