5/01/2024

Diabetic
Ketoacidosis: 1. Describe how DKA develops
Not Your and what criteria patients
must meet for diagnosis. Objectives
Average 2. Recognize common
presenting symptoms for
Sugar Rush patients with DKA.
3. Recall the guideline-
Alli Harrison, PharmD
recommended DKA treatment
PGY1 Pharmacy Resident process and be able to
IU Health Arnett evaluate its proper
implementation.

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Epidemiology Pathophysiology
 One of the most series acute complications
of diabetes
 More common in patients with T1DM, but it
still occurs in patients with T2DM
 27-37% of DKA patients are newly-
diagnosed with T1DM
 Usually evolves over a 24-hr period Absolute Build-Up of
Ketone
Insulin Lipolysis Free Fatty Acidosis
 Fatality of 1-5% Production
Deficiency Acids
 Leading cause of death in diabetic patients
< 24 years old, most often due to cerebral
edema
 Often confused with hyperosmolar
hyperglycemic state (HHS), although there
are some key differences

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Etiology Clinical Presentation

- New-onset T1DM
Lack of
Insulin
- Discontinuation of insulin
- Inadequate insulin dosing
 Polyuria
- Insulin pump malfunction
 Polydipsia
 Weight loss
Corticosteroids -  Hyperventilation
High-dose thiazides -
Antipsychotic agents -
Drugs  “Kussmaul Respirations”
Cocaine and alcohol -
 Abdominal pain
 N/V polyuria, polydipsia, weight loss, hyperventilation, GI symptoms, fruity breath, weakness

- Infection
 Fruity (ketone) breath
Acute
Illness
- Stress-induced state  Weakness/fatigue
- Pregnancy

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Diagnosis Additional Labs

 Serum glucose > 250 mg/dL - urine BUN, SCr Elevated
Dehydration and
decreased renal
perfusion
 (+) serum ketones Acetone
- blood K+: low, normal, or Na+ helps determine fluid
 pH ≤ 7.3 K+, Na+ elevated
Na+: usually falsely low
type, want to keep K+
between 4-5 mg/dL
 Serum bicarbonate ≤ 18 mEq/L
• - urine
 Anion gap > 10 mEq/L Urine
Acetoacetate
• - blood
A1c Variable To determine glycemic control for
past 3 months

 Anion gap = Na+ - (Cl- + HCO3-)

CBC Variable Rule in/out infectious causes

β-
Blood - blood Replacement generally not
serum ketone testing > urine ketone testing hydroxybutyrate
Phos Normal or elevated, decreases
with treatment
recommended until < 1 mg/dL
or symptoms develop

Urine ketone testing yields

higher rates of false-negatives!
Mag Decreased Replace if becomes < 1.2 mg/dL
or symptoms develop

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Guideline-Recommended Treatment
K+ Monitoring
Glucose should  by 10% in Maintenance IVF  < 3.3 – hold insulin and give 20-30
the 1st hour – if not, give mEq of K+ per hour until > 3.3
0.14 units/kg bolus Assess Na+ level  3.3 to < 5.2 – give 20-30 mEq of K+
Initial Fluid •Normal-high: ½NS in each liter of IVF to keep K+ 4-5
Replacement IV Insulin Drip @ 4-14 mL/kg/hr  ≥ 5.2 – do not give K+, continue
•NS @ 15-20 •0.1 units/kg •Low: NS @ 4-14 checking q2h
mL/kg/hr OR bolus, followed by mL/kg/hr
•NS @ 1 L/hr infusion of 0.1 Bicarbonate?
units/kg/hr OR When glucose is < 200,
change to D5½NS @ 150-  Consider only when HCO3- is < 6.9
1-2 hrs later… •Infusion of 0.14 250 mL/hr and decrease  Dose: dilute 100 mEq of NaHCO3 in
*Replete K+ if < 3.3 units/kg/hr insulin infusion rate by 400 mL of H20 with 20 mEq of KCl
50% running @ 200 mL/hr
Resolution of DKA &
patient able to eat,
transition to SC insulin
(overlap by 1-2 hrs)

Corrected Na+ = Na+ + 0.016 * (glucose - 100)

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Resolution of DKA Post-Resolution of DKA

If the patient CANNOT eat, continue IV insulin and
BG < 200 mg/dL AND at electrolyte replacement.
least two of the following: When the patient CAN eat, transition to SUBQ insulin.
• MUST overlap SUBQ insulin with IV insulin for 1-2 hrs
Serum bicarb Anion gap
Venous pH • For patients with known diabetes, restart usual dose if it was
15 mEq/L or 12 mEq/L or controlling glucose levels prior to DKA episode
> 7.3
greater less • For insulin naïve patients, start a basal-bolus regimen at a
starting dose of 0.5-0.8 units/kg/day

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Meet The Patient

LW – 55 YOM Medication Directions Last Fill

Calcium Carbonate (Oyster Cal 500 500 mg (1 tab) PO BID 8/25/23 for #30 tabs (15-
Brought in my EMS on 10/27 for SOB and mg tab) DS)
upset stomach – BG elevated per EMS
Cholecalciferol (Vitamin D3 125 mcg 125 mcg (1 cap) PO 8/25/23 for #30 caps (30-
cap) daily DS)
LW was just discharged on 10/21 after
being treated for DKA Cyanocobalamin (Vitamin B12 1000 1000 mcg (1 tab) PO 8/1/23 for #30 tabs (30-DS)
mcg tab) QAM

Problem List: Insulin Glargine (Basaglar Kwikpen) 35 units SUBQ BID Reports non-adherence

 T2DM, with extensive DKA hx

Insulin Lispro Kwikpen 20 units SUBQ with Reports non-adherence
 28th admission this year so far, meals
almost all for DKA
Levothyroxine 50 mcg tab 50 mcg (1 tab) PO 8/25/23 for #30 tabs (30-
 Hypothyroidism QAM DS)
 Poor compliance Metformin 500 mg tab 500 mg (1 tab) PO 7/8/23 for #60 tabs (30-DS)
 Anxiety BID

 Tobacco use Metoclopramide 5 mg tab 5 mg (1 tab) PO TID 7/8/23 for #90 tabs (30-DS)

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Labs/Vitals in the ED Emergency Department Management

1043: Started NS @ 1 L/hr
Lab Type 10/27 @ 1035 10/27 @ 1037 10/27 @ 1326
K+ was 5.6 @ 1035 - Able to start insulin!
WBC (k/cumm) 11.4 (H) - - HR: 87-102 bpm Weight = 61.3 kg
Sodium (mmol/L) 125 (L) - 131 (L)
Potassium (mmol/L) 5.6 (H) - 4.5 RR: 19-26 rpm 1119: Started insulin regular @ 6.13 units/hr (0.1 units/kg/hr)

Chloride (mmol/L) 90 (L) - 102 Afebrile 1219: Gave NS bolus @ 2 L/hr

Anion Gap (mmol/L) 29 (H) - 21 (H)

1323: Started maintenance fluid - NS @ 150 mL/hr
SCr (mg/dL) 1.54 (H) - 1.13 BP: 108-146/
81-94 mmHg K+ was 4.5 and BG was 243 @ 1505
BUN (mg/dL) 31 (H) - 28 (H)
Venous pH - 7.03 (!) - 1509: Started D5½NS + 20 mEq/L KCl @ 175 mL/hr

Bicarbonate - 5.9 (!) -

Transferred to ICU
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My Thoughts The Role of the ED Pharmacist

 The Good:  Assess adherence to outpatient
diabetes regimen
 Patient arrived at ED, was seen by ER doc, and  Speak with patient/family
was started on resuscitative fluids very quickly
 Look at fill history or call patient’s pharmacy,
 Followed recommended IU Health protocol if needed

 The Bad:  Medication review

 Did not obtain urine or serum ketone level to  Is this random or expected – A1c?
confirm diagnosis of DKA
 Monitor lab values to ensure patient
 The Ugly: is placed on proper fluids
 Protocol differs from the guidelines on insulin
dosing strategy  Advocate for the patient!
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The Road to Prevention Resources

Home ketone
meters
Close outpatient
 Dhatariya KK. Defining and characterising diabetic ketoacidosis in adults. Diabetes Res Clin Pract. 2019;155:107797.
follow-up for diabetes
doi:10.1016/j.diabres.2019.107797
management

 Eledrisi MS, Elzouki AN. Management of Diabetic Ketoacidosis in Adults: A Narrative Review. Saudi J Med Med Sci.
2020;8(3):165-173. doi:10.4103/sjmms.sjmms_478_19

 Fayfman M, Pasquel FJ, Umpierrez GE. Management of hyperglycemic crises: diabetic ketoacidosis and hyperglycemic
hyperosmolar state. Med Clin North Am. 2017;101(3):587-606. doi:10.1016/j.mcna.2016.12.011

 Muneer M, Akbar I. Acute metabolic emergencies in diabetes: DKA, HHS and EDKA. Adv Exp Med Biol. 2021;1307:85-114.
doi:10.1007/5584_2020_545
Proper patient
education
 Westerberg DP. Diabetic ketoacidosis: evaluation and treatment. Am Fam Physician. 2013;87(5):337-346.
Better access
to healthcare

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 5/01/2024

Diabetic
Ketoacidosis:
Not Your
Average
Sugar Rush
Alli Harrison, PharmD
PGY1 Pharmacy Resident
IU Health Arnett

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