September 25, 2019

REBEL Core Cast 18.0 – DKA Tips and Tricks

Take Home Points

  • When looking at pH and bicarb, the differences between VBG and ABG are miniscule. For DKA patients, stick with the VBG as is less painful and has fewer complications. 
  • LR is probably a better fluid for the large volume resuscitation required in DKA. Start with a 20 cc/kg bolus and then reassess the patient’s perfusion status.
  • Stay on top of your electrolyte repletion. If the patient has a working gut, you can aggressively replete potassium orally and don’t forget that when you are repleting potassium you also must replete magnesium.
  • Bolus dose insulin gets the patient to super-physiologic levels and has been associated with higher potassium requirements and more episodes of hypoglycemia. It’s probably fine to skip the bolus and stick with a drip alone
  • Don’t forget to think of all possible etiologies of DKA, while we most often find this in patients who have not been taking their home meds for whatever reason, don’t forget a good history to look for sources such as infection and ischemia. 

REBEL Core Cast 18.0 – DKA Tips and Tricks

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Show Notes

Diagnostic Criteria

  • Hyperglycemia
  • Acidosis
  • Ketosis

Do we need an ABG? Nah 

  • pH mean difference between abg and vbg was 0.02 pH units. PMID: 21143397
  • Bicarb had a difference of -1.41 mmol/L. PMID: 21143397
  • pCO2 had a difference of about -6 mmHg
  • Not important to know the differences but rather the fact that the differences are irrelevant both in diagnosis and treatment

How much and what kind of fluids?

  • Patients are about 5-10% fluid down which is moderate dehydration
    • If hypotensive, more dehydrated and will need more fluid
  • The standard fluid resuscitation is 20-30cc/kg normal saline. Should it be the standard though?
    • NS is 154 mEq of Na & Cl with a pH of ~5.7, not ideal for acidotic patient
    • NS bolus can lead to non-anion gap hyperchloremic metabolic acidosis stacking on the anion gap acidosis. 
  • Reach for a more balanced solution like Lactated Ringers or Plasmalyte
    • LR is 130 mEq of NA, 130 Cl, 4 K, 1.5 Ca with a pH of ~6.4

Cerebral Edema

  • Volume of fluid will likely not lead to cerebral edema PMID: 29897851

Bicarbonate

  • Bicarbonate boluses never shown to be beneficial.
  • Isotonic bicarbonate infusion may be helpful. The BICAR-ICU study showed decreased necessity for dialysis in patients treated with isotonic bicarbonate (secondary endpoint)

Electrolyte Derangement

  • Total body potassium deficient 
  • Acidosis causes potassium to shift out of cells and falsely elevated serum levels
  • If gut working, give PO (40 mEq) & IV (10-20 mEq)
  • If Low K, then assume Low Mg

When to start Insulin

  • K above 3.5, start insulin with K infusion
  • K less than 3.5, hold insulin and give K
  • No bolus dosing, just give infusion (0.1 units /kg) and give their basal insulin
  • Don’t forget to look for underlying cause of DKA!!

Resources

Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 18.0 – DKA Tips and Tricks", REBEL EM blog, September 25, 2019. Available at: https://rebelem.com/rebel-core-cast-18-0-dka-tips-and-tricks/.
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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author
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