DKA

[tyson]

had somewhat of an interesting DKA case last night and wanted to get opinions. 
21 y/o F, type 1 DM, non compliant w/ medications. 

Vitals. P. 115. BP/ 94/68 02. 100%. Temp. 93.2

Initial ABG- 6.84, Bicarb 2, C02-14, K+ 6.8, BS > 1000
Ketones 11.88 (normal <.27) 
EKG showed peaked T waves. very obvious. 

She got calcium gluconate, bolus of insulin after seeing EKG.
I ordered 3 amp of bicarb (at TTH, when I order bicarb, it goes into a drip, here, it got bolused). big oops. 
I started an insulin drip at .1 unit/kg/hr thereafter. 

Questions for discussion- 

1. I was looking at indications for bicarb and really it's only suggested under 6.9 or 7.0 depending where info is coming from. American diabetes association recommends at <6.9.  Even then, I haven't found much that shows bicarb is beneficial in this setting either way. study from 2013 posted below which says not helpful. 

Do you guys you bicarb in this setting? found it useful? do you push your amp of bicarb or just run a couple amps over 6 hours in a drip (as i intended, but did not instruct). 

2. It was suggested that LR be started. In doing some research, i've seen mixed reviews. Some think the 4mm of K+ in solution and lactate may worsen hyperkalmia and lactate could potentially be metabolized to glucose, worsening hyperglycemia. I've read some stuff on pulmcrit that suggests it avoids hyperchloremic acidosis and increases bicarb. 

Do you guys use LR? 
Do you ever do a NS bolus and then switch to LR? 
General thoughts on LR in DKA? 


Tyson



www.emdocs.net/myths-dka-management/
www.ncbi.nlm.nih.gov/pubmed/23737516
www.pulmcrit.org/2014/05/four-dka-pearls.html

[Bjs04f]

1- bicard causes paradoxical intracellular and cerebral acidosis. It has never been shown to be effective in dka. However if myocardial instability is present 1 amp is fine
2- lr has lactate that liver turns into bicarb. If they are not hyperkalemoc(which they aren't as they have depletion of k+) go for it. You pt however had high k so a normal saline is a fine start switch to lr when the insulin work and the k normalizes.

[Bjs04f]

Lastly we use normal saline a lot and it is shown to worsen acidosis. Look at Stewart principal which is the mechanism by which it works. lr has very little k per liter 4mmol/L. How much do we give to increase k by? I've been taught inc 0.1 for every 10meq given so they're k would theoretically go up 0.05 max.

[Bjs04f]

Having run this case with you my initial thought would be give can gluconate RPT every 10 min until EKG changes improve. Give a 1L NS bolus. Start insulin 0.1U/kg while running LR at 1.5 maintenance.

[Bjs04f]

Also I had heard a discussion over whether to intubate. Honestly there was a strong case to do it. Pt had significant illness and had altered mental status. Despite her needing her tachypnea to correct acidosis, that doesnt justify delaying intubation. Heres my reasoning. The lowest you can get your CO2 is 15, which she was at, she is at max compensation, and allowing her to breath 60 times a minute with AMS is not going to better this. Secondly we can set out vent to allow for increased tidal volumes to maintain this while protecting her airway. Third with intubation we cease her respiratory effort, dec lactate production from respiratory muscles. Fourth if she fatigues that compensation goes. I wouldve intubated her right off with everything else going on. No need to aspirate on top of her critical illness. The more we get into this career, the more it seems that early aggressive management provides a better outcome and doesnt give the ICU docs a bag of shit that will be impossible to turn around. Lastly really enjoy this ICU esque discussion with lots of hindsight and time to think.

[Bjs04f]

Also this is becoming a big deal, as some of the small EDs around toledo area send these guys in with horrendous mismanagement and make us look bad. THis isnt a tough case. last few I saw either got 4+L of fluid in the first two hours which is asking for bad outcome, or insulin bolus, or one guy was running insulin at 1U/kg/hr ie ten times the dose

[tyson]

i agree. i thought the girl should have been tubed right off when she was moaning, poorly responsive and w/ vital signs/ RR/acidosis. i thought that tubing her first and then lining and rescucitating should have been primary. we ended up going for a line primarily, which was complicated by her being combative, pulling at sheet etc... ends up delaying the essential care.


this case, while everything turned out fine, definitely had some hiccups.

when pt hit door, she got EKG. W/ peaked T waves, I ordered calcium gluc and insulin push. all okay. Then ABG and labs ordered. I put in order for 1 L of NS. somehow, we end up with three, that's right, 3 liters of saline running?!! i don't know if nursing just throw's a liter on, then throws another on when i order it. no idea how that happens. but like you said, it's asking for trouble.

hopefully the outside hospital that was running at 1 U/KG/HR was a nursing error and not a physician error, otherwise pretty poor.

I too enjoy CCM discussions. evidence is ever-evolving and there are new and better ways to tx serious disease. going over errors or alternatives in management definitely helps me the next case around.

[Bjs04f]

Crit cares awesome, and I agree if it wasnt 2 years and 500k lost wages totally doable. But sadly no it was reported to me from the sending doc he was running 1U/kg/hr

[tyson]

emcrit had early podcast on this exact subject. #3 to be exact.

basically went over some of the stuff you were discussing.

not a bad idea to tube the severely acidotic patient. make sure to avoid any hypoxemia. get tube done quick.

set vent tidal volume at 8 ml/kg
set vent rate at 30
set peep to appx 5

get repeat abg and make sure vent is blowing off same amount that bad DKA'r was blowing off. so if CO2 was 14 before, adjust RR to that.
weingart sees no benefit to bicarb (but doesn't give a shit if you give some).

[Bjs04f]

Sounds right, I cant see a reason to say eh lets neglect A of my ABCs.