DKA emergency protocol -
Patients with DKA are physiologically challenging patients to intubate for several reasons. Their respiratory dynamics of hyperpnea to correct their underlying metabolic acidosis means the ventilator must equally match their large tidal volume and respiratory rate.
This intrinsically puts the patient at risk for ventilator induced lung injury and subsequent development of ARDS. Furthermore, these patients with profound metabolic acidosis are at risk of circulatory collapse peri-intubation as periods of apnea during intubation will cause their pCO 2 levels to rise rapidly, worsening the acidosis.
Oxygenation is rarely an issue in DKA, but rather work of breathing and respiratory fatigue may occur. Our experts do not recommend the routine use of BiPAP in DKA patients given the risk of aspiration and emesis in these patients, as they often concurrently have gastroparesis.
Only consider NIPPV if the patient is in a highly monitored setting with one-to-one nursing care. The key to avoiding cerebral edema in the management of DKA is to go slow with resuscitation. For part 2 of this series on Diabetic Emergencies go to Episode HHS Recognition and ED Management.
Now test your knowledge with a quiz. Thank for a great podcast. I would like to offer an alternative approach to management of DKA where we do not use use an insulin infusion at all.
We give 0. Measure glucose q2 for 4 hours. At 2 hour mark if glucose is still high we will give another dose of Lispro but at 0. In this approach we have closed the gap just as fast as compared to insulin infusion and have lower incidence of hypoglycemia. The hypothesis is that kids brains have higher oxygen demand and develop global ischemia from hypo perfusion a lot faster than adult brains.
Also, the profound vasoconstriction with high catecholamines and acidosis, together with blood-brain barrier dysfunction lead to inflammatory changes causing CE. So… Going back to my question. What do I do for the shocky, Glasgow of 3, severe DKA kid? Do I correct hypovolemia? In my simple way of thinking, delaying intravascular volume repletion to 36 hrs, is delaying brain perfusion for 36 hr.
There is now enough evidence to suggest that its not the treatment, but the ischemia and blood-brain barrier dysfunction what causes CE and by delaying adequate brain perfusion we may be putting these kids at risk.
I think a larger trial of MRI pre and during treatment might be a better trial to answer the question. Do children with severe DKA already have CE prior to treatment? This is a review on pediatric DKA fluid management and cerebral edema in our EM Quick Hits by Sarah Reid….
And here is the pediatric DKA algorithm that I recommend. Hope this helps clarify fluid management in pediatric DKA. Cerebral edema seems to be from the disease itself rather than the treatment. I would prioritize the treatment of shock.
Two review articles that summarize this well: 1 Cashen K, Petersen T. Diabetic Ketoacidosis. Pediatr Rev American Academy of Pediatrics;40 8 Emergency Medicine Myths: Cerebral Edema in Pediatric Diabetic Ketoacidosis and Intravenous Fluids.
J Emerg Med ;53 2 Is this part right? Previous Next. View Larger Image. The Difficulty in Diagnosing Diabetic Ketoacidosis DKA There are no definitive criteria for the diagnosis of DKA according to the Canadian DKA Guidelines.
Severity categorization of DKA Differentiating DKA from Hyperglycemic Hyperosmolar Syndrome HHS DKA and HHS may occur concurrently. Evaluation for precipitating cause of DKA is paramount as it is often the cause of of death in patients with DKA DKA can be the initial manifestation of diabetes, but it often occurs in the context of known diabetes plus a trigger.
for suspected infection trigger β-hydroxybutyrate if diagnosis unclear Lactate is a potentially important prognostic factor in predicting the severity of DKA and in monitoring the progression or resolution. Acid-base disturbances in DKA DKA patients classically have an anion-gap metabolic acidosis due to lipolysis and an accumulation of ketoacids.
Sorting out ketonemia: The differential diagnosis of ketoacidosis The differential diagnosis for ketoacidosis includes: DKA Alcoholic ketoacidosis Starvation ketosis Isopropyl alcohol ingestion In the presence of low or normal glucose levels, it is less likely that it is DKA.
Expand to view reference list. Goguen J, et al. Hyperglycemic emergencies in adults: Clinical Practice Guidelines. Canadian Journal of Diabetes, SS Kitabchi AE, Umpierrez GE, Miles JM, et al.
Hyperglycemic crises in adult patients with diabetes. Diabetes Care. Wolfsdorf JI, Glaser N, Agus M, et al. ISPAD Clinical Practice Consensus Guidelines diabetic ketoacidosis and the hyperglycemic hyperosmolar state.
Pediatr Diabetes. Fayfman M, Pasquel F, Umpierrez G. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. Umpierrez G, Freire A.
Abdominal pain in patients with hyperglycemic crises. J Crit Care. Sheikh-Ali M, Karon B, Basu A, et al. Can serum beta-hydroxybutyrate be used to diagnose diabetic ketoacidosis?
Utility of initial bolus insulin in the treatment of diabetic ketoacidosis. J Emerg Med. Ma OJ, Rush MD, Godfrey MM, et al. Arterial blood gas results rarely influence emergency physician management of patients with suspected diabetic ketoacidosis.
Acad Emerg Med. The protocol and accompanying documents can be downloaded in a single document, the DKA Protocol Toolkit , or as individual documents:. This version auto-calculates the fluid rates and has some pop-up screens to guide in the clinical evaluation of children presenting with DKA.
We have made available a slide set for use with presenting the BCCH DKA Protocol revision to other professionals:. We hope that you will find these materials to be helpful in managing pediatric cases of diabetic ketoacidosis. We also welcome any suggestions to make this material more useful to your practice.
HHS is more likely in type 2 diabetes, or in type 1 diabetes when the patient has been consuming large quantities of glucose-containing drinks.
Some patients can present with a mixed picture of both HHS and DKA. Onset of headache or mental status changes during therapy should lead to consideration of this complication.
Intravenous mannitol in a dosage of 1 to 2 g per kg given over 15 minutes is the mainstay of therapy. Prompt involvement of a critical care specialist is prudent.
Adult respiratory distress syndrome ARDS is a rare but potentially fatal complication of the treatment of diabetic ketoacidosis. Patients with an increased alveolar to arterial oxygen gradient AaO2 and patients with pulmonary rales on physical examination may be at increased risk for ARDS.
Monitoring of oxygen saturation with pulse oximetry may assist in the management of such patients. Hyperchloremic metabolic acidosis with a normal anion gap typically persists after the resolution of ketonemia.
This acidosis has no adverse clinical effects and is gradually corrected over the subsequent 24 to 48 hours by enhanced renal acid excretion. No randomized prospective studies have evaluated the optimal site of care for patients with diabetic ketoacidosis. The response to initial therapy in the emergency department can be used as a guideline for choosing the most appropriate hospital site i.
Admission to a step-down or intensive care unit should be considered for patients with hypotension or oliguria refractory to initial rehydration and for patients with mental obtundation or coma with hyperosmolality total osmolality of greater than mOsm per kg of water.
Most patients can be treated in step-down units or on general medical wards in which staff members have been trained in on-site blood glucose monitoring and continuous intravenous insulin administration.
Milder forms of diabetic ketoacidosis can be treated in the emergency department using the same treatment guidelines described in this review. Successful outpatient therapy requires the absence of severe intercurrent illness, an alert patient who is able to resume oral intake and the presence of mild diabetic ketoacidosis pH of greater than 7.
With the use of standardized written treatment guidelines and flow sheets for monitoring therapeutic response, the mortality rate for patients with diabetic ketoacidosis is now less than 5 percent.
These outcomes have not been altered by the specialty of the primary treating physicians e. An educational program should include sick-day management instructions i.
Patients should not discontinue insulin therapy when they are ill, and they should contact their physician early in the course of illness. Indications for hospitalization include greater than 5 percent loss of body weight, respiration rate of greater than 35 per minute, intractable elevation of blood glucose concentrations, change in mental status, uncontrolled fever and unresolved nausea and vomiting.
Umpierrez GE, Khajavi M, Kitabchi AE. Review: diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome. Am J Med Sci. Umpierrez GE, Kelly JP, Navarrete JE, Casals MM, Kitabchi AE.
Hyperglycemic crises in urban blacks. Arch Intern Med. Ennis ED, Stahl EJ, Kreisberg RA. Diabetic ketoacidosis. In: Porte D Jr, Sherwin RS, eds.
Stamford, Conn. Rosenbloom AL, Hanas R. Diabetic ketoacidosis DKA : treatment guidelines. Clin Pediatr [Phila]. Kitabchi AE, Fisher JN, Murphy MB, Rumbak MJ. Diabetic ketoacidosis and the hyperglycemic hyperosmolar nonketotic state.
In: Kahn CR, Weir GC, eds. Joslin's Diabetes mellitus. Zammit VA. Regulation of ketone body metabolism: a cellular perspective. Diabetes Rev. DeFronzo RA, Matsuda M, Barret EJ. A combined metabolic-nephrologic approach to therapy. Waldhausl W, Kleinberger G, Korn A, Dudczak R, Bratusch-Marrain P, Nowotny P.
Severe hyperglycemia: effects of rehydration on endocrine derangements and blood glucose concentration. Adrogue HJ, Barrero J, Eknoyan G. Salutary effects of modest fluid replacement in the treatment of adults with diabetic ketoacidosis.
Use in patients without extreme volume deficit. Alberti KG, Hockaday TD, Turner RC. Kitabchi AE, Young R, Sacks H, Morris L. Diabetic ketoacidosis: reappraisal of therapeutic approach.
Annu Rev Med. Kitabchi AE, Ayyagari V, Guerra SM. The efficacy of low-dose versus conventional therapy of insulin for treatment of diabetic ketoacidosis. Ann Intern Med. Kitabchi AE, Fisher JN. Insulin therapy of diabetic ketoacidosis: physiologic versus pharmacologic doses of insulin and their routes of administration.
In: Brownlee M, ed. Handbook of diabetes mellitus. New York: Garland STPM, — Lever E, Jaspan JB. Sodium bicarbonate therapy in severe diabetic ketoacidosis.
Am J Med. Barnes HV, Cohen RD, Kitabchi AE, Murphy MB. When is bicarbonate appropriate in treating metabolic acidosis including diabetic ketoacidosis? In: Gitnick G, ed. Debates in medicine. Chicago: Year Book Medical, — Morris LR, Murphy MB, Kitabchi AE.
Protpcol Diabetes self-care and self-management DKKA closely with protocpl DKA protocol developed DKA emergency protocol Emergecy Translating Sugar consumption facts Knowledge for Kidswhich DDKA designed Lowering blood pressure naturally the initial DKA emergency protocol of pediatric DKA in most Canadian emergency emertency, as well Rmergency with DKA emergency protocol DKA algorithm developed emerency the Canadian Pediatric Endocrine Groupwhich protocool designed for ongoing inpatient management of DKA. The revision is also aligned with the Clinical Practice Consensus Guidelines of the International Society for Pediatric and Adolescent Diabetes ISPAD. The protocol and accompanying documents can be downloaded in a single document, the DKA Protocol Toolkitor as individual documents:. This version auto-calculates the fluid rates and has some pop-up screens to guide in the clinical evaluation of children presenting with DKA. We have made available a slide set for use with presenting the BCCH DKA Protocol revision to other professionals:. We hope that you will find these materials to be helpful in managing pediatric cases of diabetic ketoacidosis. We also welcome any suggestions to make this material more useful to your practice. In DKA emergency protocol protocl part of our e,ergency podcast protocl DKA and DKA emergency protocol, Drs Melanie BaimelBourke Tillmann and Leeor Isotonic drink performance benefits DKA emergency protocol the importance of progocol the protockl cause Diabetes self-care and self-management trigger in Emsrgency patients, the pitfall of ruling out DKA in emergehcy with normal pH or normal serum glucose, how to close the gap effectively, why stopping the insulin infusion is almost never indicated, how to avoid cardiac collapse when DKA patients require endotracheal intubation, the best alternatives to plastic in the trachea, why using a protocol improves patient outcomes, how to avoid the common complications of hypoglycemia and hypokalemia, and much more…. Podcast: Play in new window Download Duration: — Subscribe: Apple Podcasts Google Podcasts. Podcast voice editing by Raymond Cho. Cite this podcast as: Helman, A. Baimel, M. Sommer, L.
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