A Brief Synopsis of AFP's "Diabetic Ketoacidosis: Evaluation and Treatment"

A brief synopsis of

Diabetic Ketoacidosis: Evaluation and Treatment

DYANNE P. WESTERBERG, DO, Cooper Medical School of Rowan University, Camden, New Jersey

Am Fam Physician. 2013 Mar 1;87(5):337-346.

http://www.aafp.org/afp/2013/0301/p337.html

     DKA is a dangerous consequence of uncontrolled type 1 diabetes, but it can occur in type 2 as well. It occurs more often in females and in younger patients. The most common cause of death from DKA is cerebral edema.
    Patients with DKA will complain of polyuria with polydipsia, weight loss, fatigue, vomiting, dyspnea, abdominal pain, polyphagia, a recent illness, tachycardia, dry mouth, and orthostatic hypotension. They may have fruity breath, Kussmaul breathing, tiredness, lethargy or even in a stupor.
     The main differentials are all the other causes of anion gap metabolic acidosis (see "MUDPILES"), pancreatitis  gastroenteritis, MI, starvation ketosis, or hyperosmolar state. In hyperosmolar state, the ketone level is low.
     The lab values that should lead you to the diagnosis are a glucose greater than 250 mg/dL, elevated ketones, a pH less than 7.3, and a bicarbonate level less than 18 mEq/L. Changes in pH, bicarbonate, anion gap, and mental status can be used to gauge the severity. Serum ketone measurements are preferred because B-hydroxybutyrate (the primary ketone in DKA) is not picked up by urinalysis  Electrolytes, creatinine  phosphate  A1C, osmolality and BUN should also be measured.
     Fluid replacement is the treatment for DKA.  NS is given at 1 L/hr. This can be lowered to 250-500 mL/hr later on. The solution can also be changed to 1/2NS  once the sodium reaches 135 mEq/L. Dextrose can be added once the glucose drops below 200.
     Insulin can be added 1-2 hours after you start fliuds at 0.1 u/kg bolus and 0.1 u/kg/hr.  Glucose should drop 50-70 mg/dL per hour. Once the glucose gets to 200, you can drop the insulin down to 0.05-0.1 u/kg/hr. Glucose should be maintained at 150-200, so you may need to add dextrose to get there. Once the glucose is below 200, the bicarb is at 18 or higher, and the pH is above 7.3, then the DKA has resolved.
     K should also be monitored in patients with DKA.  It should be at 4-5 mEq/L. K should be given at 10-15 mEq/hr. If the K goes to 5.2 or above, hold it. If it goes below 4, you can bump it up to 20-30 mEq/hr. If it goes below 3.2, hold the insulin.
     Replacing bicarbonate, phospate, or magnesium has not been shown to change outcomes, but it is still recommended. It should be replaced when the pH is below 6.9. If the phosphate goes below 1 mg/dL, add 20-30 mEq's to the IV. Mg can be replaced if it falls below 1.2 mg/dL.