"I find it very gratifying to treat because you can see the effects of your treatment right in front of your eyes. And your patients can go from very sick to well within a matter of hours." - Marc Probst, MD
Who is Marc Probst, MD?
Courtesy of Marc Probst, MD

Marc Probst, MD, MS is an Academic Emergency Physician at The Mount Sinai Hospital in New York City.

Dr. Probst is funded by a career development grant from the National Institutes of Health (NIH).

His interests include syncope, shared decision-making, and Halloween.

Twitter @probstMD





 
Diabetic Ketoacidosis (DKA)
Biochemical Findings

Hyperglycemia
Ketosis
(High anion gap) Metabolic Acidosis

Parameters to treat DKA

Blood glucose >250mg/dL
Elevated anion gap w/albumin adjustment >10
Serum bicarbonate <18mEq/L
*Positive serum/urine ketones
pH <7.3

Causes

Lack of insulin

Poorly controlled DM

Barriers include access, insurance, expensive, etc.


Undiagnosed DM
Disasters


Infection

Mesenteric Ischemia


Cardiac (MI)
Intoxication (cocaine, ETOH)
Iatrogenic (steroids, HCTZ, SGLT2, antipsychotics)
CVA
Pregnancy
Hyperthyroidism
Click here for a nice review at emdocs

Ketosis vs. DKA

Pt can have an elevated blood glucose but not in DKA
See if they really are acedotic first - check for ketones

Ex: blood glucose 500+, pH 7.4, no ketones in serum/urine


Look at baseline labs (compare history)

Ex: Renal failure patients can live in a lower pH



Euglycemic DKA

Normal blood glucose
Has Anion gap

What's the worse that can happen?

Cerebral Edema (documented in Pediatrics)
Death

1% mortality rate and a 5% mortality rate for elderly



Symptoms

Nausea/Vomiting (can cause mixed acid-base disorder)

Combination of metabolic acidosis and metabolic alkalosis


Abdominal Pain
Altered Mental Status/Confusion
Frequent Urination
Excessive Thirst
Weakness/Fatigue
Respiratory Status - Kussmal respirations (fruity breath)- tachypnea to blow off CO2

Mental status
If they are intubated, want to match RR to pre-intubation status


Bipap? -Consider High flow nasal cannula to maximize "blowing off CO2."

Look at respiratory drive to determine airway intervention


Dehydration

Dehydration & electrolyte imbalances due to osmotic diuresis
Glucose-mediated osmotic diuresis
Nausea and vomiting
Poor PO intake.



Work-Up
POCT Blood Glucose
POCT Urinalysis
Labs

VBG

ABGs are unnecessary
VBGs are a more accurate representation of what is going on in the tissues


Chemistry Panel including Mg & P
Urinalysis

Add. Labs/Diagnostics if you suspect underlying cause, etc.

Serum ketones (suspect/known anuria secondary to dehydration or renal failure)
Troponin
EKG
Blood/Urine Cultures (suspect infection)
Lactate Level (suspect infection)


Anion Gap

Anion Gap = (Na) - (Cl + HCO3)
Click here for easy Anion Gap Calculator w/albumin adjustment


What is an Anion Gap?

Too many unmeasured anions causes metabolic acidosis.
Etiologies of increase organic acids:

MUDPILES: methanol, metformin, uremia, diabetic ketoacidosis, ethylene glycol, salicylates, and starvation.
ESKD




What’s a normal anion gap?

3-11mEq/L


Hypoalbuminemia affecting anion gap calculation - adjust for albumin

Albumin is a major source of unmeasured anions and clinically significant for treatment
A drop in albumin by 10 g/L will cause the anion gap to fall ~ 2.5mEq/L at constant pH




Management -  Lots of Nursing (Step-down or ICU)

Telemonitoring
Hourly fingersticks
VBG/BMP every 1-2 hours

In my own clinical practice I don’t find hourly labs to be useful


Mental Status & Respiratory status
Adjust Insulin Drip
Watch out for Hypokalemia and Hypoglycemia (Clinical Pearl!)

Management = Fluids, Insulin, Electrolytes
Fluids

How much Fluids? How aggressive? What’s the concern? (Controversial in Pediatrics!)

New RCT trial coming out comparing aggressive vs. gentle fluid resuscitation in Pediatric population w/DKA.