September 25, 2019

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. 

November 2, 2015

Recently, I was asked to give a lecture to both my residents and nurses at the University of Texas Health Science Center at San Antonio (UTHSCSA) on some common DKA myths. Now this topic was originally covered by my good friend Anand Swaminathan on multiple platforms and I did ask his permission to create this blogpost with the idea of improving patient care and wanted to express full disclosure of that fact. I specifically covered four common myths that I still see people doing in regards to DKA management:
  1. We should get ABGs instead of VBGs
  2. After Intravenous Fluids (IVF), Insulin is the Next Step
  3. Once pH <7.1, Patients Need Bicarbonate Therapy
  4. We Should Bolus Insulin before starting the infusion

May 12, 2014

In a prior post, we discussed the use of an initial insulin bolus in the management of diabetic ketoacidosis (DKA).  Today we will address another facet of DKA management, for which there is less than optimal evidence and that is: Any benefit to sodium bicarbonate in DKA?  Consensus guidelines for the management of DKA recommended administering sodium bicarbonate to DKA patients who present with an initial blood gas pH of < 7.0. That recommendation was updated and changed in 2009 to limit sodium bicarbonate use to DKA patients with blood gas pH of < 6.9.  More recently, Chua et al. published a systematic review of 44 articles discussing bicarbonate administration and Duhon et al. published the largest retrospective review of DKA patient with presenting pH of < 7.0.

March 27, 2014

Diabetic ketoacidosis (DKA) is a common endocrine emergency encountered in the emergency department.  DKA associated mortality is relatively low in adults, but in children with type 1 diabetes, the elderly, and adults with concomitant illnesses have a mortality rate is > 5% [cite source="pubmed"]19564476[/cite].  Guidelines for the management of hyperglycemic crisis in adults provide recommendations for intravenous fluid administration, correction of electrolyte abnormalities, insulin and bicarbonate therapy.  While the recommendations made in the American Diabetes Association (ADA) consensus statement are intended to be evidence based, there are two recommendations which have less than optimal supporting evidence which results in controversy in the emergency department: 1. Use of regular insulin boluses of 0.1 units/kg and 2. patients with a pH < 6.9 should receive sodium bicarbonate therapy.  Today we will attempt to answer the question, is there any benefit to an initial insulin bolus in DKA?
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