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DIABETIC KETOACIDOSIS     

DIABETIC KETOACIDOSIS                                                                           REF:  ACP PIER 2009  

 Screening  |  Lab  |  Diff-Dx  | Hospitalization  | Therapy of DKA  
DX:  Diabetic Ketoacidosis (DKA)
when the blood glucose is >=250 mg/dL, arterial pH <=7.30, serum bicarbonate <=15 mEq/L, and positive serum ketones.

(Hyperglycemia, ketonemia, ketonuria, metabolic acidosis)

Screening for Diabetic Ketoacidosis - Consider DKA

  • if hyperglycemia, acidosis, or ketonemia are present.
  • Screen all patients with moderate to severely elevated blood sugars (glucose >350 mg/dL).
    Measure electrolytes, glucose, ketones, and blood gases
    to determine whether anion gap metabolic acidosis is present in patients with positive ketones, constitutional symptoms, or suspicion of DKA.
  • in patients with an anion gap metabolic acidosis.
    Measure serum glucose in patients with metabolic acidosis.
  • in diabetes patients with infection, CVA, MI, or other illness.
    Measure serum glucose and if glucose >250 mg/dL, check the patient's electrolyte and ketone levels and anion gap.
  • in diabetic patients with symptoms of nausea and vomiting (with polyuria, polydipsia), even if blood glucose is <250 mg/dL.
    Measure electrolyte and ketone levels and determine anion gap in patients with diabetes and normal sugar levels
    if symptoms suggest DKA despite normal blood sugar levels.
  • in patients on atypical antipsychotics who present with hyperglycemia.
    Measure anion gap and ketones in patients on atypical antipsychotics who present with moderate to severe hyperglycemia.

   
SX:  Dehydration with hypotension, hyperventilation with fruity "acetone" odor, polyphagia, polydipsia, polyuria, altered mental status, N&V.

History and Physical Examination Elements for Diabetic Ketoacidosis

History

  • Type 1 diabetes - DKA is a frequent complication of type 1 diabetes
  • Constitutional symptoms - DKA may show vague symptoms of lethargy, diminished appetite, and headache
  • Polyuria, polydipsia - May precede the development of DKA by 1 or 2 days, especially if intercurrent illness (infection) is present.
    Or may be symptoms of new onset type 1 diabetes with weight loss, fatigue, blurry vision, and polyphagia
  • Nausea, vomiting, and abdominal pain - May be explained by combination of dehydration, hypokalemia, ketonemia, and delayed gastric emptying

Physical Exam

  • Dehydration - Poor skin turgor, postural hypotension or hypertension may be present
  • Neurologic - Change in level of consciousness or delirium may be mild to severe
  • Kussmaul respirations - Deep breathing and hyperventilation in response to metabolic acidosis
  • Fruity breath - The smell of acetone may be noted, a result of the ketonemia. Acetone is a ketone which is highly volatile
  • Acute abdomen - May be confusing. Abdominal pain and tenderness are frequent and resolve with rehydration
  • Shock and coma - In the most severe cases, hypotension, tachycardia, and coma may be seen
  • Deteriorating level of consciousness with therapy - Cerebral edema, more common in children with severe DKA
  • Evidence of intercurrent illness - Evidence of possible infection such as pneumonia or UTI should be sought. Other illness such as MI or CVA should be excluded

   
LAB & Other Studies in Diabetic Ketoacidosis
  • Plasma glucose: Usually >250 mg/dL
  • Arterial blood gas: pH is usually <7.3
  • Serum ketones:  Usually 7-10 mmol/L in DKA or >1:2 dilution
  • Anion gap (electrolytes) (Na+ - [Cl- + HCO3 -]): Usually >15 in DKA
  • Serum sodium:  Usually low
  • Serum potassium : May be high, normal, or low. Level of potassium will determine when to start potassium replacement and how much to give
  • Blood urea, creatinine levels:  Usually elevated secondary to dehydration and decreased renal perfusion
  • CBC and differential:  Leukocytosis is common and may not represent infection
  • Urine and blood cultures:  If suspicion of infection is present
  • Chest x-ray:  If suspicion of pneumonia is present
  • ECG in all patients:  Will give indication of potassium status, rule out ischemia or MI

   
Differential Diagnosis of Diabetic Ketoacidosis
  • Starvation ketosis
    Patients may have intercurrent illness and can be quite ill, usually give clear history of not eating, and possibly nausea or vomiting
    Blood glucose can be elevated but not drastically; it can be normal or low.
    Starvation ketosis does not lead to acidosis; bicarbonate levels are usually >18 mEq/    L
  • Alcoholic ketoacidosis
    History of excessive alcohol intake in patients with chronic alcohol abuse Blood glucose is the key.
    If blood glucose is normal or low in the presence of ketonemia and metabolic acidosis, alcoholic ketoacidosis is likely and an osmolar gap may be present (difference between measured and calculated osmolality)
  • Lactic acidosis
    Serum lactate is usually ~5 mmol/L Can coexist with DKA.
    Measure lactate if there is suspicion of lactic acidosis or history of metformin use
  • Salicylate intoxication
    Anion gap metabolic acidosis, but often with primary respiratory alkalosis
    Blood glucose is usually not elevated and may be low. Measure the salicylate level
  • Methanol intoxication
    Ketones are not significantly elevated, symptoms include blurry vision and abdominal pain
    Blood glucose may be normal to elevated. Measure methanol level to confirm
  • Ethylene glycol intoxication
    Ketones are not normally elevated but there is typically a high anion gap and an osmolar gap
    Blood glucose is variable. Calcium oxalate and hippurate crystals can be seen in the urine. Measure ethylene glycol
  • Chronic renal failure
    Mild acidosis with slight increase in anion gap but ketones are not elevated
    History of elevated creatinine level
  • Pseudoketosis
    Paraldehyde or isopropyl alcohol ingestion
    pH is normal and anion gap is normal

   
Consider hospitalization for all patients with moderate to severe DKA to units familiar with its management if:
  • The arterial pH level is <7.25
  • The bicarbonate level is <15
  • There is a precipitating illness requiring hospitalization

Rationale:

  • * Adequate therapy will require treatment and observation for 24 hours to ensure that relapse is not likely and to evaluate for precipitating illness.
  • * Patients with DKA require frequent blood work, frequent capillary blood glucose monitoring, and continuous iv insulin therapy.
  • * Accompanying illness must be treated to prevent relapse of DKA or any complications.
  • * Patients with MI or other illness may require specialized therapy such as that found in a coronary care unit.

   
          Screening  |  Lab  |  Diff-Dx  | Hospitalization  | Therapy of DKA  
Drug Therapy for Diabetic Ketoacidosis                   See  Drug Rx for DKA 2009  |   DKA Rx in .pdf form  

  • Begin rehydration with IV fluid for DKA immediately.
  • Begin insulin therapy when serum electrolytes are available.
  • Monitor potassium levels closely and replace potassium deficit in all patients with DKA.
  • Determine the need for bicarbonate therapy.

Begin IV fluid rehydration for DKA immediately.

  • Initial IV infusion bolus of 0.9% NaCl normal saline, ~1 Liter in first hour (15-20 mL/kg/h) depending on the fluid deficit, continue 0.9% NaCl if fluid deficit is large or corrected serum Na and osmolality are high. Once major deficit is corrected, and corrected serum Na is normal or high, use 0.45% NaCl, continue at 4-14 mL/kg·h
    Switch to dextrose containing fluids once the blood sugar level is approximately 250 mg/dL.
    Once glucose is between 250-300 mg/dL, begin IV fluid 5% dextrose with 0.45% NaCl  (D5 1/2 NS) at 150-200 mL/h.
    Maintain insulin infusion at 0.05-0.1 U/kg·h, use 10% dextrose if needed
  • Estimate fluid deficit:  Orthostatic tachycardia ~10% fluid deficit, orthostatic drop ~15%-20% deficit, supine hypotension ~20% decrease in extracellular fluid volume
  • Use extra caution in children, who have higher incidence of cerebral edema associated with DKA therapy, and in children at risk of pulmonary edema.
  • Fluid: Deficit (in liters) usually = 10-15% of BW (kg)
    IV 0.9% saline 2-3 liters first 2 hrs in adult without cardiac disease; continue at 1 liter/h until BP is stable & urine output >30 mg/h; then adjust rate per clinical status.

Begin IV insulin infusion therapy when serum electrolytes are available.

  • Initial IV regular insulin infusion (if serum potassium is >=3.3 mEq/L) bolus of 0.1 U/kg, then followed by  0.1 U/kg/h (~5-10 U/h) IV infusion.
  • Hold insulin Rx if K is <3.3 mEq/L, replace K at 20 to 30 mEq/h (may add 40 to 60 mEq of KCl in 500 mL of 1/2 NS) and monitor frequently.
  • Once blood glucose level is ~<200-250 mg/dL, switch fluids to 5% dextrose in 1/2 NS; insulin dose may then be reduced to 0.05 to 0.1 U/kg·h; monitor therapy using the anion gap and presence of serum ketones. Target blood glucose to 150-250 mg/dL.  
    Monitor therapy using the anion gap and presence of serum ketones.
    Once DKA is resolved, bicarbonate >15 mEq/L, and pH >7.3, can change to multiple dose insulin regimen when DKA resolves.
  • Early reduction or cessation of insulin therapy because of normalization or low blood glucose may result in worsening of DKA and delay of cure.
  • As an alternative to regular insulin infusion, treat uncomplicated mild-to-moderate DKA in adults with subcutaneously administered rapid acting insulin analogs (lispro, aspart) at 0.2 U/kg every 2 hours after initial bolus of 0.3 U/kg.
  • Treat children with mild-to-moderate DKA with subcutaneous lispro at 0.15 U/kg given every 2 hours.

Begin IV  KCl infusion to replace potassium deficit in all patients with DKA if potassium level is <5.5 mEq/L.
Monitor potassium levels closely.

  • Measure serum potassium at baseline, at 1 hour, then every 2 hours during initial therapy.
    Monitor potassium at least every 2 hours until normal.  
    Consider ECG and cardiac monitoring to monitor potassium status.
  • Initiate potassium therapy once the serum potassium level is <5.5 mEq/L unless the patient is anuric or in significant renal failure.
  • If potassium level is <3.3 mEq/L, replace with IV KCl infusion (in 0.9 or 0.45% NaCl saline) at 20-30 mEq/h;
    If potassium is >3.3 and <5.5 mEq/L, replace with IV KCl infusion (in 0.9 or 0.45% NaCl saline) at ~ 20 mEq/h unless the patient is anuric or in significant renal failure.
    Can use 2/3 as KCl and 1/3 KPO4 to prevent excessive Cl levels.
  • Potassium: Deficit (in meq) usually = 5 meq/kg BW

Determine the need for IV Na-bicarbonate therapy.

  • Consider bicarbonate therapy only if pH is <=7.0.
  • If pH is <6.9, give 100 mmol NaHCO3 in 400 mL of water at 200 mL/h and repeat every 2 hours until the pH is >7.0.
    If pH is 6.9 to 7.0, give 50 mmol of NaHCO3 in 200 mL of water at 200 mL/h and repeat every 2 hours until the pH is >7.0.

Determine the need for IV phosphate therapy.

  • If serum PO4 is <1 mg/dL - Add to replacement fluid 20-30 mEq of KPO4 over several hours.
  • Although phosphate level may be low, replacement is not necessary except in unusual circumstances of extremely low phosphate level.
    Phosphate administration may lead to severe hypocalcemia and deposition of calcium phosphate. If phosphate is used, monitor calcium levels. Use 20-30 mEq of KPO4 over several hours if needed
  • See also hypophosphatemia.htm  

Monitoring DKA therapy:

  • Vital signs & urine output q1-2h initially.
  • Blood glucose, electrolytes, ketone, BUN, Creat q1-2h initially.
  • Blood phosphorus 1-2x/d initially

   
          Screening  |  Lab  |  Diff-Dx  | Hospitalization  | Therapy of DKA  

         2009  

2009 General Guidelines for Management of Patients Presenting with High Blood Sugars           See Diabetic Ketoacidosis Rx above

For blood glucose 300 - 500 mg/dl:
  1. Give 10 units Regular or Novolog (Aspart) insulin + 10 units NPH insulin subcutaneously.
  2. Order the following STAT labs the day of the visit:
    " RBS, lytes, BUN, Cr, ketones (add appropriate lab studies if not done recently i.e. non-fasting DM panel (HbA1c, urine Microalbumin, non-fasting HDL, LDL, ALT).
  3. If DCC follow-up is desired, schedule same-day (SDD) appointment for the next working day.
    Phone: 8-327-2440 (Imperial ext. 72440) or Fax a referral: 8-327-2402 (Imperial ext. 72402)
    Order stat FBS, ketones and lytes if abnormal on day of initial visit.
  4. Start oral agent and give diabetes education packet.
    " Order on Health Connect or give prescription for One Touch Ultra glucose meter kit with extra strips (Sure Step, if elderly).
    " Please call DCC or patient may contact the Call Center to schedule for a meter instruction class (60-90 minutes) at DCC
    Imperial Bldg. B Suite 327, # 8-327-2440 (Imperial ext. 72440).
    **It is important that patient is told to bring his/her machine to the class.
  5. Recheck blood sugar before patient is discharged home. Goal: blood sugar <300.
  6. Review with patient the need to force fluids and eat on schedule.

For blood glucose greater than 500 mg/dl  (but glucose less than 700 mg/dL and serum CO2>20):

  1. Give 15 units Regular or Novolog (Aspart) insulin + 10 units NPH insulin subcutaneously.
  2. Order the following STAT labs on the day of the visit: RBS, lytes, BUN, Cr, ketones
    " Add appropriate lab studies if not done recently i.e.,non -fasting DM panel (HbAlc, urine microalbumin, and non-fasting HDL, LDL, ALT).
  3. Start IV hydration with 1 liter normal saline. Give 20 meq KCl p.o. if K+ is <3.5.
    " Blood sugar should be checked hourly.
    " Call DCC 8-327-2440 (Imperial ext. 72440) if assistance is needed.
    During after-hours, send the patient to ED for hydration and further treatment after initial insulin injection.
  4. If DCC follow-up is desired, schedule same-day (SDD) appointment for the next working day.
    Phone: 8-327-2440 (Imperial ext. 72440) or Fax a referral: 8-327-2402 (Imperial ext. 72402)
    Labs to be done before follow-up visit: stat FBS, ketones, and lytes (if abnormal on day of initial visit).
  5. Start oral agent or add insulin if indicated.
    " Give diabetes education packet and encourage pt. to attend MHE classes.
    " Order on Health Connect or give prescription for One Touch Ultra glucose meter kit and extra strips (Sure Step, if elderly).
    " Please call DCC or patient may contact the Call Center to schedule for a meter instruction class (60-90 minutes) at DCC
    Imperial Bldg. B, Suite 327, tie line 8-327-2440 (Imperial ext. 72440). **It is important that patient is told to bring his/her machine to the class.
    " Insulin instruction classes (60 minutes) can also be scheduled at DCC 8-327-2440 (Imperial ext. 72440).
    **Please provide patient with prescriptions for insulin and syringes before discharge. Include a separate written order that notes dose of insulin you want patient to be started on.
  6. Recheck blood sugar before patient is discharged home. Goal: blood sugar <300.
  7. Review with patient the need to force fluids and eat on schedule.

For blood glucose >700 mg/dl or C02 <20,

  • patients should be sent to Emergency Room Department after giving insulin and 20 meq KCL p.o if K+ is <3.5. If patient appears dehydrated, start one liter normal saline IV and transport by ambulance.

Endocrinology (KP Imperial Diabetic Clinic 2-2006)

Infections in Patients with diabetes Mellitus - Johns Hopkins Advanced Studies in Medicine Feb 2006  

       2007

REF: The Washington Manual® of Medical Therapeutics (WashMan™) 2007

HYPOGLYCEMIA Treatment

Isolated episodes of mild hypoglycemia may not require specific intervention. Recurrent episodes require a review of lifestyle factors; adjustments may be indicated in the content, timing, and distribution of meals, as well as medication dosage and timing. Severe hypoglycemia is an indication for supervised treatment. › Readily absorbable carbohydrates (e.g., glucose and sugar-containing beverages) can be administered orally to conscious patients for rapid effect. Alternatively, milk, candy bars, fruit, cheese, and crackers may be adequate in some patients with mild hypoglycemia. Hypoglycemia associated with acarbose or miglitol therapy should preferentially be treated with glucose. Glucose tablets and carbohydrate supplies should be readily available to patients with DM at all times.

  1. IV dextrose is indicated for severe hypoglycemia, in patients with altered consciousness, and during restriction of oral intake. An initial bolus, 20–50 mL of 50% dextrose, should be given immediately, followed by infusion of D5W (or D10W) to maintain blood glucose above 100 mg/dL. Prolonged IV dextrose infusion and close observation is warranted in sulfonylurea overdose, in the elderly, and in patients with defective counterregulation.
  2. Glucagon, 1 mg IM, IV or SC (1/2 life 8 to 18 minutes), is an effective initial therapy for severe hypoglycemia in patients unable to receive oral intake or in whom an IV access cannot be secured immediately. Vomiting is a frequent side effect, and therefore care should be taken to prevent the risk of aspiration. A glucagon kit should be available to patients with a history of severe hypoglycemia; family members and roommates should be instructed in its proper use.
  3. Education regarding etiologies of hypoglycemia, preventive measures, and appropriate adjustments to medication, diet, and exercise regimens are essential tasks to be addressed during hospitalization for severe hypoglycemia.
  4. Hypoglycemia unawareness can develop in patients who are undergoing intensive diabetes therapy. These patients should be encouraged to monitor their blood glucose frequently and take timely measures to correct low values (<60 mg/dL). In patients with very tightly controlled diabetes, slight relaxation in glycemic control and scrupulous avoidance of hypoglycemia can restore the lost warning symptoms.

       2009