DKA Myths

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Paul B., M.D. -

Great talk. What do you do if someone gives the insulin before supplementing the potassium and the patient arrests? How fast can you give potassium in that situation?

Also how fast do you replete the potassium in the critical DKA patient with hypokalemia? Do you do so at the same rate that you would replete a normal hypokalemic patient? Thanks!

brendanC -

I have a big myth that I would like you to address. I have been practicing
NOT giving 6 L of NS to DKA but IVF bolus to attain hemodynamic stability, followed by NS @500cc/hr. The rationale is that too aggressive hydration eliminates Acetone in the urine which is required to regenerate bicarb. This prevents the non-gap, hypercloremic acidosis that always happens with "conventional" hydration.Thoughts? ( I picked this up in Hardwood-Nuss 12 years ago and it hasn't failed me yet.)

Ruth R., M.D. -

Last night 23 year old patient with ESRD on hemodialysis came in in DKA. (Ph 7.2 k 4.3 BS 600) Advice?

Anand S., M.D. -

Sorry, I've been slow to return the comments
@Paul - If they arrest and hypokalemia is the culprit, I wouldn't hesitate to give larger doses but there's really no literature out there to help guide us here. I wonder if there would be a role for a beta blocker as those are used in hypokalemic periodic paralysis? My guess is no since the patient has already arrested and it won't circulate effectively. I think I would probably push 20 mEq at a time. They've already arrested anyway, right?
@ Brendan - I agree that a lot of NS will generate a hyperchloremic acidosis simply based on the NaCl concentrations in NS. I would mix my fluids if they are in shock giving a couple of liters of NS, maybe some 1/2 NS and maybe some LR. Once they are HD stable, I stop aggressive hydration as well.
@ Ruth this is always tough. What about ESRD and sepsis? Any volume issues in ESRD make our job difficult. If the patient has not recently been dialyzed (likely since you would think someone at the dialysis center would notice the DKA) I would start an insulin drip and closely monitor the potassium. They won't be total body potassium or fluid down since they don't have an osmotic diuresis like normal DKA patients.

Mel H. -

From: Brad Reynolds, MD

Just wanted to pass this on given the discussion on DKA recently. We did a study (presented at ACEP last year) on how ejection fraction was effected by the acidosis caused by DKA. Bottom line – 14 patients - no significant difference in EF between acidotic (<7.1) & normal pH. SO – likely any depression of EF is caused by something besides acidosis.

EMRAP rocks!


Brad Reynolds, MD

Whit F., M.D. -

Hey there Anand. You're awesome. A few questions:

1) One horrible nightmare is the septic patient in DKA (often one of those 'mixed' diabetic emergencies) who simply can't keep up their respiratory rate anymore, due to pneumonia or fatigue. Intubating one of these people is the last place I ever try to go, but it does happen. If they have a crappy pH of 6.8 and you are about to paralyze them, how do you feel about pushing two amps of bicarb DURING INTUBATION to keep them from becoming fatally acidotic during that transient period of apnea? Of course the real solution will be lots of ventilation to keep them corrected once the tube is in, but that brief period of intubation is especially scary. This is leaving out other options like awake intubation and so on.

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