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| {{familytree/start |summary=Diabetic ketoacidosis}} | | {| class=wikitable |
| {{familytree | | | | | | | | | | | | | | | | A01 | | | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:'''
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| | | DKA|| HHS |
| ❑ Abdominal pain <br> ❑ Altered mental status <br> ❑ Fever <br> ❑ [[Kussmaul breathing]] <br> ❑ Vomiting
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| | | Plasma [[glucose]] || >250 mg/dL ||>250 mg/dL ||>250 mg/dL || >600 mg/dL |
| '''Identify precipitating factors:'''
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| | | Arterial pH|| 7.25-7.30|| 7.00 to <7.24|| <7.00|| >7.30 |
| ❑ Infections <br> ❑ Insulin deficiency <br> ❑ Myocardial infarction <br> ❑ New onset DM type 1 <br> ❑ Pregnancy <br> ❑ Stress </div>}}
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| {{familytree | | | | | | | | | | | | | | | | |!| | | | |}}
| | | Serum [[bicarbonate]] (mEq/l)|| 15-18|| 10 to <15|| <10 ||>18 |
| {{familytree | | | | | | | | | | | | | | | | B01 | | | |B01='''Examine the patient'''}}
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| {{familytree | | | | | | | | | | | | | | | | |!| | | | |}}
| | | Urine [[ketone]]|| Positive|| Positive|| Positive|| Small |
| {{familytree | | | | | | | | | | | | | | | | C01 | | | |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Consider alternative diagnosis:''' <br> ❑ Starvation ketosis <br> ❑ Alcoholic ketoacidosis <br> ❑ Drug abuse ([[salicylate]], [[methanol]], [[ethylene glycol]]) <br> ❑ [[Lactic acidosis]] <br> ❑ Other causes of high anion gap [[metabolic acidosis]] </div> }}
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| {{familytree | | | | | | | | | | | | | | | | |!| | | | |}}
| | | Serum [[ketone]]|| Positive|| Positive|| Positive|| Small |
| {{familytree | | | | | | | | | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''Order tests:'''
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| | | Effective serum [[osmolality]]|| Variable|| Variable|| Variable|| >320 mOsm/kg |
| ❑ Serum glucose <br> ❑ [[ABG]] <br> ❑ [[CBC]] <br> ❑ [[Electrolytes]] <br> ❑ Serum & urinary [[ketone]]s <br> ❑ [[Urinalysis]] <br> ❑ [[BUN]] <br> ❑ [[Creatinine]] <br> ❑ [[Osmolality|Plasma osmolality]]
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| | |Anion gap|| >10 || >12 || >12 || Variable |
| ❑ [[EKG]] <br> ❑ [[CXR]] <br> ❑Urine, sputum, blood cultures (not routine)</div>}}
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| {{familytree | | | | | | | | | | | | | | | | |!| | | | |}}
| | | Mental status|| Alert|| Alert/drowsy|| Stupor/coma|| Stupor/coma |
| {{familytree | | | | | | | | | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">'''Diagnostic criteria'''
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| ❑ Anion gap > 10 <br> ❑ Blood glucose > 250 mg/dL <br> ❑ pH < 7.3 <br> ❑ Serum bicarbonate < 18 mEq/L <br> ❑ Serum ketones (+)</div>}}
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| {{familytree | |,|-|-|-|-|-|-|-|-|-|v|-|-|-|-|^|-|-|-|-|v|-|-|-|-|-|-|-|-|-|.| | }}
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| {{familytree | F01 | | | | | | | | F02 | | | | | | | | F03 | | | | | | | | F04 | | | |F01=<div style="float: left; text-align: left; line-height: 150% ">'''IV fluid therapy'''
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| ❑ Check hydration status
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| ❑ Mild dehydration
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| :❑ Evaluate for corrected Na+levels
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| :❑ High/Normal Na+levels
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| ::❑ Switch to 0.45% NaCl (250-500mL/hr)
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| :❑ Low Na+ levels
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| ::❑Continue to 0.9% NaCl (250-500mL/hr)
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| ❑ Check blood glucose levels <br>
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| ❑ At serum glucose levels ~ 200 mg/dL, switch to 5% dextrose with 0.45% NaCl (150-250 ml/hr)
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| ❑ Severe dehydration
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| :❑ Start 0.9% NaCl (1L/hr) initially
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| ❑ [[Cardiogenic shock]]
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| :❑ Pressors/ Monitor hemodynamics
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| </div>
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| |F02=<div style="float: left; text-align: left; line-height: 150% ">'''Insulin''' | |
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| ❑ IV - Complicated DKA
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| :❑ Regular insulin (0.1 U/kg) bolus
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| :❑ Continuous infusion (0.1 U/kg/hr)
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| ❑ SC - Uncomplicated DKA
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| :❑ Rapid action insulin 0.3 U/kg then 0.2 U/kg after 1 hr
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| :❑ SC insulin 0.2 U/kg every 2 hrs
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| ❑ Double insulin infusion if blood sugar doesn't fall by 50-70 mg/dL in first hr <br>
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| ❑ At serum glucose = 200 mg/dL reduce IV insulin to 0.02-0.05 U/kg/hr or SC insulin (0.1 U/kg) every 2 hrs <br>
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| ❑ Target blood sugar to 150-200 mg/dL till DKA resolves</div>
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| |F03=<div style="float: left; text-align: left; line-height: 150% ">'''Need for K<sup>+</sup>replacement?''' | |
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| ❑ < 3.3 mEq/dL
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| :❑ Hold insulin
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| :❑ supplement K+ (20-30 mEq/hr) till K+ > 3.3 mEq/L
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| ❑ 3.3-5.3 mEq/dL
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| :❑ Administer 20-30 mEq/L K+
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| ❑ >5.3 mEq/dL
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| :❑ Don't supplement, check 2 hourly </div>
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| |F04=<div style="float: left; text-align: left; line-height: 150% ">'''Need for bicarbonate replacement?''' | |
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| ❑ pH < 6.9
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| :❑ Dilute NaHCo3(100 mmol) in 400 ml H2O with 20 mEq KCl infused over 2 hrs
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| :❑ Reassess
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| ❑ pH > 7.0
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| :❑ No bicarbonate needed</div>}}
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| {{familytree | |`|-|-|-|-|v|-|-|-|-|'| | | | | | | | }}
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| {{familytree | | | | | | G01 | | | | | | | | | | | | | |G01=<div style="float: left; text-align: left; line-height: 150% ">❑ Check labs every 2-4 hrs <br> ❑ Transition to SC insulin (0.8 U/kg/day) when pt tolerates oral feeding <br> ❑ Stop IV insulin gradually <br> ❑ Monitor for complications:
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| ❑ Hypogylcemia <br> ❑ Hypokalemia <br> ❑ Cerebral edema <br> ❑ Respiratory distress <br> ❑ Sepsis <br> ❑ Acute gastric dilation </div> }}
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| {{familytree/end}}
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| Adapted from the recommendations given by American Diabetes Association (ASA) and other sources.<ref name="Nyenwe-2011">{{Cite journal | last1 = Nyenwe | first1 = EA. | last2 = Kitabchi | first2 = AE. | title = Evidence-based management of hyperglycemic emergencies in diabetes mellitus. | journal = Diabetes Res Clin Pract | volume = 94 | issue = 3 | pages = 340-51 | month = Dec | year = 2011 | doi = 10.1016/j.diabres.2011.09.012 | PMID = 21978840 }}</ref>
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