Transcript DKA - UNM Hospitalist Group / FrontPage

Surviving DKA
(as house staff)
Matt Bouchonville
Endocrinology Division
Thursday School
July 25, 2013
↓ insulin
+
↑ counterregulatory
hormones
= DKA
↓ insulin
↑ glucagon
↑ gluconeogenesis
↓ glucose utilization
Hyperglycemia
DKA
↑ lipolysis
Ketosis
↑ ketone bodies
Acidosis
↓ insulin
↑ lipase
↑ glycerol
↑ FFA
Adipocytes
↑ glucagon
↑ GH
↑ cortisol
↑ catecholamines
Liver
gluconeogenesis
ketoacids
(acetoacetic acid,
betahydroxy butyrate)
↑ Counterregulatory
Hormones
Relative Insulin
Deficiency
Absolute Insulin
Deficiency
Absent or minimal
ketogenesis
↑ Ketoacidosis
HHS
DKA
DKA on the rise
Discharges (in Thousands)
2009: 140,000 admissions for DKA
~10% of all diabetes-related
admissions
Year
http://www.cdc.gov/diabetes
Number
Rate (per 100,000)
DKA: Mortality rates stable
Year
http://www.cdc.gov/diabetes
Year
DKA: Mortality rates stable
Age group (yrs)
• Mortality:
– Precipitating event-related
– DKA-related
• Hyperglycemia  osmotic diuresis  dehydration  shock
2006 – Overall mortality
• Acidosis  electrolyte imbalance  arrhythmias
rate for DKA: 0.41%
 impaired cardiac contractility  shock
 vasodilation  shock
http://www.cdc.gov/diabetes
Mortality (%)
Objectives
• Diagnosis
• Management
• Common “Pitfalls”
• Clinical cases
Diabetes Care, Vol 32 (7)1335-1343, 2009
Diagnosis of DKA
• Clinical presentation
• Physical Exam
• Polydipsia/polyuria
• Tachycardia
• Constitutional symptoms
• Postural hypotension
• Nausea/vomiting
• Kussmaul respirations
• Abdominal pain (40-75%)
• Fruity breath
• Altered sensorium
• Altered sensorium
• Abdominal tenderness
Diagnostic Criteria
Diagnostic criteria
Laboratory Parameters
Serum glucose, mg/dL
> 250
Arterial pH
< 7.3
Bicarbonate, mEq/L
<18
Ketones (urine, serum)
+
DKA Severity
Mild
Moderate
Severe
> 250
>250
>250
7.25-7.30
7.00-7.24
<7.00
15-18
10-14
<10
Ketones (urine, serum)
+
+
+
Anion gap
↑
↑
↑
Laboratory Parameters
Serum glucose, mg/dL
Arterial pH
Bicarbonate, mEq/L
Electrolytes and Hydration
Total Water, L
Serum
Total body deficit
n/a
5-8
↓(↑↔)
7-10
Laboratory Parameters
Na, mEq/kg
Cl, mEq/kg
K, mEq/kg
3-5
↑ (↓↔)
3-5
Phos, mEq/kg
5-7
Mg, mEq/kg
1-2
Ca, mEq/kg
1-2
The Usual Suspects
Factors Precipitating DKA
Most Common
Other
Infection (UTI, PNA)
Myocardial infarction
Noncompliance
Stroke
New-onset diabetes
Trauma
Pregnancy
Pancreatitis
EtOH abuse
Medications
Objectives
• Diagnosis
• Management
• Common “Pitfalls”
• Clinical cases
Management of DKA
?
IV Fluids
?
Insulin
Assess ?need for
bicarbonate
?
Potassium
Management of DKA
Severe
dehydration
IV Fluids
0.9% NaCl 1L/hr
Na high
0.45% NaCl
250-500 cc/hr
Mild dehydration
Insulin
Calculate
corrected Na
Shock
Pressors
Potassium
Na normal
Na low
Assess need for
bicarbonate
Change
to D5 0.45% NaCl
0.9% NaCl 250500 cc/hr
150-250 cc/hr when glucose
reaches 200 mg/dL
Insulin
+/-
IV Bolus: 0.1
U/kg regular
IV Continuous
infusion: 0.1
U/kg/hr
Serum glucose
↓ to 200 mg/dL:
decrease IV rate
to 0.05-0.1
U/kg/hr
If serum glucose
does not fall by
50-70 mg/dL in
first hour,
double IV rate
Target glucose: 150-200
mg/dL until DKA resolved
Potassium
Establish
adequate renal
function (UOP
~50 cc/hr)
Serum K+ ≤ 3.3
mEq/L: Hold insulin
& give 20-30 mEq/hr
K+ until serum K+ >
3.3 mEq/L
Serum K+ 3.45.2 mEq/L: Give
20-30 mEq K+
in each liter of
IV fluid to
maintain serum
K+ 4-5 mEq/L
Serum K+ ≥ 5.3
mEq/L: Do not
give K+ but
check serum K+
every 2 hrs
Assess need for bicarbonate
pH < 6.9
pH 6.9 - 7
Dilute NaHCO3 (100
mmol) in 400 ml water
with 20 mEq KCl.
Infuse 2 hr
Dilute NaHCO3 (50
mmol) in 200 ml water
with 10 mEq KCl.
Infuse 1 hr
Repeat NaHCO3
infusion every 2 hr until
pH > 7.0. Monitor K+
pH > 7.0
No HCO3
Criteria for resolution of DKA
• Serum glucose < 200 mg/dL
• pH < 7.3
• Anion gap < 14
• Serum bicarbonate ≥ 18 mEq/L
• Ready for transition to SQ insulin?
• Eating >50% meal?
Transition from IV to SQ insulin
• Total daily dose:
• Resume previous outpatient dose
• Insulin naïve (new diagnosis of T1D)
• Weight based or infusion rate derived?
½ basal
• 0.5-0.8 units/kg/day
½ bolus
• Timing of SQ insulin dose?
1-2 hours before
stopping IV insulin
Objectives
• Diagnosis
• Management
• Common “Pitfalls”
• Clinical cases
Common Pitfalls
• Hypoglycemia (10-25%)
• Hypokalemia
• Hyperchloremic (nongap) acidosis
• NaCl treatment
• Loss of substrate for bicarbonate regeneration
• Recurrent DKA
• Failure to overlap SQ insulin with IV insulin
(Less) Common Pitfalls
• Cerebral edema
•
•
•
•
•
Associated with rapid correction of serum osmolality
1% of children with DKA
Reported in young adults
Mortality 40-90%
Clinical manifestations:
•
•
•
•
Lethargy
Seizures
Bradycardia
Respiratory arrest
Objectives
• Diagnosis
• Management
• Common “Pitfalls”
• Clinical cases
Case #1
• 34 yo F with T1D treated with glargine and
humalog presents to ER in DKA. Which of the
following antihypertensive medications may be
precipitating her current presentation?
A)
B)
C)
D)
Lisinopril
HCTZ
Amlodipine
Losartan
Answer: B) HCTZ
• Medications which may precipitate DKA:
• HCTZ
• Beta blockers
• Steroids
• Phenytoin
Case #2
• 56 yo obese M with T2D treated with metformin,
HTN treated with HCTZ, lisinopril brought in by
EMS. Obtunded and found to have the following
labs:
• Gluc 286 mg/dL
• Creat 3.5 mg/dL
• Bicarb 8 mEq/L
• Anion gap 20
• Serum ketones neg
Case #2
• What is the most likely cause of this patient’s
presentation?
A)
B)
C)
D)
DKA
HCTZ use
Metformin use
Vitamin D deficiency
Answer: C) Metformin use
• Differential diagnosis:
• Starvation ketosis
• Generally not hyperglycemic
• Alcoholic ketoacidosis
• Bicarb rarely < 18; generally not hyperglycemic
• Anion gap acidosis
• Lactic acidosis, salicylates, toxic alcohols
Case #3
• 29 yo M presents to ER with abdominal pain, nausea,
vomiting, weight loss, and polyuria. Found to be in DKA
with likely new dx T1D. Hemodynamically stable.
Exam remarkable for abdominal tenderness, no
peritoneal signs. Labs remarkable for an elevated
serum amylase. What next step would be most
appropriate to determine whether the patient has acute
pancreatitis?
A)
B)
C)
D)
CT abdomen
Abdominal ultrasound
Serum lipase
Whipple procedure
Answer: C) Serum lipase
• Serum amylase levels commonly elevated in
patients with DKA (up to 80% cases)
• Lipase much less commonly elevated
Case #4
• 17 yo F with T1D, poor compliance, admitted with
DKA. Treated with aggressive IV fluids, IV insulin.
Receives supplemental potassium, phosphate, and
magnesium overnight. Presents with tetany in the
morning. Which laboratory abnormality could
explain this finding?
A)
B)
C)
D)
Serum potassium
Serum phosphate
Serum magnesium
Serum calcium
Answer: D) Serum calcium
• Phosphate replacement:
• Prospective randomized studies have failed to show
benefit in DKA outcomes
• Risk of severe hypocalcemia (younger patients)
• Not routinely recommended
• ADA: “Careful phosphate replacement may sometimes
be indicated in patients with cardiac dysfunction,
anemia, or respiratory depression and in those with a
serum phosphate concentration of < 1.0 mg/dL”
Case #5
• 28 yo M with unknown medical history is brought in
by EMS after being found down. The patient is
obtunded and found to be in DKA. Serum glucose
is 400 mg/dL, serum bicarbonate is 10 mEq/L,
anion gap is 20, serum osmolality is 298, serum
ketones are positive. Which answer most
accurately describes his mental status?
A) It is likely related to the DKA and should improve with
treatment
B) It is unlikely to be related to the DKA
C) Both, A & B are correct
D) Answer A
Answer: B) Unlikely related
• ADA:
• “The occurrence of stupor or coma in diabetic patients
in the absence of definitive elevation of effective
osmolality (320 mOsm/kg) demands immediate
consideration of other causes of mental status
change.”
Objectives
• Diagnosis
• Management
• Common “Pitfalls”
• Clinical cases
Questions?