Welcome to the inaugural IBCC chapter!
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The IBCC chapter on DKA is located here.
- The podcast & comments are below.
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Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
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How are you finding the sepsis initiatives – especially the push to give antibiotics quickly – playing out your DKA patients in the ER? They all have SIRS and they all *could* have an infection causing all this. Thus, many could end up falling under SEP1. I find it sometimes silly that we would give all of these patients antibiotics but my intensivists are saying ‘hey, these are sick patients, are you really worried about a single dose of rocephin until we figure it out upstairs?’ In the podcast you mention missing sepsis as a big potential pitfall, so perhaps… Read more »
It’s hard to overstate how much I hate all the sepsis initiatives. There is no simple answer here, unfortunately. If there is a genuine concern about sepsis then yes – giving antibiotics is the safer way to go. However, if we give antibiotics to every single patient with pancreatitis then this causes CDiff and drug resistance. Ultimately I think you just need to use your clinical judgement. My practice is to use blind empiric antibiotics relatively rarely. In most cases there is a reasonably well-defined cause of DKA (e.g. noncompliance, gastroenteritis), which reduces the likelihood of occult sepsis and allows… Read more »
hi josh very well written article
would like to ask what do you mean by critical hyperkalemia in patient with ongoing dka treament? how do we define it (by numbers or ecg changes or both).
great question! We have a chapter on hyperkalemia coming up in several weeks – this is a bit of a nebulous concept really. I’d say it’s probably some combination of three things: 1) Absolute level of potassium (somewhere >7 perhaps things get scary) 2) Acuity of hyperkalemia (ESRD patients often do fine with chronic hyperkalemia; acute hyperkalemia is probably more dangerous) 3) EKG changes (wide QRS or arrhythmias such as bradycardia) Different sources say different things with regards to a potassium cutoff. I’m not aware of any literature that actually risk-stratifies who is most likely to have a malignant arrhythmia… Read more »
Great chapter, thanks! Just as a correction, in the “how to avoid cerebral edema” section, you write “e.g. D5 LR can be used as a source of glucose-containing IV fluid, rather than hypotonic fluids such as D10W or D5 1/2 NS).” However, it is my understanding that D10W and D5 1/2 are both hypertonic solutions, not hypotonic.
This is tricky. Within the body (under the influence of insulin), glucose isn’t an effective osmole. So although glucose contributes to the measured osmolality of fluid in the bag, it probably doesn’t contribute to the biologically effective tonicity (e.g. the effect of the fluid on the patient’s sodium concentration). Perhaps the best example of this is D5W which technically has an osmolality of 260 mOsm/L but in practice has an effective osmolality which is much much lower (probably close to free water). In practice, the effective osmolality of a solution is primarily related to its sodium concentration. So D10W (no… Read more »
You emphasize that long-acting insulin should be start early. How early in the treatment process are you giving subQ insulin (glargine/detemir)?
1) It’s impossible to give the glargine too early.
2) I included the glargine in the second group of interventions, because it’s not mission-critical to give it immediately (and thus not a priority to give it during the initial resuscitation). However, ideally it should be given >>2 hrs before stopping the insulin drip. Traditional teaching has been that you can give the long-acting insulin and stop the insulin infusion two hours later. However, that was based on NPH insulin – and glargine may take a bit more time to reach peak levels.
Great review on DKA. I look forward to the next chapters.
Thanks for this fantastic review and resource. 1. As a resident it was always drilled into me (but I never witnessed or questioned the dogma) that because these patients are profoundly hypovolemic, initial treatment with insulin prior to volume resuscitation can cause dangerous fluid shift intracellularly which can cause fatal hemodynamics collapse. Therefore it makes me nervous to see insulin listed before crystalloid in your checklist. 2. I don’t treat kids or ICU but follow a lot of FOAM and podcasts and I thought the recent NEJM article by Kupperman dispelled IVF resuscitation rates as the cause of encephalopathy- at… Read more »
1) I have seen that in various articles. Have never encountered this phenomenon in real life. In practice all of these patients will be started on IV fluids almost immediately so I don’t think it’s a real issue.
2) Yeah, I don’t treat pediatric DKA so I don’t have much wisdom to offer here. Unfortunately the study was underpowered due to the low rate of cerebral edema… so unsure that you can draw any firm conclusions from it.
super -cool, Josh.
congratulations on this inaugural podcast.
love it.
In regards to enteral nutrition, I wonder if it would it be a good idea to start these folks on a feeding solution like glucerna in “mealtime” boluses and giving them their parandial insulin doses? Plus if we have an NG in place and something in the stomach to prevent ulcerations, couldn’t we use oral K+ to help with the replacement? Free water administration through the tube may be more comfortable as well since they wouldn’t have to pause their respiration to swallow. Are there any studies on early enteral feeding/drinking in DKA?
While I agree with your points about the vbg not being all that helpful. As a paramedic who mostly works in the triage area of a busy ED. I love one thing about the VBG is it comes back in like 5-10 min vs the chem 7 or beta-hydroxybutyrate that can take an hour or so. If I send a vbg and it looks terrible I can use that to get somebody to order more fluids, room the patient next, etc. While its not a perfect test it allows some early decision making.
Great chapter. Thanks.
You mentioned DKA infusion protocol — I would really like to see yours.
Thanks in advance.
In regards to starting early insulin, what if they’re on an NPH at home? Thanks