5/15/12
Emergency Management of DKA in adults
Click to edit Master subtitle style By
Nitin Sahi
5/15/12
Diabetic ketoacidosis
Triad of hyperglycaemia, acidosis and ketonaemia. Criteria (all 3 must be present)
ketones > 3mmol/l or urine ketones ++
Diagnostic
Cbg > 11mmol/L or known diabetes mellitus
Capillary Venous
pH < 7.3 and/or bicarbonate < 15mmol/L
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Presentation
Symptoms Polydipsia, Nausea
polyuria, weight loss
+ Vomiting, non specific abdo pain confusion, stupor, coma
Lethargy,
Signs Dehydration Kussmauls Tachycardic Acetone
Respiration and hypotensive
breath
Risk Factors! Inadequate insulin Infection MI Others surgery pancreatitis, stroke, drugs
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Kussmauls Breathing
http://
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Differential Diagnosis
Condition Hyperosmolar nonketotic (HONK) coma Differentiating signs/symptoms Differentiating tests
Older T2DM patients Glucose > 35 mmol/l Insidious course days to weeks Osmolarity > 340 mOsm/kg Stupor + Coma more common Ketones - neg or trace pH > 7.30 Very similar to DKA History suggestive of aspirin overdose Serum lactate > 5 mmol/l Resp alkalosis then anion gap metabolic acidosis Salicylate in blood/urine
Lactic acidosis Salicylate poisoning
Methanol/Ethylene glycol intoxication
History of ingestion of antifreeze, serum methanol/ethylene detergents, paints, methylated glycol spirits anion gap metabolic acidosis Long-standing alcoholics relying on ethanol for calories who stop drinking 3 to 14 days starvation Ketonuria/aemia always present anion gap metabolic acidosis Normal glucose Ketonuria but no ketonaemia
Alcoholic ketoacidosis
Starvation ketosis
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Management
ABC IV
(JBDS Guidelines 2010)
fluid replacement assessment
Temp, BP, O2 Sats,
Clinical RR,
GCS Clinical
Examination
Investigations CBG,
venous glucose, VBG, FBC, U+Es, Cultures, ECG, CXR, Urinalysis and culture
Continuous
cardiac monitor and pulse
oximetry
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Assessing severity
Senior
review + ?HDU if any of:
ketones > 6 mmol/L level < 5 mmol/L pH < 7.1
Blood
Bicarbonate
Venous/arterial Hypokalaemia GCS O2
on admission (< 3.5 mmol/L)
Young people aged 18-25 years Elderly Pregnant Heart or kidney failure Other serious co-morbidities
< 12 or abnormal AVPU scale
Sats < 92% on air (assuming normal baseline respiratory function) BP < 90 mmHg
Systolic Pulse Anion
> 100 or < 60 bpm gap >16
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Initial Fluid Replacement
SBP
< 90
0.9% Saline over 10-15 mins if SBP remains < 90 + get senior input - ?
500ml
Repeat
ITU
SBP
> 90
1L
0.9% Saline over 1st hour (+KCl if already given 1L)
K+ 1L 0.9% Saline + KCl over 2 hours per Litre IV level KCL replacement (mmol/L) fluid 1L 0.9% Saline + KCl over 2 hours > 5.5 Nil 1L 3.5-5.5 0.9% Saline + KCl over 4 hours 40 mmol/L
1L
0.9% Saline + KCl over 4 hours
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Insulin Therapy (IV Insulin Infusion IVII)
Continuous 50U Rate
fixed rate IVII not sliding scale!
Actrapid in 50mls 0.9% Saline (1U=1ml) = 0.1unit/kg/hour (7ml/hr if 70kg) long acting insulin as normal
blood ketones by > 0.5 mmol/l/hr HCO3 rising by > 3 mmol/l/hr blood glucose falling by > 3 mmol/l/hr
Continue Aims Reduce Venous
Capillary Increase Continue
insulin infusion 1U/hr until aims met fixed rate IVII until resolution:
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Monitoring
1o
capillary blood glucose levels and blood ketones (if available) blood gas for pH, bicarbonate and potassium at 60 minutes, 2 hours and then 2o, 4o U+Es glucose < 14 mmol/l, give 10% glucose at 125ml/hr alongside 0.9% saline and replace K+ as appropriate for complications
overload, cerebral oedema
Venous
If
Monitor Assess fluid
Specialist
diabetes team
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Additional Measures
Regular
(EWS)
observations and Early Warning Score
Accurate
fluid balance chart, minimum urine output 0.5ml/kg/hr if incontinent or anuric (not passed urine by 60 minutes) tube with airway protection if patient obtunded or persistently vomiting ABG and repeat CXR if O2 sats < with LMWH 92%
Catheterise
NG
Measure
Thromboprophylaxis
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Prognosis and Prevention
Prognosis Mortality Cerebral Adults
rates have fallen significantly in the last 20 years from 7.96% to 0.67% oedema is main cause of mortality, particularly in young children and adolescents - severe hypokalaemia, ARDS, and comorbid states (pneumonia, MI, sepsis)
Prevention Education Patients
signs
Sick day rules, triggers, early warning professionals awareness of presentation
Medical
