Tasty Morsels of EM 122 – #FRCEM DKA and diabetic emergencies

• Ketnoaemia:
  • urine ++ ketones
  • >3mmol/l
• Glucose
  • >11
  • known diabetes
• Bicarbonate < 15 or venous pH <7.3

this is of course a superficial summary of the bits that have changed in recent years and that I’m likely to forget…

• venous gases rather than arterial
• can also be used for electrolytes with intermittent lab confirmation
• bedside blood ketone and glucose monitoring encouraged
• use fixed rate insulin infusions (0.1unit/kg/hr) (note no bolus)
• aim for
  • reduce ketones 0.5/hr
  • reduce glucose 3/hr
  • keep K between 4 and 5.5
• add 10% glucose infusion when glucose <14 (continue the saline too)
• continue the patients normal long acting insulin
• they suggest systolic of 90 as the trigger for fluid boluses otherwise it’s a bit slower (1000 in first hour, 1000 over the following 2 hours etc…)
• don’t forget the euglycaemic DKA with the new meds

(2012 Guideline)

• Features
  • hypovolaemia
  • glucose >30 without significant ketonaemia or acidosis
  • osmoloality >320
• Fluid losses 10-20 litres!
• give 0.9% saline and expect a small rise in sodium initially
  • only use 0.45% if sodium not falling or rising AND sugar not falling
  • the key is osmolality, when 0.9% saline given the sodium often rises but the sugar drops much more and overall osmolality goes down which is the important bit
• don’t reduce the sodium more than 10 in 24 hrs
• aim +ve fluid balance of 3-6 littres at 12 hours
• aim to reduce sugar no more than 5/hr
• only introduce insulin IV if the sugar stops falling with fluids (and even then at 0.05units/kg, half that of DKA)
• most patients should have VTE prophylaxis
• they highlight the frequency of foot ulceration in these folk

BSPED 2015

• Diagnosis
  • pH<7.3, Bicarb <18
  • Ketonaemia >3
  • usually glucose >11
• pH<7.1 = severe DKA
• Management
  • do not give fluid bolus unless shocked, even if pH<7.1
  • if giving it in a shocked DKA kid give a single 10ml/kg bolus
  • Fluid requirement = deficit + maintenance
    • they acknowledge that estimating deficit is witchcraft inaccurate so give this guide
      • 5% deficit if pH>7.1
      • 10% deficit if pH<7.1
      • replace this over 48 hrs
    • Maintenance is lower than normal (and not the usual APLS)
      • <10kg = 2ml/kg/hr
      • 10-40kg = 1ml/kg/hr
      • >40kg = fixed 40ml/hr
    • they note that all fluids should contain potassium (0.9% saline 500mls with 20mmol KCL)
  • Insulin
    • give 1-2 hrs after fluid starts
    • use 0.05-0.1 unit/kg
  • Once glucose under 14 then need to add glucose. The concentration depends a bit on the ketone level. See the guideline
• Signs of cerebral oedema
  • headache
  • irritability
  • slowing pulse
  • increasing pulse pressure
  • reducing GCS
• If suspected give mannitol (20% 0.5-1 g/kg over 10-15 minutes)