Dr. Peters mixed up her race series. Charlie Kimball, her patient, runs in the U.S. based Indycar series, not Formula 1. (He did race and win in British Formula 3 racing prior to coming back to the U.S. and racing initially in the Firestone Indy Lights series and later racing for Chip Ganassi Racing in Indycar the last 2 years). Incidentally, his major sponsor is Novo Nordisk, makers of novolog and levemir insulins.
This should have been 20 minutes long, not 41+. Mel the beauty of Emrap to me was that it didn't go on and on, it got to the point Boom! Busted knowledge into our heads, then was gone like a frat boy bearing rufees, it seems the whole thing is getting seriously drawn out. I think most listeners would prefer the abbreviated version....my .02 cents. I will save this for those days I just can't seem to get to sleep.....
Apparently in the East coast and Midwest, we give our potassium( po or IV) when giving the insulin. The worry is the IVF and insulin will cause hypokalemia to a significant level. So start early, 20 meq in the second IV. Never made a pt hyperkalemic in 18 years.
While the West coast follows, wait for the potassium to return, then hang insulin drip. The worry is hyperkalemia will occur w/o knowledge of exact amount of K+ or status of renal function.
Some authors recommend, potassium can be initiated after the pt urinates. The functioning kidney will never allow hyperkalemia to occur.
I wish the review would have mentioned the ADA guidelines are consensus based, which was revelation to me during residency. Limited studies on almost every facet of the DKA Rx.
Thanks for all the comments. Vik- thanks for your perspectives on potassium administration. Sean G - we will keep trying to trim things down and shorten our commentary and material. The lecture that Dr. Peters gave was originally over 60 minutes so we were pretty pleased we got it down (with commentary) to 41+! I like your idea though - consider it your Ambien-substitute if that works for you. Arthur - thanks for the clarification on the Formula 1/Indycar situation. Had no idea. makes sense that Novo Nordisk is his sponsor though. That works out well.
I was disappointed how all the speakers from this DKA "update" profess that slow IVF administration is the key to avoiding cerebral edema in treating pediatric DKA. This is folklore! Hard to look at a kid in bad DKA breathing like a fish out of water, vomiting, and not give IVF to restore intravascular volume at decent tempo (after all, most severe DKAers are in a serious degree of shock). See the best/biggest analysis of cerebral edema in peds DKA--N Engl J Med 2001;344:264-9. Their conclusion: "Neither the initial serum glucose concentration nor the rate of change in the serum glucose concentration during therapy was associated with the development of cerebral edema, after adjustment for other covariates; the same was true of the rates of fluid, sodium, and insulin administration." Glaser and Kuppermann-Pediatric Emergency Care Volume 20, Number 7, July 2004: "Some studies have suggested that mild, subclinical cerebral edema may be present in most patients with DKA, but only 1% or fewer develop cerebral edema of a degree sufficient to cause symptoms of increased intracranial pressure and CNS dysfunction." Cerebral edema is likely a freak unfortunate occurrence that results from severe peds DKA. We dont even really understand the pathophysiology of cerebral edema in DKA!
EMRAP is usually great about dispelling medical myths!
Treat shock, just dont flood them! Realize cerebral edema is something that results from severe DKA and has less to do w rate IVF/Na/glucose correction in DKA. Avoid HCO3- and intubating DKAers.
One of the (many) great things about EMRAP is the variety and different styles of the speakers (arguably essential for the subscribing cohort of EM docs with their extremely short attention spans). In my opinion the Jan and Aaron banter is hilarious and makes a refreshing new addition to the mix. Very nice that they over-ruled Anne Peters on the ABG issue too. I do agree with Sean G that shorter bolus dose talks are more effective though. Cheers all- love your work Mel.
great review. quick question. my ICU doctor states I'd be hard pressed to find any literature that did not support starting insulin concurrently with IV fluid rehydration in the treatment of dka in adults. my practice has been to give three liters of normal saline initially, reassess, do another accu check, then start an insulin drip. the intensivist stated there was no reason not to start an insulin drip from the start, assuming the patient has a normal potassium. thoughts?
Great podcast, however, I have an issue with not giving bicarb unless the pH < 6.9.
Although this is easy to say in theory, it's difficult in practice in the critically ill DKA patient. I had someone a few weeks ago with glucose >1200, pH 7.1, and a gap of 4 who was too agitated to get IV access. We needed to sedate her for an IV and then intubate her for the facilitation of the rest of the work up and to get central access and potassium replacement.
In this case, I believe bicarb was indicated for prophylaxis against peri-intubation acidosis and potential arrest to compensate for taking away her respiratory drive.
Furthermore, we talk about hypertonic saline as the treatment of elevated ICP in head injury patients, yet shun bicarb for concern about cerebral edema, even though it's really just 7.5-7.8% hypertonic saline.
Matt, thanks. Yeah, DKA is one of those topics that people love and devour every biochemical detail or look at like a 3 sentence topic and can't figure out why everyone is so interested. It reminds me of debates on pressors and antibiotics. It's something to talk about. I tend toward the latter on DKA and this lecture was long. Interestingly though the emails I got are split down the middle of "too long" vs "why didn't you cover x?". Ah humanity!
Jeff, I think your logic sounds reasonable on both points. All of these "rules" are made to be broken. Thank God right? Who wants a job that a robot could do with a bunch of algorithms? Well, maybe I want that if I can also program the robot to make me breakfast on it's way to the hospital... I'll have to think about it.
Just a 2 small nitpicky points on your excellent board style questions: Question 16, what is the most appropriate next step in management? Dr Peters (if I am not mistaken stated in her lecture and also as typed in your written summary) stated you can either give the bolus then drip or just start the drip, both are equivalent. Furthermore, as stated and as typed, if your were going to just go with the drip, it should be started a little higher at 0.14 units/kg/hr. The correct answer you have listed is 0.1units/kg/hr. Probably pretty insignificant clinically. My problem with test taking is that I am very detail oriented and always read to much into the questions!
Given that we know acidosis from the Bicarb and Anion Gap, don't give bicarb for a low pH, know how sick they are from the presentation, then why do we need an ABG or VBG? I have asked lecturers about this for 15 years and all are dismissive and say that is what we do! Is there a real reason or just more info?
When we are calculating the anion gap, do we use corrected or uncorrected sodium??? Also, if you have a really sick kiddo in DKA who is clearly very dehydrated, is it too risky to give a 20cc/kg bolus as I was trained to do in ill children of other etiologies?
in our icu everyone uses uncorrected sodium to calculate gap. the Na in HHS is real not fake--it has to do with solvent drag, so you really should be using uncorrected.
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Tracy K. - March 3, 2013 9:47 AM
this lecture stopped at 11:48 min
Dan G. - March 4, 2013 11:14 AM
Seems to be working fine now
Arthur S. - March 4, 2013 2:48 PM
Dr. Peters mixed up her race series. Charlie Kimball, her patient, runs in the U.S. based Indycar series, not Formula 1. (He did race and win in British Formula 3 racing prior to coming back to the U.S. and racing initially in the Firestone Indy Lights series and later racing for Chip Ganassi Racing in Indycar the last 2 years). Incidentally, his major sponsor is Novo Nordisk, makers of novolog and levemir insulins.
Sean G., M.D. - March 11, 2013 10:43 PM
This should have been 20 minutes long, not 41+. Mel the beauty of Emrap to me was that it didn't go on and on, it got to the point Boom! Busted knowledge into our heads, then was gone like a frat boy bearing rufees, it seems the whole thing is getting seriously drawn out. I think most listeners would prefer the abbreviated version....my .02 cents. I will save this for those days I just can't seem to get to sleep.....
VJ - March 11, 2013 11:18 PM
When start potassium in DKA is a debate(?).
Apparently in the East coast and Midwest, we give our potassium( po or IV) when giving the insulin. The worry is the IVF and insulin will cause hypokalemia to a significant level. So start early, 20 meq in the second IV.
Never made a pt hyperkalemic in 18 years.
While the West coast follows, wait for the potassium to return, then hang insulin drip. The worry is hyperkalemia will occur w/o knowledge of exact amount of K+ or status of renal function.
Some authors recommend, potassium can be initiated after the pt urinates. The functioning kidney will never allow hyperkalemia to occur.
I wish the review would have mentioned the ADA guidelines are consensus based, which was revelation to me during residency. Limited studies on almost every facet of the DKA Rx.
Big fan of the cast of characters on the "show".
Jan S. - March 12, 2013 12:09 PM
Thanks for all the comments. Vik- thanks for your perspectives on potassium administration. Sean G - we will keep trying to trim things down and shorten our commentary and material. The lecture that Dr. Peters gave was originally over 60 minutes so we were pretty pleased we got it down (with commentary) to 41+! I like your idea though - consider it your Ambien-substitute if that works for you. Arthur - thanks for the clarification on the Formula 1/Indycar situation. Had no idea. makes sense that Novo Nordisk is his sponsor though. That works out well.
cyril w., Dr. - March 13, 2013 7:03 AM
Bee Gees ... British born but raised in Australia!!!!
Sean G., M.D. - March 13, 2013 12:25 PM
Jan S thanks for having a sense of humor and not taking offense to constructive criticism! That's a rare quality in people and I commend u for it!
Abdullah Al-Somali - March 17, 2013 2:39 PM
EXTREMELY BORING ..!
jack B. - March 19, 2013 8:22 PM
I was disappointed how all the speakers from this DKA "update" profess that slow IVF administration is the key to avoiding cerebral edema in treating pediatric DKA. This is folklore! Hard to look at a kid in bad DKA breathing like a fish out of water, vomiting, and not give IVF to restore intravascular volume at decent tempo (after all, most severe DKAers are in a serious degree of shock).
See the best/biggest analysis of cerebral edema in peds DKA--N Engl J Med 2001;344:264-9. Their conclusion: "Neither the initial serum glucose concentration nor the rate of change in the serum glucose concentration during therapy was associated with the development of cerebral edema, after adjustment for other covariates; the same was true of the rates of fluid, sodium, and insulin administration."
Glaser and Kuppermann-Pediatric Emergency Care Volume 20, Number 7, July 2004: "Some studies have suggested that mild, subclinical cerebral edema may be present in most patients with DKA, but only 1% or fewer develop cerebral edema of a degree sufficient to cause symptoms of increased intracranial pressure and CNS dysfunction." Cerebral edema is likely a freak unfortunate occurrence that results from severe peds DKA. We dont even really understand the pathophysiology of cerebral edema in DKA!
EMRAP is usually great about dispelling medical myths!
Treat shock, just dont flood them! Realize cerebral edema is something that results from severe DKA and has less to do w rate IVF/Na/glucose correction in DKA. Avoid HCO3- and intubating DKAers.
Matt D L J, M.D. - March 20, 2013 3:32 AM
One of the (many) great things about EMRAP is the variety and different styles of the speakers (arguably essential for the subscribing cohort of EM docs with their extremely short attention spans).
In my opinion the Jan and Aaron banter is hilarious and makes a refreshing new addition to the mix. Very nice that they over-ruled Anne Peters on the ABG issue too.
I do agree with Sean G that shorter bolus dose talks are more effective though. Cheers all- love your work Mel.
Charles-Antoine B. - March 28, 2013 9:27 AM
Anyone know where that old study of ``DKA and IV fluids only`` is from...I wanted interested in taking a look at it, but can't seem to find it.
robert b. - March 28, 2013 11:40 AM
great review. quick question. my ICU doctor states I'd be hard pressed to find any literature that did not support starting insulin concurrently with IV fluid rehydration in the treatment of dka in adults. my practice has been to give three liters of normal saline initially, reassess, do another accu check, then start an insulin drip. the intensivist stated there was no reason not to start an insulin drip from the start, assuming the patient has a normal potassium. thoughts?
Sean G., M.D. - March 28, 2013 12:45 PM
Robert how does one know the potassium instantly?
Jeff, M.D. - April 5, 2013 12:21 PM
Great podcast, however, I have an issue with not giving bicarb unless the pH < 6.9.
Although this is easy to say in theory, it's difficult in practice in the critically ill DKA patient. I had someone a few weeks ago with glucose >1200, pH 7.1, and a gap of 4 who was too agitated to get IV access. We needed to sedate her for an IV and then intubate her for the facilitation of the rest of the work up and to get central access and potassium replacement.
In this case, I believe bicarb was indicated for prophylaxis against peri-intubation acidosis and potential arrest to compensate for taking away her respiratory drive.
Furthermore, we talk about hypertonic saline as the treatment of elevated ICP in head injury patients, yet shun bicarb for concern about cerebral edema, even though it's really just 7.5-7.8% hypertonic saline.
Aaron B. - April 6, 2013 9:05 AM
Matt, thanks. Yeah, DKA is one of those topics that people love and devour every biochemical detail or look at like a 3 sentence topic and can't figure out why everyone is so interested. It reminds me of debates on pressors and antibiotics. It's something to talk about. I tend toward the latter on DKA and this lecture was long. Interestingly though the emails I got are split down the middle of "too long" vs "why didn't you cover x?". Ah humanity!
Jeff, I think your logic sounds reasonable on both points. All of these "rules" are made to be broken. Thank God right? Who wants a job that a robot could do with a bunch of algorithms? Well, maybe I want that if I can also program the robot to make me breakfast on it's way to the hospital... I'll have to think about it.
Ricky G - April 26, 2013 2:30 AM
Just a 2 small nitpicky points on your excellent board style questions: Question 16, what is the most appropriate next step in management?
Dr Peters (if I am not mistaken stated in her lecture and also as typed in your written summary) stated you can either give the bolus then drip or just start the drip, both are equivalent. Furthermore, as stated and as typed, if your were going to just go with the drip, it should be started a little higher at 0.14 units/kg/hr. The correct answer you have listed is 0.1units/kg/hr. Probably pretty insignificant clinically. My problem with test taking is that I am very detail oriented and always read to much into the questions!
Skins, MD - May 8, 2013 3:25 PM
Given that we know acidosis from the Bicarb and Anion Gap, don't give bicarb for a low pH, know how sick they are from the presentation, then why do we need an ABG or VBG? I have asked lecturers about this for 15 years and all are dismissive and say that is what we do! Is there a real reason or just more info?
Jessica R. - September 25, 2014 4:36 PM
When we are calculating the anion gap, do we use corrected or uncorrected sodium???
Also, if you have a really sick kiddo in DKA who is clearly very dehydrated, is it too risky to give a 20cc/kg bolus as I was trained to do in ill children of other etiologies?
Mohammed A. - December 11, 2014 4:31 PM
in our icu everyone uses uncorrected sodium to calculate gap. the Na in HHS is real not fake--it has to do with solvent drag, so you really should be using uncorrected.