Episode 60.0 – Aggressive Resuscitation of Diabetic Ketoacidosis

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

August 22nd, 2016 Download Leave a Comment Tags: , , , ,

Show Notes

Take Home Points

  1. DKA should be suspected in any patient with altered mental status and hyperglycemia. Get a VBG (ABG not necessary) to confirm the diagnosis.
  2. Hypokalemia kills in DKA. Aggresively replete potassium and consider holding insulin, which drops serum potassium, until K is greater than 3.5
  3. 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
  4. 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
  5. 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

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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