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Criteria of DKA & Severity of DKA

#DKA #ICU #stop the insulin infusion only after the following criteria are met: (a) Resolution of ketoacidosis (anion gap < 10-12 mEq/L). An exception here is a patient with end-stage renal disease, who may chronically have an elevated anion gap due to uremia which never normalizes. In this situation, normalization of the beta-hydroxybutyrate level (<0.6 mM) is a more useful way to determine that ketoacidosis has resolved. (b) The patient isn't significantly acidotic (bicarbonate ≧18 mEq/L). (British guidelines) Acidosis increases insulin resistance, so if the patient remains acidemic then there is an increased risk that the anion gap will open up. Many patients will develop a NAGMA, leading to a persistent acidosis that doesn't respond to insulin. This may be treated with IV bicarbonate as described below. (c) The patient has received the full daily dose of long-acting insulin >2 hours previously. (d) Glucose is reasonably well controlled (e.g., <250 mg/dL or <14 mM). (e) The patient should ideally be hungry (this is an excellent sign suggesting that the ketoacidosis has resolved). If the insulin infusion is stopped and the patient doesn't eat anything or receive any IV glucose, this increases the risk of recurrent DKA. An exception can be made for patients with gastroenteritis or diabetic gastroparesis, who may not be hungry for several days. In this situation, the insulin infusion can be stopped, but patients should remain on low-dose intravenous glucose (e.g. D5W at 50-75 ml/hr). If the patient's glucose level increases, they should be treated with PRN short-acting insulin. Ongoing administration of carbohydrate plus PRN insulin will help prevent DKA recurrence.

#Note #ICU #Diabetic_Ketoacidosis (#DKA) is a serious medical emergency that requires prompt management. Initial treatment in the ICU focuses on stabilizing the patient's condition and correcting metabolic abnormalities. steps in the initial management of an adult patient with DKA in the ICU: 1. Fluid Resuscitation: - initial Fluid Replacement: Administer 0.9% normal saline at a rate of 15-20 ml/kg/hour (usually 1-1.5 liters) during the first hour, to correct hypovolemia. - Subsequent Fluid Replacement: After the initial bolus, the rate of normal saline infusion should be adjusted based on hemodynamic status, urine output, and serum electrolytes. Typically, 250-500 ml/hour is given. 2. Electrolyte Management: - Potassium: Monitor serum potassium levels frequently. If potassium is <3.3 mEq/L, hold insulin and give 20-30 mEq of potassium per hour until potassium is >3.3 mEq/L. - Once potassium is above 3.3 mEq/L and insulin therapy is started, typically 20-30 mEq of potassium is added to each liter of IV fluid to maintain serum potassium levels between 4-5 mEq/L. 3. Insulin Therapy: - After initial fluid resuscitation, start a regular insulin drip at 0.1 unit/kg/hour. A bolus might be given initially, but care must be taken if the potassium is low. - Monitor glucose levels hourly. The goal is to decrease blood glucose by 50-70 mg/dL/hour. - Once blood glucose reaches around 200 mg/dL, switch to 5% dextrose in 0.45% saline (D5-1/2NS) to prevent hypoglycemia and continue insulin to correct ketosis. 4. Bicarbonate Therapy: - Generally reserved for severe acidosis (pH < 6.9). If indicated, give 100 mmol of sodium bicarbonate diluted in 400 ml water with 20 mEq potassium chloride (KCl) over 2 hours. - Monitor and repeat as necessary based on arterial blood gas (ABG) results. 5. Monitoring and Support: - Frequent Monitoring: Vital signs, neurological status, and intake/output should be closely monitored. - (Laboratory Monitoring) : - Blood glucose every 1-2 hours. - Serum electrolytes (especially potassium) every 2-4 hours initially. - Blood gases initially, then as needed to assess acid-base status. 6. Addressing Precipitating Factors: - Identify and treat any underlying infections, myocardial infarction, or other causes of DKA. Continued management will focus on the careful adjustment of fluids, electrolytes, and insulin until the patient is stabilized and out of the critical phase.

In DKA, serum K is often elevated at presentation due to insulin deficiency and acidemia causing ↑ extracellular K. Monitor closely, as this can drop rapidly when insulin is started. Don’t forget to look for underlying causes of diabetic ketoacidosis (DKA) such as infection, MI, surgery, stress. It can also be the presenting symptom for type 1 DM.

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🔇🟦 bicarbonate administration should be considered if the acidosis is severe (i.e., pH <7.0). 🟠 If indicated🔊 then 100 mmol of sodium bicarbonate (8.4% solution) in 400 ml of 💲sterile water (an isotonic solution) can be given every 2 h to achieve a pH >7.0

❎ Routine bicarbonate administration is not recommended. ✅ Intravenous fluid resuscitation and insulin administration are usually sufficient to resolve the metabolic acidosis of DKA ✖️ potential detrimental effects of bicarbonate therapy have been reported🔛 such as an increased risk of hypokalaemia ✖️ decreased tissue oxygen uptake 🟥 cerebral oedema 🟥 and development of paradoxical central nervous system acidosis

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