DKA Treatment

Question 1

Goals of therapy (5)

Answer 1

1. Volume repletion
2. Reversal of metabolic consequences of insulin insufficiency
3. Corection of electrolyte and acid-base imbalances
4. Recognition and treatment of precipitating causes
5. Avoidance of complications

ORDER OF PRIORITY:
1. VOLUME
2. K DEFICIT
3. INSULIN

Question 2

Specific goals of treatment

Answer 2

BG <200mg/dl
HCO3 > or = 18mEqs/L
Venous pH >7.3

Question 3

Fluid of choice

Answer 3

Normal saline
LR
Balance crystalloid

16 or 18G
IVF 1: PNSS or LR or Balanced
IVF 2: 0.45 PNSS

Question 4

Rate of fluid given initially

Answer 4

Fluid bolus at 15-20ml/kg/hr during the 1st hr

Based on clnical suspicion alone

rate depends on stability, hydration, urine output, electrolytes

Question 5

After initial fluid bolus, what is the fluid regimen?

Answer 5

NS at 250-500ml/hr in HYPOnatremic patients
0.45NS 250-500ml/hr in Eunatremic and HYPERnatremic patients

Question 6

General fluid regimen in DKA

Answer 6

First 2L administered rapidly over 0-2hrs
Next 2L over 4-6hrs
Additional 2L over 6-12 hrs

Once BG is at 250mg/dl, shift to 5% dextrose + 0.45% NS

in patients without severe depletion, 250 to 500ml over 4 hours may be done

Question 7

Reversal of metabolic consequences in DKA should be done in what timeframe

Answer 7

24 to 36 hours

monitor q2

Question 8

For each __ decrease in pH, Serum potassium rises ___ meqs/L

Answer 8

0.1 decrease in pH
0.5 meqs/L increase in K

Rises due to acidosis (hydrogen exchange, total body fluid deficit, diminished renal function)

Question 8

Initial hypokalemia indicates?

Answer 8

Severe total body potassium deficits

requirement of a large amount of replacement in the 1st 24 to 36hrs

HypoK during treatment:
primarily occurs due to inslin promoting entry into cells
secondary: dilution of ECF, correction of acidosis, urinary losses

Question 8

Most severe life threatening electrolyte derangement during DKA treatment

Answer 8

Rapid development of severe hypokalemia

Question 8

Initial K 3.3-5.2mEqs/L

Answer 8

Add 20 to 30mEqs/L K to PNSS for 4 hrs

Question 8

Initial K <3.3mEqs/L

Answer 8

20 to 30mEqs/h K and HOLD insulin

resume once K > or equal to 3.5

Hold or decrease K replacement if oliguric or w renal insufficiency

Question 8

use of potassium phosphate may induce

Answer 8

hypocalemia and precipitation of calcium phosphate in tissues

Question 9

Rate of K correction

Answer 9

NO FASTER THAN
10 meqs/hr via peripheral line
20meqs/hr via central line

during the 1st 24 hours 100 to200 mEqs of KCl is usually required

Question 10

Dose of K2PO4 replacement

Answer 10

2.5 - 5mg/kg

Started only once <1mg/dl
Complications: Hyperphosphatemia, Hypernatremia Hypocalcemia, Hypomagnesemia, Metastatic soft tissue calcification, Volume loss
HypoP most severe 24-48 hrs after insulin initiation

Question 11

Hypomagnesemia inhibits PTH secretion and results to

Answer 11

Hypocalcemia
Hyperphosphatemia

if <2.0mEq/L (<1.0mmol/L) give 2g TIV over 1 hr

Question 12

Insulin infusion dose

Once Hypokalemia is excluded

Answer 12

0.1 to 0.14u/kg/hr
then reduce to 0.02 to 0.05 u/kg/hr

Alt: 0.1u/kg IM if no IV line followed by 0.1u/kg/hr

HL: 4-5mins
Tissue HL: 20-30mins

Question 13

Expected drop of blood glucose when on infusion

Answer 13

50-75mg/dl/h

If no decrease by 10% 1 hr after therapy, or 3mmol/L/h, give 0.14u/kg bolus then resume drip OR increase rate by 1u/hr

Question 14

what to give in severe acidosis with pH <6.9

Answer 14

100meqs of NaHCO3 in 400ml of water with 20mEqs of KCL at 200ml/hr for 2 hrs until pH 7.0

Pros: improved contractiliy, increased vfib threshold, improved catecholamine tissue response, decreased work of breathing

Cons: Hypokalemia, CNS acidosis, Intracellular acidosis, Impaired shift to the left oxyhemoglobin dissociation, hypertonicity, Na overload, Delayed recovery from ketosis, elevated lactate, cerebral edema

Question 15

What is done to avoid relapse of hyperglyecemia and DKA?

Answer 15

Initiate SC insulin 2-4 hrs before discontinuing IV infusion

Give 50% of long acting 2hrs prior stopping infusion

new DM dose: 0.5 to 0.8 u/kg

Question 16

Can SC Insulin be used in DKA?

Answer 16

Yes for mild to moderate uncomplicated DKA

SC lispro: 0.3 u/kg then 0.1u/kg q1
OR
0.3u/kg then 0.2u/kg q2 until BG <250mg/dl

subsequent doses are decreased by half and given q1-2 until DKA resolved

Question 17

Main contributors to mortality

Answer 17

Infection and myocardial infarction

moratality is mainly from sepsis or cardiopulmonary complications in elderly

Question 18

Most common and feared cause of mortality in children, adolescents, and newly diagnosed DM

Answer 18

Cerebral edema

develops in 4-12 hrs, present in 24-48 hrs

(+) AMS early in TX : give mannitol 1-2/kg or HTS 3% 5 to 10ml/kg over 30 mins

Question 19

Major trigger for recurrent DKA

Answer 19

Insulin non-compliance