DKA
                                      ===
þ Looking for causes of DKA
 - [Nyenwe, et al. Endocr Pract, Jan-Feb 2007. Active use of cocaine: an 
   independent risk factor for recurrent DKA]
 - infection
   <DM.TXT -infections>
 - noncompliance
   <DM.TXT -85% of admits>  
 
þ When is SQ Insulin OK?
 - Mild to mod DKA, no vomiting, mild acidosis, no concurrent illness
 - 2 small RCTs, one aspart, one lispro
 - Rapid acting insulin 0.3u/kg initial dose, then 0.2u/kg 1h later, then
   0.2u/kg q 2h until control
 - Benefits of ultrashort acting—shorter peak action, less time in ED, less
   likely delayed hypoglycemia

þ Who Can Go Home?
 - Taking pos, no concurrent illness, anion gap closed, glucose improved
 - Has or is able to get insulin/ oral meds and use them
 - When glucose controlled, acidosis and vomiting resolved, start SQ insulin
  + Total daily dose ~1u/kg
  + basal/bolus— 1/2 TDD glargine,
  + ½ TDD as aspart or lispro, each meal ~15-20% of TDD

þ Bicarb?
 - bicarb for kids in DKA can cause cerebral edema and is best avoided
   [Glaser et al. Risk factors for cerebral edema in children with DKA. NEJM
   2001;344:264-9.]                                     
 - Algorithm recs for NaHCO3 for pH<7.0
 - No great data
 - 21 adults with DKA, pH 6.9-7.14, randomized to NaHCO3 or not, no differences
   in rate of glucose or ketone decline, no diff in time to correction of
   acidosis or outcomes*
 - Retrospective study 147 kids with DKA, 57 no NaHCO3, including 9 with pH<7, 1
   pH6.73, NaHCO3 group longer hospitalization, but similar time to metabolic
   recovery**
  
þ Insulin/fluid Drips for DKA:
 - as of January 2001, per Dr. Jann Johnston, new standing orders for adult
   DKA are for:
 + 0.9% NS (+/- KCl) until sugar less than 250
 + D5 1/2NS (+/- KCl)
 + Insulin 0.1 mg/kg IV stat
 + Insulin 0.1 mg/kg/hr drip

þ Insulin Loading Dose or Not?
 - RCT, 37 pts total in DKA
 - Load group: 0.07 u/kg bolus followed by 0.07 u/kg/h drip
 - No load group: 0.07 u/kg/h drip
 - Twice no load group: 0.14u/kg/h drip
 - Bottom line: no load group needed additional insulin to decrease glu 10%,
   load and twice load the same, however usual dose 0.1u/kg/h

þ Highlights DKA Protocol
 - Volume resuscitation with NS 1L/h
 - Continue NS if corr Na+ low, if normal to high, use 1/2 NS (~1.6meq Na for
   each 100mg/dl glu> 100mg/dl), 250-500ml/h, depending on volume status
 - When glucose ~250, change to D5 1/2NS
 - IV insulin, 0.1u/kg IV bolus, then 0.1u/kg/hr
 - May use SQ insulin mild to mod DKA, rapid acting, 0.3u/kg initial, then
   0.2u/kg 1h later, q2h

þ K+ and DKA
 - Measured K+ artificially high due to acidosis and osmotic shifts, shifts K+
   out of cells
 - DKA= K+ wasting, total body depletion ~3-6mml/kg, MUST replace
 - If K+ <3.3, hold insulin and replete K+
 - If K+ high, make sure to restore urine output before replacement
 - EKG can suggest symptomatic hypo or hyperK+

þ Tidbits
 - PO4 is lost, but no benefit to replacement unless <1.0, can induce
   hypocalcemia, hypomag
 - Elevated WBC characteristic, elevated band count more specific for
   infection
 - Acromegaly can have DKA as first presentation-insulin resistance due to
   growth hormone excess

þ Highlights HHS Protocol
 - DX: glu>600, pH>7.3, bicarb>15
 - RX: same as DKA
 - Typically greater volume requirements than DKA by several liters
 - Mortality rate HHS ~15%, DKA <4%
 - Age>65 significant independent predictor of mortality by logistic regression
   analysis, especially if serum osm>375mg/dl*
 
þ Kids and DKA?
 - Younger kids, lower socioeconomic status more likely to present with DKA as
   initial presentation
 - Larger surface area relative to total body mass, higher metabolic rate
 - Cerebral and other autoregulatory mechanisms not as well developed, cerebral
   edema <1%, MCC of M&M in kids
 - MCC DKA adolescents due to not taking insulin, lots of psychosocial
   factors—depression, eating disorders, troubled family life, etc..
 - Insulin pump failure
 - Volume resus with 10-20ml/kg NS first h, may repeat h2-4
 - Estimate 5-7% volume depletion mod DKA, 10% severe,  replace deficit over
   48h, use NS if corr serum NA low, otherwise 1/2NS*
 - Add KCL 20meq/L + KPhos or K Acetate 20meq/L (unless initial K+ high—assure
   urine output prior to K+ replacement)
 - Insulin 0.1u/kg/h, no bolus in kids**
 - Add D5 (or D10) when glucose ~250 until ketosis resolves

þ Cerebral Edema
 - Headache, recurrent vomiting
 - Inappropriate decrease HR, increased BP, decreased O2 sats
 - AMS—restlessness, irritability, drowsiness, incontinence, focal neuro changes
 - Typically occurs 4-12h after treatment, but can occur prior to rx and up to
   24-28h
 - Rx: supportive, ETT, mannitol*, avoid hyperventilation
 - Increased risk with lower art pCO2, higher BUN*, lower pH**
 - Can be found on MRI even without clinical signs***
 - MR diffusion weighted imaging suggests hypoperfusion/vasogenic etiology
   rather than osmotically mediated fluid shifts


þ