August 22, 2016

Episode 60.0 – Aggressive Resuscitation of Diabetic Ketoacidosis

10 minutes

This week we discuss how to aggressively resuscitate patients with DKA as well as dispelling some dogmatic teachings on the topic.

https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_60_0_Final_Cut.m4a

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Tags: Cerebral Edema, DKA, Hypokalemia, Insulin, Resuscitation

Show Notes

Take Home Points

DKA should be suspected in any patient with altered mental status and hyperglycemia. Get a VBG (ABG not necessary) to confirm the diagnosis.

Hypokalemia kills in DKA. Aggresively replete potassium and consider holding insulin, which drops serum potassium, until K is greater than 3.5

The insulin bolus isn’t necessary and appears to cause more episodes of hypokalemia. Just start insulin as an infusion at 0.14 units/kg

Be vigilant about cerebral edema. Any change or deterioration in mental status should prompt treatment and evaluation. Mannitol in the euvolemic, normotensive patient and 3% hypertonic saline in the hypotensive/hypovolemic patient

Finally, don’t forge to always hunt down the underlying cause of the DKA. Infection and non-compliance is the most common so liberally administer broad spectrum antibiotics if you’ve got even a hint of infection brewing

https://www.youtube.com/watch?v=P9sKk4JZmso

Additional Reading

LITFL: EBM Diabetic Ketoacidosis

Core EM: DKA

Core EM: Episode 13.0 – Diabetic Ketoacidosis: A Case

emDocs: Myths in DKA Management

REBEL EM: Is There Any Benefit to an Initial Insulin Bolus in Diabetic Ketoacidosis?

References

Aurora S et al. Prevalence of hypokalemia in ED patients with diabetic ketoacidosis. Am J Emerg Med 2012; 30: 481-4. PMID: 21316179

Boyd JC et al. Relationship of potassium and magnesium concentrations in serum to cardiac arrhythmias. Clin Chem 1984; 30(5): 754-7. PMID: 6713638

Duhon B et al. Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother 2013; 47: 970-5. PMID: 23737516

Fagan MJ et al. Initial fluid resuscitation for patients with diabetic ketoacidosis: how dry arethey? Clin Ped 2008; 47(9): 851-6. PMID:

Goyal N et al. Utility of Initial Bolus insulin in the treatment of diabetic ketoacidosis. J Emerg Med 2010; 38(4): 422-7. PMID: 18514472

Green SM et al. Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis. Ann Emergency Medicine 1998; 31: 41-48. PMID: 9437340

Kitabchi AE et al. Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis? Diabetes Care. 2008;31(11):2081. PMID: 18694978

Lebovitz HE: Diabetic ketoacidosis. Lancet 1995; 345: 767-772. PMID: 7891491

Morris LR et al. Bicarbonate therapy in severe diabetic ketoacidosis. Ann Intern Med 1986;105(6):836. PMID: 3096181

Muir AB et al. Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification. Diabetes Care 2004; 27(7):1541-6. PMID: 15220225

Okuda Y et al. Counterproductive effects of sodium bicarbonate in diabetic ketoacidosis. J Clinical Endocrinology Metabolism 1996; 81: 314-320. PMID: 8550770

Savage MW et al. Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabet Med. 2011 May;28(5):508-15. PMID: 21255074

Villon A et al. Does bicarbonate therapy improve management of severe diabetic ketoacidosis? Crit Care Med 1999; 27: 2690-2693. PMID: 10628611

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