Definition

  • Hyperglycemia (> 200mg/dl)
  • pH < 7.3 or HCO3 < 15 mmol/L
  • Ketonuria and ketonemia

Severity

  • Mild: pH < 7.3 / HCO3 < 15
  • Moderate: pH < 7.2 / HCO3 < 10
  • Severe: pH < 7.1/ HCO3 < 5

Labs

  • Blood gas q2 till pH > 7.3
  • Accucheck q1 while on insulin gtt
  • BMP admission and q24
  • Serum Na and K q2 until stable
  • HBA1C on admission
  • CBCD
  • Cultures as appropriate
  • Endocrine labs

Clinical features

  • Dehydration
  • Kussmaul Respirations
  • Nausea, Vomiting and Abdominal pain
  • Lethargy/Obtundation
  • Leucocytosis with left shift
  • ↑ serum amylase

General goals of therapy

  • Rehydration
  • Correct acidosis
  • Correct ketosis
  • Restore BG to normal
  • Avoid complications
  • Treat precipitating event

Pathophysiology

  • Insulin deficiency
  • ↑ counter regulatory hormones (Glucagon, GH and Cortisol)
  • ↑ Gluconeogenesis
  • ↑ Glycogenolysis
  • ↑ Lipolysis
  • ↑ ketogenesis

Average fluid/electrolyte deficits (range)

  • Water: 70ml/kg (30-100)
  • Na: 6mEq/kg (5-13)
  • K: 5mEq/kg (3-6)
  • Cl: 4mEq/kg (3-9)
  • P: 0.5-2.5mEq/kg

Risk factors for cerebral edema

  • Age < 5 yrs
  • Initial Fluid bolus > 20ml/kg
  • Severe acidosis (pH < 7.1)
  • Elevated BUN
  • ↓Na despite improving BG
  • HCO3 therapy

Monitoring

  • Q1 neurochecks
  • Q1 accucheck
  • Q2 VBG with Na and K
  • Strict I/O
  • Urine ketones

Fluid therapy

  • 1.5 x maintenance fluids
  • Add Dextrose to IVF once BG < 250-300 mg/dl
  • Order 2 bags of IVF
    1. NS or 1/2 NS with 20meq/l of K Phosphate and 20meq/l of K acetate
    2. D10 NS or D101/2 NS with 20meq/l of K Phosphate and 20meq/l of K acetate 
  • Titrate fluid rate from these bags to maintain BG 100-200
  • Avoid hypotonic fluids if concerns of cerebral edema
  • Add K to IVF once UO documented and no renal failure

Insulin therapy

Infusion at 0.05-0.1u/kg/hr till pH > 7.3 and HCO3 > 15

Transition to SQ insulin

Allow PO diabetic diet, administer SQ insulin, wait 30 minutes and D/C IV insulin and IVF