DKA & HHS – treatment myths busted

26 Jun

submitted by Amit Kumar, M.D.

MYTH BUSTING:

*ABG >VBG: False, ABG = VBG.

Additionally, VBG is less painful and avoids complications like radial artery aneurysms, hematoma, and radial neuropathy. Lactate on VBG is equally reliable despite length of tourniquet time or temperature. pH of VBG is assumed to be 0.03 less than ABG. Only level missing in VBG are PaO2 and SpO2 (for which we have the pulse-ox). In general, ABGs are only useful in patient where knowing PaO2 is vital, and A-a gradient is desired.

 

*Shotgun insulin order s/p IVF: False. Correcting electrolytes is higher priority.

Serum K is low to begin with due to acidosis. Additional insulin and IVF will shift more K into cells, further depleting serum K. If K <3.5, replete K and hold insulin. If K 3.5-5.5, replete K with insulin. If K >5.5, may just give insulin.
fig04

 

*Insulin bolus, then drip: False.  Pediatric guidelines actually do not recommend bolus for potential risk for hypercorrection of serum glucose and cerebral edema.

Hypoglycemia is worse than hyperglycemia for mortality. So why do it? Per comparison studies, gtt at 0.14U/kg/h is better at providing a good therapeutic plateau, compared to 0.1U/kg bolus followed by 0.1U/kg/h gtt.
Replete Phos <1 mg/dL (vital for generating ATP) and Mg <2. Monitor Ca as well.

 

*HCO3 for pH <7.1: False. Bicarbonate exacerbates hypokalemia, and may even potentially increase risk of cerebral edema.

Bicarb also shifts O2 dissociation curve leftward, inducing hypoxia in a state of high demand. If given, just start a drip sans bolus, and mix with D5W (mixing with NS will cause precipitation and make solution hypertonic).

 

References:

*Kitabchi AE, Hirsch IB, Emmett M. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment. In: UpToDate (Accessed on July 27, 2016)

*Swaminathan A, Herbert M. (2013, May). DKA Myths [Audio podcast]. Retrieved from: emrap.org

*Wolfson AB, Hendey GW, Ling LJ, Rosen CL, Schaider J, Sharieff GQ. Harwood Nuss’ Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

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