Asynchrony EM: 'Oh Sugar!'

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM. Digital resources and #FOAMed are curated and packaged by topic, following Brown EM's curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section.
Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.

Endocrine: DKA and HHS

 Sugar overload!

Sugar overload!

Here's our next stop in the Endocrine block: managing DKA (in adults and kids --because it's not the same) and hyperosmolar hyperglycemic state (HHS). We've got core content and controversy (especially on the pediatric DKA front!) -- sweet!

Our theme song: "Sugar, We're Going Down" by Fall Out Boy. (Because, you know, you want the sugar to go down?...right? You get it.)

Let's go!

1) First, the basics of adult DKA. This is a long-ish review but it covers all the bases. You may know a lot of this, so just scan through, click through the sections, and pick up any pointers you may have missed along the way. Also, ignore the pediatric DKA stuff -- more to follow on that. Medscape Practice Essentials: DKA (7/20/16). 

2) Now some finer points. EM Lyceum (11/2014), with four DKA Questions (on adult DKA):

1. When you are suspicious for DKA do you get a VBG or an ABG? How good is a VBG for determining acid/base status? 
2. Do you use serum or urine ketones to guide your diagnosis and treatment of DKA?
3. Do you use IV bicarbonate for the treatment of severe acidosis in DKA? If so, when?
4. When do you start an insulin infusion in patients with hypokalemia? Bolus or no bolus?

And their answers: DKA Answers

After reading that, know that the bicarb issue is still controversial. There is no clear role for bicarb -- however if you look at the ADA Guidelines, or in Up to Date, you'll still see a recommendation to use it (on Up to Date, they recommend it for a pH of 6.9 or lower, although they do make clear there is no good evidence to support this practice and that there is potential harm...so, it's clear as mud.) And remember, we are talking about ADULTS here. More on kids to follow (spoiler: never bicarb!)

 

3) Now: Hyperosmolar Hyperglycemic State (HHS). Another quick click-through review from Medscape (August 2016). 

 

4) Something these patients might have, and you might need to learn a little more about. From ALiEM: Insulin Pumps and what you need to know about them (12/2013).  Read the comments, as they are helpful.

 

5) PEDIATRIC DKA. Lots and lots of controversy surrounding management, especially regarding fluids. Why? Because of the DKA complication of cerebral edema, which happens almost exclusively in kids -- and is often devastating. 

We will have some real answers about fluids in about four months, when the PECARN DKA FLUID study results are released (and our Hasbro Children's Hospital was a site in this study). I picked the brain of our Hasbro expert Dr. Aris Garro for DKA management pearls based on this changing landscape. His answers to my questions are as follows (and please note the differences from the FOAM resources that follow): 

Fluid management is very controversial but the lead investigators out of UC Davis argue that most cerebral injury occurs because we underperfuse the brain (their data supports a hypoperfusion / reperfusion phenomenon). Therefore they do not advocate limiting fluid administration. That teaching unfortunately came after horribly flawed studies in the 90's that did not take into account that sicker children (aka more likely to get cerebral edema) got more fluid by indication. 

To address your points:

1. Children with DKA definitely need a fluid bolus as they are intravascularly volume depleted initially and perfusion needs to be restored. Most of us start with 10 mL/kg and reassess peripheral perfusion, HR, MS. Most children's intravascular volume is adequately replaced with 10-20 mL/kg.

2. After that you can start your long-term fluid resuscitation. Easy way to calculate is 1.5 x maintenance rate. Verdict is out on NS vs. 1/2NS but stay tuned for FLUID study results...

2. Yes, give some fluid before starting insulin drip (the initial fluid bolus is generally sufficient)

3. Never give Insulin boluses! 

4. All kids are whole body potassium depleted. Don't need serum K back from lab to start insulin (unlike in adults). Need to start K replacement as soon as you know the child is not anuric (i.e., they pee.)

5. Never give bicarb boluses!

6. Everything we need for DKA is on the VBG since it is not a primary respiratory problem

One last teaching point that eludes some trainees is that the dreaded cerebral edema from DKA is almost exclusively a pediatric problem. Therefore the lessons about treating pediatric DKA should not be applied to adults and vice versa.

GOT THAT? (For the thousandth time, kids are not little adults.)

Now, with that in mind, here's what's out there in the FOAM world about it -- and remember that all of this will need updating once the FLUID data is out in public. But you've got to know where we've been to understand better where we're going, and this is the way a lot of docs still manage pedi DKA.

a)FOAMCast Episode 29 (June 2015): summarizing an EM Cases podcast about pedi DKA and then some "Rosenalli" core content from the textbooks. Does have a nice review of the differences in current treatment between adult DKA and HHS.

b) From Pediatric EM Morsels: Cerebral Edema and DKA  (2014).

c) From PEMGeek, the Pediatric DKA Guideline 2015: What's New?  The links/summary neatly show what many folks are doing currently, but remember, this will all be changing soon! (see Dr Garro's commentary above.)

The OPTIONAL EXTRAS:

a) From EM:RAP (remember you have a subscription through EMRA): a recent "Paper Chase" segment (August 2016) on a study about fluid boluses in pediatric DKA  and that more volume might be OK (again, just wait until FLUID is out.) 

b) From EMedHome: a DKA Case discussion(click through to EM Cast, use the little dropdown menu to find Archived EMCast episodes, pick the August 2015 EM Cast, and choose the DKA chapter). 

c) There are some good resources out there that you can direct patients to for more information on managing their diabetes, especially new onset adults who may be discharged from the ED. Check out the American Diabetes Association  page.

d) Hot off the press (January 10, 2017): "Enterovirus may predict Type 1 Diabetes in Kids" (Very intriguing.)

e) Also intriguing: Hope for Reversing Type 2 Diabetes (NYT, 4/18/16).

That's it for this week! Keep tuned for our next module.

**Brown EM Residents, remember you have to complete your modules in Canvas (hit the discussion board, and pass the quiz) to claim credit.**

Let us know in the comment section:

  • Other #FOAMed resources you find helpful
  • About your current practice in pediatric DKA and how it may differ from what's discussed here
  • Interesting DKA/HHS cases you'd like to discuss!