014 You’re TOO Sweet! DKA Emergency w/Marc Probst, MD

"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.