DKA Pearls

Risk factors:
• Infections
• Cardiac events
• Medications ( such as steroids)

Think DKA:
• Positive anion gap
• Sick patient with diabetes
• Patient with sustained nausea and vomiting
• New initiation of anti-psychotic medications
• High glucose levels

Important Labs:
• Potassium, potassium, potassium (also phos and magnesium!)
• Glucose
• Beta hydroxybutyrate
• Labs for anion gap : Na- (Cl +HCO3)
• ABG followed by venous pH

Pitfalls:
• Not being vigilant about replacing potassium
• Treating DKA towards normalization of blood glucose instead of reducing the acidosis (
normalization of anion gap)

DKA Management Pearls:

Fluid fluids fluids!!! ( deficit generally 5-11 liters)
o Normal saline or ½ normal saline at 1 l/hr for first 2 hours, than 250-500 cc/hr
o Follow JVD/orthostatics/ volume exam and continue IV till volume replete and can tolerate PO
o Examine patient regularly

Potassium replacement ( should start once potassium falls below 4.5)
o Maintain normal potassium to avoid cardiac arrhythmia’s
o Replace potassium when it is normal, not low
o Use KPO4 if phos is low’
o Patient should be on telemetry and have EKG followed closely

Bicarbonate therapy
o Not necessary unless pH<7.0 or patient is shock
o Do not give bicarbonate bolus
o May delay recovery from acidosis
o May cause worsening hypokalemia

Phosphate therapy

o Phosphate like potassium re-enters the cell during insulin therapy
o Very low phosphate <1.5
o Cardio respiratory compromise
o KPO4 20-30 MeQ/L over 2-3 hours
o Watch for hypocalcemia

Insulin therapy
o Give initially as 0.1 units/kg bolus
o Then continuous infusion 0.1 units/kg/hour
o Regular insulin is used and insulin infusion is adjusted with rise and decrease in hourly glucose
o Goal Blood Glucose: 150-200 mg/dl
o  T1/2 of IV insulin is 7-10 minutes
Some form of subcutaneous insulin must be given at least 1-2 hours before the insulin drip is stopped

Restart Subcutaneous Insulin
o Usually based on patients previous outpatient dose or recalculate based on rate and renal
function
o Generally 0.5-0.8 units/kg total daily dose, divided before meals and bedtime insulin
o 0.3 units/kg daily dose with renal impairment
o Remember to give rapid acting insulin initially-not just basal-and continue insulin drip for 1-2
hours or until glucose<200 mg/dl

Pitfalls
• T2 DM can have DKA as an emergency
• Younger patients can present with euglycemic DKA
• Consider other autoimmune co-morbid conditions
o Adrenal insufficiency
o Thyroid storm
o MI

Save the patient:

• Add Dextrose to IV fluids when BG 200-300
• Stop IV insulin 1-2 hour after SC insulin
• Remember Type 2 DM does not protect from DKA

Manish Suneja MD

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