Episode 60.0 – Aggressive Resuscitation of Diabetic Ketoacidosis

This week we discuss how to aggressively resuscitate patients with DKA as well as dispelling some dogmatic teachings on the topic.Show NotesTake Home Points DKA should be suspected in any patient with altered mental status and hyperglycemia. Get a VBG (ABG not necessary) to confirm the diagnosis. Hypokalemia kills in DKA. Aggresively replete potassium and consider holding insulin, which drops serum potassium, until K is greater than 3.5 The insulin bolus isn’t necessary and appears to cause more episodes of hypokalemia. Just start insulin as an infusion at 0.14 units/kg Be vigilant about cerebral edema. Any change or deterioration in mental status should prompt treatment and evaluation. Mannitol in the euvolemic, normotensive patient and 3% hypertonic saline in the hypotensive/hypovolemic patient Finally, don’t forge to always hunt down the underlying cause of the DKA. Infection and non-compliance is the most common so liberally administer broad spectrum antibiotics if you’ve got even a hint of infection brewing [embed]https://www.youtube.com/watch?v=P9sKk4JZmso[/embed] Additional Reading LITFL: EBM Diabetic Ketoacidosis Core EM: DKA Core EM: Episode 13.0 - Diabetic Ketoacidosis: A Case emDocs: Myths in DKA Management REBEL EM: Is There Any Benefit to an Initial Insulin Bolus in Diabetic Ketoacidosis? References Aurora S et al. Prevalence of hypokalemia in ED patients with diabetic ketoacidosis. Am J Emerg Med 2012; 30: 481-4. PMID: 21316179 Boyd JC et al. Relationship of potassium and magnesium concentrations in serum to cardiac arrhythmias. Clin Chem 1984; 30(5): 754-7. PMID: 6713638 Duhon B et al. Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother 2013; 47: 970-5. PMID: 23737516 Fagan MJ et al. Initial fluid resuscitation for patients with diabetic ketoacidosis: how dry arethey? Clin Ped 2008; 47(9): 851-6.