Ver el código de «Diabetic ketoacidosis»

==Background==
*Hyperglycemia
**Leads to osmotic diuresis
***Loss of fluid, Na, Cl, K, Phos, Ca, Mg
*Acidosis
**Due to lipolysis / loss of ketoanions
**Causes respiratory alkalosis
**Breakdown of adipose > prostaglandin I2, E2
***Prostaglandins + acidosis = vasodilation
***Prostaglandins cause N/V/abd pain
*Dehydration
**Causes Renin system activation
***K and ketoanion loss (in exchange for chloride)
****Worsens metabolic acidosis

==Causes==
**Insulin non-compliance
**Infection
**Ischemia
**Intra-abd process
**Meds
***Steroids, antipsychotics, thiazides
**ETOH/drug abuse
**Pregnancy
**Hyperthyroidism
**GI hemorrhage

==Classification==
*Diagnosis = BS >250, AG >10, bicarb <15, pH <7.3, mod ketones
**BS may be lower if impaired gluconeogenesis (liver failure)
**Bicarb may be normal if concurrent alkalosis (e.g. vomiting)
***In this case an elevated gap may be the only clue
*Severity
**Mild (ketosis): gap <12
**Mod: gap 12-18
**Severe: gap >18

==Workup==
*CBC
*Chem 10
*UA
*Serum ketones
*hCG
*ECG
*VBG
**Venous pH ~ 0.03 lower than arterial pH
**Verify that respiratory compensation is as expected
*CXR

==Treatment==
*Volume then potassium then insulin
===Labs===
*Glucose check Q1hr
*Chem 10 Q4hr
*Corrected Na:
**Add 1.6 for each glucose of 100 >100

===Fluids===
*Most pts 3-6L depleted
*If severe hypovolemia: 1L NS/hr for up to 3 hr
*If mild dehydration then evaluate corrected Na+
**If hypernatremic: 1/2NS @ 250-500ml/hr
**If hyponatremic: NS @ 250-500ml/hr
*When BS < 250 switch to D51/2NS@ 150-200 ml/hr(+/- KCl)
*Bolus NS as needed for unstable VS

===Insulin===
*Check K prior to insulin Tx!
**If K < 3.3 do not administer insulin
*IV Route
**IV gtt 0.1 U/kg/hr
***Bolus dose unnecessary
**If BS does not decrease by 50-70/hr then double infusion rate qhr until achieved
***Refractoriness is often due to infection
**When BS <200, reduce to 0.02-0.05 U/kg/hr IV OR give subQ 0.1 U/kg q2hr
***Maintain BS between 150 and 200 until resolution of DKA
***Continue IV infusion for 1-2 hr after SC insulin tx is begun
*SubQ route (appropriate only for mild DKA)
**Insulin lispro or aspart 0.3 U/kg initially
***0.2 U/kg one hr later
****0.2 U/kg q2hr thereafter
**If BS does not decrease by 50-70/hr then double dose qhr until achieved

===Potassium===
*Ensure adequate urine output before giving K
*Prevent hypokalemia
*>5.5: don't give, but recheck q2hr
*3.3-5.5: give 30 meq/hr in each liter bag
**1/2NS is preferred b/c adding 30meq to NS = hypertonic soln
*<3.3: hold insulin and give 30 meq/hr until K >3.3

===Bicarb===
*Consider for pH <6.9 AND:
**Decreased contractility
**Hypotension
**Severe hyperkalemia
**Coma
*100 meq NaHCO3 in 400mL H2O @ 200 mL/hr
**Dose as needed until pH > 7.00

===Phosphate===
*Hypophosphatemia following insulin tx usually asymptomatic
**Repletion is associated with hypoCa and hypoMg
*Consider repletion (KPO4 20-30 meq/L)if:
**Phosphate <1.0
**Cardiac dysfunction
**Respiratory dysfunction
**Evidence of hemolysis or rhabdo

==Complications==
*Cerebral Edema
**Almost all affected pts are <20yr
**Associated with initial bicarb level; not rate of glucose drop
**Premonitory symptoms:
***Headache
***Incontinence
***Mental status change / seizure
**Treatment
***Mannitol IV 1-2gm/kg OR
***3% NS 5-10mL/kg over 30min
*Noncardiogenic pulmonary edema

===Sliding Scale===
*200-250 = 4u sq
*251-300 = 6
*301-350 = 8
*351-400 = 10

==Treatment Algorithm==
[[File:ADA_DKA.gif]]

==Source==
Tintinalli, UpToDate
DKA Algorithm figure from UpToDate
[[Category:Endo]]