Diabetic Ketoacidosis
Chief Complaint
abdominal pain and vomiting
History of Present Illness
This 35 yo male presented with
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One day history of severe abdominal pain in
epigastrium
Sharp, constant ,radiating to the back accompanied by
nausea
Few episodes of non bloody vomiting without relief
Patient denies same previous episodes, diarrhea,
constipation, fever, sick contact, nobody at home had a
same symptoms, no recent traveling
Denies melena, blood in the stool
Previous medical history
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DM type 2
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HTN
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CAD
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S/P stent placement
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Familial Hypercholesterolemia
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Hypothyroidism and ETOH abuse
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Surgical hx none
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Allergy:
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NKDA
Home Medications
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Metformine
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Lisinopril
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Clonidine
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Glyburide
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Levothyroxin
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Lopressor
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Nexium
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Plavix
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ASA
Social History
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Lives at home with his mother
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Employe at Burger King
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Current smoker 4 cigarettes daily for 18 years
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Vodka 1 pint daily
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Denies illicit drug using
Physical exam
35 year-old Hispanic Male appears alert, oriented and
cooperative
Vital Signs:
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Blood Pressure 131/96
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Pulse 120
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Respirations 20
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No check for orthostatic BP/P
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Temperature 100.1 degrees
Skin:
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Normal in appearance and texture
Physical exam (cont'd)
HEENT:
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Scalp normal
Pupils equally round, 4 mm reactive to light and
accommodation
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Sclera and conjunctiva normal
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External auditory canals normal.
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Nasal mucosa normal.
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Oral pharynx is normal without erythema or exudate.
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Tongue and gums are normal
Physical exam (cont'd)
Neck:
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Easily moveable without resistance
No abnormal adenopathy in the cervical or
supraclavicular areas
Trachea is midline and thyroid gland is normal without
masses
Carotid artery upstroke is normal bilaterally without
bruits
No JVD
Physical exam (cont'd)
Chest:
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Lungs are clear to auscultation and percussion
bilaterally no crackles , wheezing.
CVS S1/S2 normal, no S#
Abdomen:
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The abdominal exam revealed mild epigastric
tenderness to palpation but no rebound tenderness or
guarding
Mild distention, bowel sounds are normal in quality and
intensity in all areas
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No bruit
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No masses or splenomegaly are noted
Physical exam (cont'd)
Extremities:
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No cyanosis, clubbing, or edema are noted
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Peripheral pulses are normal
Nodes:
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No palpable nodes in the cervical, supraclavicular,
axillary or inguinal areas
Genital/Rectal:
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Normal rectal sphincter tone
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No rectal masses or tenderness
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Stool is brown and guaiac negative.
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Pelvic examination reveals normal external genitalia
Physical exam (cont'd)
Neurological:
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Cranial nerves II-XII are normal
Motor and sensory examination of the upper and lower
extremities is normal.
Gait and cerebellar function are also normal
Reflexes are normal and symmetrical bilaterally in both
extremities.
Initial Problem List
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Abdominal pain
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Vomiting
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Fever, Tachycardia
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DM
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HTN
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ETOH abuse
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CAD
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Hyprecholesterolemia
Laboratory results
CBC
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WBC 14.8
HGB 13.1
HCT 38.3
Platelets 200
NEUT 84.0
UA
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CMP
GLUCOSE 436
BUN 10.0
CR 1.3
NA 136
uprotein > 300
ur glucose >1000
Ketones >80
PH 7.18/22.6/24.6/8.3
K 6.8
CL 99
CO2 less 5
BIL 0.7
ALT 54
AST 27
Alk. Phosp. 217
Amylase 161
DKA Definition
DKA is defined as a plasma glucose level >250 mg/dl,
plasma bicarbonate <15 mEq/l, pH <7.35, ketonemia, and
an elevation in the anion gap. This patient clearly meets
the criteria for DKA based on his blood glucose of 436
mg/dl, CO2 of <5, pH of 7.18, anion gap of 32, and
obvious ketonemia.
Management: Phase 1 - Fluids
1.
2.
Correct Volume Deficit
1.
Protocol 1 (standard protocol)
1.
Replace first 50% volume deficit in first 8 hours
1.
Use Normal Saline or Lactated Ringers
2.
Replace remaining 50% deficit over next 16 hours
1.
Use D5 1/2 NS at 150-250 ml per hour
2.
Protocol 2
1.
NS at 10 cc/kg/hr (+/- 5 cc/kg/hr)
1.
Until Serum Glucose <250 mg/dl
2.
Then D5 1/2NS with 20 kcl
1.
Give 150-250 cc/hour
Precautions
1.
Do not drop Serum Osmolality (calc) >3 mOsms/hour
1.
Risk of cerebral edema
2.
Slow replacement if Fluid Overload risk
1.
Congestive Heart Failure
2.
Chronic Renal Insufficiency
3.
Myocardial Infarction
3.
Follow Intake and output closely
Management: Phase 2 - Acidosis,
electrolytes
1.
Potassium Replacement
1.
Precautions
1.
Hypokalemia must be corrected prior to Insulin
2.
Hold Insulin until potassium >3.3 meq/L in adults
2.
Prerequisites
1.
Electrocardiogram without signs of Hyperkalemia
2.
Adequate urine output
3.
Administration: Adults
1.
Serum Potassium <3.3 meq/L
1.
Do not administer Insulin until
potassium >3.3
2.
Give KCl 40 meq/hour IV until corrects
1.
Requires hourly recheck of
Serum Potassium
2.
This is maximum IV potassium
rate!
3.
Requires cardiac monitoring
2.
Serum Potassium 3.3 to 5.0 meq/L
1.
Standard replacement: 20-30 meq per
liter
3.
Serum Potassium >5.0 meq/L
1.
Do not administer any potassium
2.
Monitor every 2 hours until <5.0
Management: Phase 2 - Acidosis,
electrolytes (cont'd)
2.
Phosphate Replacement
1.
Indications
1.
Serum Phosphorus < 0.5-1.0 mg/dl (Severe
Depletion)
2.
Controversial - May not be required
3.
Consider if cardiopulmonary adverse affects
2.
Contraindications
1.
Renal Insufficiency
3.
Administration
1.
Determine Potassium Replacement as above
2.
Replace part of potassium with potassium
phosphate
1.
Potassium Phosphate: Replace one
third potassium
2.
Potassium Chloride: Replace two thirds
potassium
Management: Phase 2 - Acidosis,
electrolytes (cont'd)
3.
Magnesium Replacement
1.
Indications
1.
Symptomatic Hypomagnesemia (Magnesium <1
meq/L)
2.
Administration
1.
MgSO4 50%: 2.5-5.0 ml (20-40 meq) IM
4.
Sodium Bicarbonate Replacement
1.
Indications
1.
ABG pH < 6.9 to 7.0 after initial hour of hydration
2.
Other contributing factors
1.
Shock or Coma
2.
Severe Hyperkalemia
Management: Phase 3 - Blood Glucose
Control
1.
Precautions
1.
2.
Hypokalemia must be corrected prior to Insulin
Adult Insulin protocol
1.
IV Insulin administration
1. Initial
1. Give IV bolus of 0.15 units/kg
2. Start 0.1 units/kg/hour Insulin Drip
2. Maintenance
1. Anticipate Serum Glucose drop of 50-70 mg/dl/hour
1. If inadequate drop, then increase drip
2. Increase Insulin Infusion rate by 50-100%
3. Continue at increased rate until adequate
2. When Serum Glucose <200-250 mg/dl
1. Keep Serum Glucose at 150 to 200 mg/dl
2. Decrease rate by 50% (to 0.05 units/kg) or
3. Discontinue Insulin Drip and start SC dosing
2.
IM or SC Insulin administration
Management: Phase 3 - Blood Glucose
Control (cont'd)
3.
4.
Glucose monitoring
1.
Glucose monitoring every 30 minutes to 1 hour
2.
Target glucose decrease 50-70 mg/dl/h
Dextrose Administration
1.
Add 5% Dextrose to fluids when glucose < 250 mg/dl