Transcript DKA
Diabetic Ketoacidosis
Chief Complaint
abdominal pain and vomiting
History of Present Illness
This 35 yo male presented with
One day history of severe abdominal pain in epigastrium Sharp, constant ,radiating to the back accompanied by nausea Few episodes of non bloody vomiting without relief Patient denies same previous episodes, diarrhea, constipation, fever, sick contact, nobody at home had a same symptoms, no recent traveling Denies melena, blood in the stool
Previous medical history
DM type 2 HTN CAD S/P stent placement Familial Hypercholesterolemia Hypothyroidism and ETOH abuse Surgical hx none Allergy:
NKDA
Home Medications
Metformine Lisinopril Clonidine Glyburide Levothyroxin Lopressor Nexium Plavix ASA
Social History
Lives at home with his mother Employe at Burger King Current smoker 4 cigarettes daily for 18 years Vodka 1 pint daily Denies illicit drug using
Physical exam
35 year-old Hispanic Male appears alert, oriented and cooperative
Vital Signs: Blood Pressure 131/96 Pulse 120 Respirations 20
No check for orthostatic BP/P Temperature 100.1 degrees
Skin: Normal in appearance and texture
Physical exam (cont'd)
HEENT:
Scalp normal Pupils equally round, 4 mm reactive to light and accommodation Sclera and conjunctiva normal External auditory canals normal.
Nasal mucosa normal.
Oral pharynx is normal without erythema or exudate.
Tongue and gums are normal
Physical exam (cont'd)
Neck:
Easily moveable without resistance No abnormal adenopathy in the cervical or supraclavicular areas Trachea is midline and thyroid gland is normal without masses Carotid artery upstroke is normal bilaterally without bruits No JVD
Physical exam (cont'd)
Chest:
Lungs are clear to auscultation and percussion bilaterally no crackles , wheezing.
CVS S1/S2 normal, no S# Abdomen: The abdominal exam revealed mild epigastric tenderness to palpation but no rebound tenderness or guarding Mild distention, bowel sounds are normal in quality and intensity in all areas No bruit No masses or splenomegaly are noted
Physical exam (cont'd)
Extremities: No cyanosis, clubbing, or edema are noted Peripheral pulses are normal
Nodes: No palpable nodes in the cervical, supraclavicular, axillary or inguinal areas
Genital/Rectal: Normal rectal sphincter tone No rectal masses or tenderness Stool is brown and guaiac negative.
Pelvic examination reveals normal external genitalia
Physical exam (cont'd)
Neurological: Cranial nerves II-XII are normal
Motor and sensory examination of the upper and lower extremities is normal.
Gait and cerebellar function are also normal
Reflexes are normal and symmetrical bilaterally in both extremities.
Initial Problem List
Abdominal pain Vomiting Fever, Tachycardia DM HTN ETOH abuse CAD Hyprecholesterolemia
Laboratory results
CBC WBC 14.8
HGB 13.1
HCT 38.3
Platelets 200 NEUT 84.0
UA uprotein > 300 ur glucose >1000 Ketones >80 PH 7.18/22.6/24.6/8.3
CMP GLUCOSE 436 BUN 10.0
CR 1.3
NA 136 K 6.8
CL 99 CO2 less 5 BIL 0.7
ALT 54 AST 27 Alk. Phosp. 217 Amylase 161
DKA Definition
DKA is defined as a plasma glucose level >250 mg/dl, plasma bicarbonate <15 mEq/l, pH <7.35, ketonemia, and an elevation in the anion gap. This patient clearly meets the criteria for DKA based on his blood glucose of 436 mg/dl, CO2 of <5, pH of 7.18, anion gap of 32, and obvious ketonemia.
Management: Phase 1 - Fluids
1.
2.
Correct Volume Deficit 1.
Protocol 1 (standard protocol) 1.
Replace first 50% volume deficit in first 8 hours 2.
1.
Use Normal Saline or Lactated Ringers Replace remaining 50% deficit over next 16 hours 2.
1.
Use D5 1/2 NS at 150-250 ml per hour Protocol 2 1.
NS at 10 cc/kg/hr (+/- 5 cc/kg/hr) 2.
1.
Until Serum Glucose <250 mg/dl Then D5 1/2NS with 20 kcl 1.
Give 150-250 cc/hour Precautions 1.
Do not drop Serum Osmolality (calc) >3 mOsms/hour 2.
1.
Risk of cerebral edema Slow replacement if Fluid Overload risk 3.
1.
2.
3.
Congestive Heart Failure Chronic Renal Insufficiency Myocardial Infarction Follow Intake and output closely
Management: Phase 2 - Acidosis, electrolytes
1.
Potassium Replacement 1.
Precautions 1.
Hypokalemia must be corrected prior to Insulin 2.
2.
Hold Insulin until potassium >3.3 meq/L in adults Prerequisites 3.
1.
2.
Adequate urine output Administration: Adults 1.
Electrocardiogram without signs of Hyperkalemia Serum Potassium <3.3 meq/L 1.
Do not administer Insulin until 2.
potassium >3.3 Give KCl 40 meq/hour IV until corrects 1.
Requires hourly recheck of 2.
Serum Potassium This is maximum IV potassium 2.
3.
3.
Requires cardiac monitoring Serum Potassium 3.3 to 5.0 meq/L 1.
Standard replacement: 20-30 meq per liter rate! Serum Potassium >5.0 meq/L 1.
Do not administer any potassium 2.
Monitor every 2 hours until <5.0
Management: Phase 2 - Acidosis, electrolytes (cont'd)
2.
Phosphate Replacement 1.
Indications 1.
Serum Phosphorus < 0.5-1.0 mg/dl (Severe Depletion) 2.
2.
3.
Controversial - May not be required Consider if cardiopulmonary adverse affects Contraindications 1.
Renal Insufficiency 3.
Administration 1.
Determine Potassium Replacement as above 2.
Replace part of potassium with potassium phosphate 1.
2.
Potassium Phosphate: Replace one third potassium Potassium Chloride: Replace two thirds potassium
Management: Phase 2 - Acidosis, electrolytes (cont'd)
3.
4.
Magnesium Replacement 1.
Indications 1.
Symptomatic Hypomagnesemia (Magnesium <1 meq/L) 2.
Administration 1.
MgSO4 50%: 2.5-5.0 ml (20-40 meq) IM Sodium Bicarbonate Replacement 1.
Indications 1.
2.
ABG pH < 6.9 to 7.0 after initial hour of hydration Other contributing factors 1.
2.
Shock or Coma Severe Hyperkalemia
Management: Phase 3 - Blood Glucose Control
1.
2.
Precautions 1.
Hypokalemia must be corrected prior to Insulin Adult Insulin protocol 1.
IV Insulin administration 1.
Initial 1.
Give IV bolus of 0.15 units/kg 2.
2.
Start 0.1 units/kg/hour Insulin Drip Maintenance 1.
Anticipate Serum Glucose drop of 50-70 mg/dl/hour 2.
1.
2.
If inadequate drop, then increase drip Increase Insulin Infusion rate by 50-100% 3.
Continue at increased rate until adequate When Serum Glucose <200-250 mg/dl 2.
1.
2.
3.
Keep Serum Glucose at 150 to 200 mg/dl Decrease rate by 50% (to 0.05 units/kg) or Discontinue Insulin Drip and start SC dosing IM or SC Insulin administration
Management: Phase 3 - Blood Glucose Control (cont'd)
3.
4.
Glucose monitoring 1.
2.
Glucose monitoring every 30 minutes to 1 hour Target glucose decrease 50-70 mg/dl/h Dextrose Administration 1.
Add 5% Dextrose to fluids when glucose < 250 mg/dl