Diabetic Ketoacidosis

Welcome back to the podcast and our next Roadside to Resus episode, this time we’re taking a look at Diabetic Ketoacidosis, DKA.

In this episode we’ll be getting our heads around the pathophysiology that underpins DKA, consider the clinical picture and severity of patients that present and look at both the in-hospital and pre-hospital management of these patients including topics such at fluid choice, insulin boluses and nasal ETCO2 for diagnosis of DKA.

Let us know any thought and comments you have.

Enjoy!

SimonRob & James

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References

LITFL; Diabetic Ketoacidosis

Joint British Diabetes Societies Inpatient Care Group; The Management of Diabetic Ketoacidosis in Adults. Second Edition Update: September 2013

NHS; Diabetic Ketoacidosis

Guidelines for management of diabetic ketoacidosis: time to revise? Dhatariya, K. The Lancet Diabetes & Endocrinology. 2017

RCEMLearning; DKA-Induction

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols.T. Tran. Endocrinol. 2017

Joint British Diabetes Societies for Inpatient Care; Intravenous Insulin Prescription and Fluid Protocol. 2018

EM Cases; DKA

Predictive Value of Capnography for Suspected Diabetic Ketoacidosis in the Emergency Department. Hassan Soleimanpour. West J Emerg Med. 2013

Diagnostic value of end tidal capnography in patients with hyperglycemia in the emergency department. Ralphe Bou Chebl. BMC Emerg Med. 2016
EMS MED;Be All End-Tidal: The Expanding Role Of Capnography In Prehospital Care
Hyperglycemic Crises: Diabetic Ketoacidosis (DKA), And Hyperglycemic Hyperosmolar State (HHS). Adair R Gosmanov. Endotext. 2018

4 Comments

  • It was delightful to hear! Thank you much for producing this content. Spot on the physiology, very well summarised without a lot of abstract cellular level fluff. It’s also refreshing to hear something else rather than COVID19. Looking forward to tune in the next episode.

  • I enjoyed your excellent summary of DKA but I just wanted to pick up on one area. The concern about cerebral oedema is based on observations of paediatric cohorts. I myself have never seen this feared complication in the adult population, although I understand it does rarely occur. Far more commonly I see hypovolaemic shocked adult patients under-treated by strictly adhering to the fluid resuscitation protocols in a one size fits-all approach. Further to this it is definitely not proven that over-zealous fluid resuscitation causes cerebral oedema. The development of cerebral oedema is probably multifactorial with initial osmolarity, rate and time to first insulin infusion playing a part. There is even retrospective registry data which found no association between rapid fluid resuscitation or rate of change of glucose and subsequent development of cerebral oedema but did find that initial blood urea was predictive (which we obviously cannot modify) – https://pubmed.ncbi.nlm.nih.gov/11172153/. Indeed the paediatric literature seems to emphasise repeated clinical examination to identify this complication early rather than recommend any specific fluid protocol – https://academic.oup.com/jcem/article/85/2/509/2852029. The pathophysiology of DKA dictates that adult patients will be massively fluid deplete and therefore you are much more likely to harm the adult patient by being restrictive and conservative with your fluid rather than protecting against a rarely occurring complication. What is most important in treating the adult with DKA is that you repeatedly assess their fluid state and adjust your treatment accordingly. Thanks again for uploading this informative episode.

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