Treating DKA in Type 2
Diabetes
GABRIELLE RUTENBERG
CASE STUDY 2015
Objectives
Anatomy
and
Physiology
Presentation
Patient
Disease
Process
Medical
Nutrition
Therapy
Symptoms
Treatment
Methods of
Diagnosis
Introduction

Type 2 diabetes has become a major epidemic in
the last decade

29 million people in the U.S. already have T2D (CDC)

More than 1 in 3 have pre-diabetes
Continued



Diabetic ketoacidosis (DKA) typically in type 1
diabetes
type 2 diabetes
138 consecutive admissions for DKA observed that
21.7% had type 2 diabetes
Anatomy and Physiology
of the Organs
Pancreas

Two functions:

Exocrine: involves small glandular cells that
produce digestive juices made up of water, salt,
sodium bicarbonate and digestive enzymes

Endocrine: made up of cell clusters called islets that
produce hormones such as insulin and glucagon
Liver
Kidneys

Waste filtering and disposal system

Filter glucose that the cells do not use

Keep electrolytes stable
Disease Process
Disease Process
Symptoms
Polyuria
Polydipsia
Shortness of Breath
Confusion
Dehydration
Nausea/Vomiting
Weakness/Fatigue
Methods of Diagnosis
Blood Test
results DKA
,
Labs
Value
Glucose
>250 mg/dL
Blood pH
<7.3
Serum Bicarbonate
<15 mEq/L
Serum Ketones
positive
Potassium
>3.5 mEq/L
Sodium
<135 mEq/L
Phosphorous
<2.3 mEq/L
Chloride
<97 mEq/L
BUN
>18 mg/dL
Creatinine
>1.3 mg/dL
White Blood Cells
Elevated
Other Methods

Urinalysis: ketones

Electro-cardiogram: cardiac complications,
hypokalemia or hyperkalemia

Chest X-ray: respiratory conditions
Treatment of DKA
To Treat DKA…..
3
Steps:
Fluid
Replacement
Insulin Therapy
Electrolyte
Replacement
Other Goals for Treatment

Promote return to wellness

Monitor precipitating factors (e.g. d/c of insulin, surgery, MI,
or trauma)

Prevent complications (e.g. shock, arterial thrombosis, and
cerebral edema)

Adjust insulin doses as needed
Fluid Replacement

Choice for fluid replacement

NaCl 0.45% or 0.9%

Glucose <250 mg/dL
5% Dextrose is used
Insulin Therapy

Oral diabetic medications and other insulin’s should be
discontinued

Regular insulin (short-acting)

Insulin IV bolus or an hourly insulin infusion

Glucose should
first hour
50–75 mg from the initial value in the
Potassium Replacement

Potassium levels should be monitored every 2-4 to four
hours in early stages of DKA

Treatment goal = 4–5 mEq/L

Hypokalemia = hold insulin therapy and begin
replacement with fluid therapy until levels >3.3 mEq/L
(to avoid arrhythmias + respiratory muscle weakness)

Urine output is <30 mL/hr = hold therapy
pH Balance
Bicarbonate:
 If pH <6.9 = give 100mEq sodium bicarbonate in 1L D5W
and infuse at 200ml/hr

If pH is 6.9-7.0 = give 50mEq sodium bicarbonate in 1L
D5W and infuse at 200ml/hr

Treatment should be continued until pH is >7.0

If pH is >7.0= this step can be avoided
When is DKA Resolved?
Labs
Values
Plasma Glucose
<200 mg/dL
Bicarbonate
>18 meq/L
Blood pH
7.3-7.4
Ketones
Negative
Medical Nutrition Therapy
Goals for the RD

Reinforce nutritional guidelines
for diabetes

Complications that can arise
from the disease

Healthful eating patterns (e.g.
Carbohydrate consistency)

Attain glycemic, blood
pressure, and lipids goals
Recommendations from the American
Diabetes Association
Markers
Goals
HbA1c
<7 %
Blood Pressure
<140/80 mmHg
LDL
<100 mg/dL
HDL
>40 mg/dL (men); >50 mg/dL
(women)
Triglycerides
<150 mg/dL
Calorie Needs

25-30 cal/kg (ASPEN)

Varies depending on
the person's age, sex,
activity level, current
weight, body style, and
comorbidities
Macronutrients
CHO: 45-65%
Protein: 15-20%
Fat: 25-35%
Fiber

Beneficial in controlling blood sugar levels

Hunger control

Soluble fiber: oatmeal, lentils, apples, oranges, pears

Nutrition Care Manual: 44-50 gm to improve glycemia

25 grams for women and 38 grams for men
Micronutrients

Sodium:
 At risk for hypertension
 2,300 mg or less per day
(American Diabetes
Association)
 For hypertension: 1,500
mg/day (American Heart
Association
Continued…..

Magnesium

Blood glucose control, blood
pressure, atherosclerosis, and
prevent of retinopathy

Elevated blood glucose levels
increase the loss of magnesium in
the urine

DKA: urinary loss of magnesium
can be seen (55%)

400 mg/d to 420 mg/d for adult
men and 320 mg/d for adult
women. (RDA)
Continued….

Phosphate

Phosphate concentrations will
decrease with insulin therapy

No benefits to phosphate replacement
during treatment
Education/Prevention
Carbohydrate Counting


Keep track of how
much carbohydrate
you are eating per
meal
Tighter control over
glucose readings
Approximate
Energy (kcal)
Meal
Carbohydrate
Servings
Snack Servings
per Day
1,200-1,500
3 (45g)
1 (15g)
1,600-2,000
4 (60g)
2-3 (30-45g)
2,100-2,400
5 (75g)
4-6 (60-90g)
Insulin and Mealtimes

Carbohydrate ratio

Coordinate your insulin injection with the
times you plan to have your meals

You want the insulin to begin working in
your body at the same time your food is
being absorbed
Glucose Monitoring

Pre-Prandial Glucose:
70-130 mg/dL

Post-Prandial Glucose:
<180 mg/dL

HbA1c: <7%
Sick Days

Body goes under a great deal of stress

Hormones get released to help fight
disease

Blood sugar

Important to come up with a plan
Plan of care for sick days
Continue
insulin/medication
Do not skip
meals
Monitor blood
sugars
(4 hours)
Adequate fluids
Test for ketones
if BS >300
mg/dL
Presentation of the Patient
About the patient

I.N. is 55 years old

Lives on the 2nd floor of a two family house; alone

PMH: hypertension, type 2 diabetes, obesity, schizophrenia, and depression.

Home medications: Metformin, Levemir, Haloperidol, Lisinopril, Benztrophine,
Hydrochlorothiazide, and Paliperidon.

Admitted July 2014/discharged 5 days later
Admission Profile

November 6, 2014,

Readmitted to Clara Maass Medical Center

Slurred speech, nausea/vomiting, abdominal pain, altered mental status

Insulin not available 3 days prior (Levemir, long-acting)

Hx of non-compliance with her medications

Medical team performed a finger stick glucose test, ECG, blood test, stool specimen,
chest x-ray
Labs
Values
Values
Values
Dates:
November 6th
November 7th
November 13th
WBC
24.8
15.7
12.1
Blood glucose
689 mg/dL
267 mg/dL
137 mg/dL
Bicarbonate
5 mEq/dL
No value recorded
19 mEq/dL
Arterial blood pH
6.8
No value recorded
No value recorded
Potassium
5.2 mEq/dL
3.1 mEq/dL
4.2 mEq/dL
Sodium
129 mEq/dL
140 mEq/dL
138 mEq/dL
Magnesium
No value recorded
No value recorded
1.3 mEq/dL
BUN
30 mg/dL
31 mg/dL
8 mg/dL
Creatinine
1.3 mg/dL
1.1 mg/dL
0.7 mg/dL
Blood acetone
positive
positive
negative
Serum ketones
positive
positive
negative
Initial Assessment-November 7th

Weight: 220 lb. /100 kg

Diet order: Clear liquid diet

Height: 69’’/175 cm


BMI: 32 (Grade 1)
D5W 5% @ 250 mL/hr with
potassium chloride and
NaCl

IBW: 160 lb. /73 kg (+10%)

po intake <50% (poor)

Braden score 13, stage 2
pressure ulcer (sacrum)
Nutritional Needs
Cal: 25-30 cal/kg IBW (73 kg) = 1,825-2,190
Protein:1.2 g/kg IBW (73 kg) = 88
Fluids: 25-30 mL/kg IBW (73 kg) = 1,825-2,190
Diagnosis
PES statement:
Inadequate oral intake related to decreased ability
to consume sufficient energy as evidenced by
episodes of nausea/vomiting and meeting <50% of
caloric/protein needs
Intervention

Diet prescription: Progress to high consistent carbohydrate (2000
kcal), 2 gram Na diet. Multivitamin once daily, vitamin C 500 mg BID
for wound care. Diabetishield TID (450 cal/ 21 gm protein)

Goal: Patient able to consume >75% of meals, BS <140 mg/dL,
electrolytes WNL, provide 100% of wound healing nutrients

Education: Patient felt nauseas and did not want to discuss food at
that time. Will provide education during f/u

High risk (3-5 days)
Monitor/Evaluate

Monitor: po intake, hydration, BS levels, electrolytes,
skin integrity

Evaluate: Intake/fluids for adequacy, BS control,
electrolytes WNL, need for other wound healing
nutrients
Follow-up Assessment

November 13th:

Calorie, protein, and fluid needs stay the same

Stage 2 pressure ulcer (sacrum)

Current Diet Order: 2 gm Na diet

po intake >75% (good)
Follow-up Diagnosis
New PES:
Increased nutrient needs (cal, protein, vitamins) related
to increased needs for wound healing as evidenced by
stage 2 pressure ulcer
Excessive carbohydrate intake related to self monitoring
deficit as evidenced by HbA1c 15.1% and Hx of mental
illness
Follow-up Intervention

Diet prescription: Change to high consistent carbohydrate (2000
kcal), 2 gram Na diet. Multivitamin once daily, vitamin C 500 mg BID
for wound healing

Education: Diabetic/low sodium diet/wound healing nutrients (e.g.
protein/vitamins)

Goal: Patient will be able to name 2 high carbohydrate foods, 2
sodium substitutes, name 2 high protein foods, provide 100% wound
healing nutrients

Moderate risk (7 days)
Follow-up Monitor/Evaluate

Monitor: Intake, hydration, BS levels, skin integrity

Evaluate: Intake for compliance, adequacy of
fluids, BS control, need for other wound healing
nutrients
Critical Comments

Stabilize the patient

What I would’ve done differently

Role of social services
Thank you

Clara Maass Medical Center

Gayanne and Christina
Questions
References
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