Critically Ill diabetic ketoacidosis is usually a bit of a misnomer. Despite numbers that look HORRIBLE–most of these patients are not particularly at risk of death. In fact, for almost all critical DKA patients, we can have them home or on a floor bed in about ~16 hours. Today on EMCrit, we tackle the optimal approach to the sick DKA patient.
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Amended British DKA (not sure how much really changed) June 2021:
https://abcd.care/resource/management-diabetic-ketoacidosis-dka-adults
Looking to hopefully implementing a similar protocol to your “2(ish) bag system” at our shop soon!
thanks for the updated guidelines!!!!!!!!!!!!!!!!!
Nice synopsis of ED management.
I spoke to our very experienced ED pharmacist about the issue of insulin binding to plastic IV tubing and bags. He says it happens but is not really clinically significant in the tubing because it has a short contact time. The IV bags bind more insulin because of more contact time and is one reason insulin drips come in small bags and are changed every 24 hrs. With a patient on a drip, you are going to be checking their sugars hourly and increasing the drip rate by a certain amount if the glucose is not coming down. It wouldn’t… Read more »
the issue is significant. i have added to pdfs in the body of the text above. it is not an issue of hourly b/c eventually the drip rate would be increased as you say. it is an issue of time to actual full initiation of the insulin therapy.
Does use of low absorbent tubing (similar to nitro drips) avoid the need to waste running the insulin through the tubing?
great ?
my guess would be no, or we would be using it–but I am not sure
If you look at Figure 1 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783010/ they have a nice comparison of PE (low absorbing) and PVC tubing for the output insulin concentration over time. Low absorbing tubing does look to me as though it both has lower amount of absorption at a given flow rate and also becomes saturated in a shorter amount of time. However, this only really looks clinically relevant at flow rates of <2 units/hr (1 unit/ml). Once that rate is exceeded it looks like the dwell time is not sufficient for substantial absorption to occur and initial concentrations were reduced by <5%. To… Read more »
thanks Grayson!!! excellent work
Hi Scott,
Great podcast, thank you. Two queries from me:
Your 0.15 units/kg/hour is that total body weight, ideal body weight, adjusted BW?
What drug are you using for your potassium replacement?
Our peripheral replacement is exclusively KCl, at 20mmol/L or 40mmol/L, in saline, but centrally, we have KCl in sterile water, in smaller volumes. This makes early central venous access attractive as it means you can provide central potassium replacement early, with the provision of balanced crystalloids (usually Hartmann’s solution).
Hey Dean!!
total body weight on the insulin
not sure what you mean about the potassium. Why would smaller volume be better. In a DKA pt, they can definitely use the volume. We use KCl in 10 meq runs, though we have higher concentrations available. Almost all of our pts manage with oral alone,
None of our DKA pts need or get a central line unless something else is going on requiring pressors.
Would def put in a central line for severe hypoK with DKA as they are holding up my insulin until I can get the K up.
If anyone interested similar one’s have a look here
Mahindra Bolero Pickup
I’ve been having good luck using glargine in addition to the insulin drip for established diabetics. They almost all will require additional insulin on top of their basal to not only correct their hyperglycemia but also the underlying stress that often triggered their DKA. I use full dose for patients that can eat and half-dose for those with significant vomiting or generally feeling too poorly to eat (gastroparesis or generally feeling like crap). The basal also helps prevent the rebound phenomenon when I have to stop their drip because their potassium still dropped even though we are supplementing it or… Read more »
We use subcutaneous protocol with lantus, lispro, lyte replacement and IVF for DKA. Unless they have another reason to be in the ICU, they are admitted to the floor. Works fine.
Carol
can you comment on the frequency of fingersticks allowed on floor patients–your hospital would be a true outlier if it is >q4 hours
Awesome episode! I work in a critical access hospital. No central lines. In our DKA’ers w/ hypo K+, we can only give a max of 20mEq of KCl peripherally. I like your idea of giving 40 PO (if they can tolerate PO) since it seems like that 20/hr is insufficient to maintain their K+ when we start insulin. What’s your experience been as far as absorption goes and keeping K+ up with insulin going? Do you give IV KCl simultaneously if you give the 40 PO?
Thanks!
oral alone is usually enough
40 sustained release
supplemented with 10 instant release
So if I’m reading the order set right, the first potassium they get is 40meq sustained release PO if its between 4-5, and then when you check their K every 2-3 hours if it’s between 3.3 and 5 you top up with 20 meq immediate release PO?
yep, but these are standing orders for the nurses. If I see a 3.3 I am going to add on supplementary K, probably in IV form. I’d like them to be in the > 4 range
In DKA patient with K of < 3 but unable to produce any urine… what is your approach? do you give KCL IV bolus anyway? or do you follow the Brit DKA management pathway where they consider urinary cath if not passed urine by 60minutes in order to start your KCL IV bolus? Would you wait to start the insulin drip until your K is a little higher in this case?
Fantastic… I really appreciate your work as you provide unique and different content for us all the time. Thanks
new holland 3630
Thank you for the Podcast.
We are trying to update the guidelines in our hospital but I’m having trouble finding a POC BHB meter. Can you recommend a device or provider?
Thanks