Diabetic Ketoacidosis ManagementHeidi Chamberlain Shea, MDEndocrine Associates of DallasGoals of Discussion Pathophysiology of DKA Biochemical criteria for DKA Treatment of DKA Prevention of DKA Hyperosmolar Nonketoic SyndromeEpidemiology Annual incidence in U.S. 5-8 per 1000 diabetic subjects 2.8% of all diabetic admissions are due to DKA Overall mortality rate ranges from 2-10% Higher is older patientsDKA Precipitating Factors Failure to take insulin Failure to increase insulin Illness/Infection Pneumonia MI Stroke Acute stress Trauma Emotional Medical Stress Counterregulatory hormones Oppose insulin Stimulate glucagon release Hypovolmemia Increases glucagon and catecholamines Decreased renal blood flow Decreases glucagon degradation by the kidneyDiabetic KetoacidosisDue to: Severe insulin deficiency Excess counterregulatory hormones Glucagon Epinephrine Cortisol Growth hormoneRole of Insulin Required for transport of glucose into Muscle Adipose Liver Inhibits lipolysis Absence of insulin Glucose accumulates in the blood Liver Uses amino acids for gluconeogenesis Converts fatty acids into ketone bodies Acetone, Acetoacetate, -hydroxybutyrate Increased counterregulatory hormonesCounterregulatory Hormones - DKAIncreases insulin resistanceActivates glycogenolysis and gluconeogenesisActivates lipolysisInhibits insulin secretionEpinephrineXXXXGlucagonXCortisolXXGrowth HormoneXXXInsulin DeficiencyGlucose uptake ProteolysisLipolysisAmino AcidsGlycerolFree Fatty AcidsGluconeogenesis GlycogenolysisHyperglycemiaHyperglycemiaKetogenesisAcidosisAcidosisOsmotic diuresisDehydrationDehydrationSigns and Symptoms of DKA Polyuria, polydipsia Enuresis Dehydration Tachycardia Orthostasis Abdominal pain Nausea Vomiting Fruity breath Acetone Kussmaul breathing Mental status changes Combative Drunk ComaLab Findings Hyperglycemia Anion gap acidosis (Na + K) (Cl + Bicarb) 12 Bicarbonate 50020.00Complications of DKA Infection Precipitates DKA Fever Leukocytosis can be secondary to acidosis Shock If not improving with fluids r/o MI Vascular thrombosis Severe dehydration Cerebral vessels Occurs hours to days after DKA Pulmonary Edema Result of aggressive fluid resuscitation Cerebral Edema First 24 hours Mental status changes Tx: Mannitol May require intubation with hyperventilationOnce DKA Resolved Treatment Most patients require 0.5-0.6 units/kg/day Pubertal or highly insulin resistant patients 0.8-1.0 units/kg/day Long acting insulin 1/2-2/3 daily requirement NPH, Lente, Ultralente or Lantus Short acting insulin 1/3-1/2 given at meals Regular, Humalog, Novolog Give insulin at least 2 hours prior to weaning insulin infusion.Prevention of DKA Sick Day Rules Never omit insulin Cut long acting in half Prevent dehydration and hypoglycemia Monitor blood sugars frequently Monitor for ketosis Provide supplemental fast acting insulin Treat underlying triggers Maintain contact with medical teamGoals of Discussion Pathophysiology of DKA Biochemical criteria for DKA Treatment of DKA Prevention of DKA Hyperosmolar Nonketoic SyndromeHyperosmolar Nonketotic Syndrome Extreme hyperglycemia and dehydration Unable to excrete glucose as quickly as it enters the extracellular space Maximum hepatic glucose output results in a plateau of plasma glucose no higher than 300 -500 mg/dl When sum of glucose excretion plus metabolism is less than the rate which glucose enters extracellular space.Hyperosmolar Nonketotic Syndrome Extreme hyperglycemia and hyperosmolarity High mortality (12-46%) At risk Older patients with intercurrent illness Impaired ability to ingest fluids Urine volume falls Decreased glucose excretion Elevated glucose causes CNS dysfunction and fluid intake impaired No ketones Some insulin may be present Extreme hyperglycemia inhibits lipolysisHyperosmolar Nonketotic Syndrome Presentation Extreme dehydration Supine or orthostatic hypotension Confusion coma Neurological findings Seizures Transient hemiparesis Hyperreflexia Generalized areflexia Hyperosmolar Nonketotic Syndrome Presentation Glucose 600 mg/dl Sodium Normal, elevated or low Potassium Normal or elevated Bicarbonate 15 mEq/L Osmolality 320 mOsm/LHyperosmolar Nonketotic Syndrome Treatment Fluid repletion NS 2-3 liters rapidly Total deficit = 10 liters Replete in first 6 hours Insulin Make sure perfusion is adequate Insulin drip 0.1U/kg/hr Treat underlying precipitating illnessClinical Errors Fluid shift and shock Giving insulin without sufficient fluids Using hypertonic glucose solutions Hyperkalemia Premature potassium administration before insulin has begun to act Hypokalemia Failure to administer potassium once levels falling Recurrent ketoacidosis