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?