Morning Report

Morning Report: DKA

Presented by Dr. Alex Harding.

33 yo female with hx of T1DM p/w nausea, vomiting, and diarrhea that began at 4AM.

HR 110 BP 135/85 RR 22 SPO2 100% FSBG 465.

PE: uncomfortable, retching female, mildly obese. Indurated, sunken, yellowish lesion noted to L foreleg

What is the skin finding?

diss_f1_icm1109700_4

 

What’s the skin finding? Necrobiosis lipoidica diabeticorum

NLD – occurs in women with DM, 0.3% of the diabetic population, 3:1 female to male

  • Usually shins, often bilaterally
  • Can occur elsewhere
  • No good treatment

 

Treatment algorithm:

  • Goals: correct fluid losses, electrolyte imbalance, and hyperglycemia
  • Correct serum na = add 1.6 mEq for each 100 mg/dl glucose above 100 mg/dl
  • Fluids: Pts often approx 6L behind – give bolus NS
    • 2nd bolus – ½ NS if sodium normal/elevated, or NS if sodium low
    • When glucose reaches 200 and sodium normalizes, use 5% dextrose in ½ NS
  • Potassium: correct before insulin therapy
    • K<3.3 – give KCl 20-30 mEq/hr until K>3.3
    • K 3.3-5.2 – hold insulin, give 20-30 mEq K in each liter of IVF
    • Maintain serum K 4-5
    • K > 5.2 – do not give K
  • Bicarb: only for pH < 6.9
  • Insulin therapy: used only if K > 3.3 mEQ
    • Use low-dose regular insulin (short half life, easy to titrate)
    • Initial bolus controversial (may saturate insulin receptors, make other therapy more difficult)
    • Preferred regimen: continuous IV infusion at 0.14 units/kg/hr
    • If blood glucose drop not adequate (<10% in first hour or <50 mg/dl/hr) can bolus 0.14u/kg/hr and continue continuous infusion
    • BG reaches 200, add 5% dextrose to IVF, reduce infusion of insulin to 0.02-0.05 u/kg/hr (or rapid-acting insulin at 0.1u/kg sc q2h)
    • If transferring from IV to SC insulin, keep IV infusion going for 1-2 hrs

Dispo: consult ICU, depending on pt status can go to ICU/SDU/5SJ (diabetic floor), very mild cases may go home if they have good follow up

Note: always look for a precipitating cause! (lack of insulin in pump, kinked pump, infection/stressor)

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