Anesthesia Considerations 

Diabetic Ketoacidosis

 

 

 

 

Diagnosis 

 

• Glucose > 14

• HCO3 < 18 

• pH < 7.3

• + ketones in urine/blood 

 

 

Considerations

 

• Life threatening anion gap metabolic acidosis (ketoacidosis)

  • CNS: ↓ LOC (hypovolemia, cerebral edema)

  • Cardiovascular: cardiac arrythmias, congestive heart failure 

  • Hyperventilation (very high minute ventilation, caution with intubation & positive pressure ventilation)

• Hypovolemia:

  • Osmotic diuresis (hyperglycemia)

  • Crystalloid volume replacement

• Electrolyte abnormalities:

  • Depletion of potassium, phosphorus, magnesium

  • Hyponatremia (factitious hyponatremia)

• Consequences of therapy:

  • Electrolyte abnormalities

  • Hypo/hyperkalemia, hypomagnesemia, hypophosphatemia 

  • Hypoglycemia

  • Cerebral edema, central pontine myelinolysis

• Address underlying cause:

  • Infection, trauma, intoxication (cocaine), pancreatitis, acute coronary syndrome 

  • Medication noncompliance (insulin)

 

Conflicts

 

• Resuscitation vs. emergency surgery

• Severe metabolic acidosis vs. intubation/ventilation

• Hypovolemia vs. aspiration risk (RSI)

 

 

Crises

 

• Electrolyte abnormalities (hyper/hypokalemia, hypomagnesemia, hyponatremia) 

• Hypoglycemia

• Cerebral edema (glucose correction without correcting hyponatremia)

• Central pontine myelinolysis (rapid serum sodium correction)

 

 

Management

 

• Treat as per hospital protocol in consultation with endocrinology

• For example, see BC Children's Hospital's DKA protocol:  

 

 

Goals

 

• Normal anion gap (AG) 

• pH > 7.2

• Potassium > 3.5

• Bicarbonate > 20

• Glucose < 13

• Urine output 1 ml/kg/hr 

• Volume replacement: 

  • Normal saline to correct hypovolemia (3-5L deficit)

  • Then slow to maintenance (up to 500ml/hr)

  • Change to D5NS when glucose < 14

  • Add potassium to IV fluids once < 4.5 & urinating

• Insulin R 

  • Start infusion at 0.14 u/kg/hr (10units/hr in 70kg male) OR give 0.1 u/kg bolus followed by infusion 0.1 u/kg/hr

  • DO NOT start insulin if potassium <3.3 

  • Glucose goal 10-15 mmol/L

  • When glucose <11: add D5W to solution 

• Potassium management 

  • If < 3.3: DO NOT start insulin, give 20-30 meq/hr of potassium until K > 3.3  

  • If > 3.3 & < 5.3: give potassium 20meq/L of fluid 

  • If > 5.3: Do NOT give potassium 

• Frequent monitoring: ABG, electrolytes (AG), BUN, creatinine, osmolality, plasma & urinary ketones, magnesium, phosphate, lactate

• Consider sodium bicarbonate if pH < 7 & myocardial dysfunction or vasodilation or life-threatening hyperkalemia

 

 

Complications

 

• Cerebral edema 

• Pulmonary edema