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Basics ⬇

Description
Epidemiology

Incidence

  • In the US, there were 115,000 hospital discharges for DKA in 2003
  • Annual incidence rate for DKA estimated from population-based studies ranges from 4.6 to 8 episodes per 1,000 patients with diabetes.

Mortality

Mortality <5% in experienced centers

Etiology/Risk Factors
Physiology/Pathophysiology
Anesthetic Goals/Guiding Principles

Diagnosis ⬆ ⬇

Symptoms

Weakness

History

  • Evaluate diabetes severity, prior episodes of DKA, and comorbidities
  • Inquire about diabetic medications: Insulin regimen and adherence as well as last dose
  • Assess for precipitating factors: Sepsis, pancreatitis, MI, CVA, drugs (corticosteroids, thiazides, sympathomimetics)

Signs/Physical Exam

  • Polyuria
  • Polydipsia
  • Weight loss
  • Vomiting
  • Abdominal pain
  • Dehydration
  • Distinct breath odor—described as "fruity" due to presence of expired acetone
  • Tachypnea early followed by deep labored breathing (Kussmaul respirations) as the acidosis worsens
  • Altered mental status
  • Shock
  • Coma
  • Volume status: Skin turgor, dry mucus membranes
Treatment History
Medications
Diagnostic Tests & Interpretation

Labs/Studies

  • Serum glucose
  • HgA1C: Poor control may suggest the presence of diabetes-related comorbidities.
  • Ketonuria: Presence of -hydroxybutyrate, acetoacetate, and/or acetone in the urine. Measured with urine dipstick:
    • Small amount <20 mg/dL
    • Large amount >80 mg/dL
  • Electrolyte: Hyperchloremic anion gap acidosis: AG = [Na+] – ([Cl-] + [HCO3-])
  • BUN and serum creatinine
  • ABG (pH)
  • Serum osmolality
  • CBC: Leukocytosis may be related to ketoacidosis, not necessarily infection.
  • Amylase: May be elevated due to a nonpancreatic source in DKA
CONCOMITANT ORGAN DYSFUNCTION
Circumstances to delay/Conditions

Delay elective procedures: The goal is to correct the inciting factor, re-establish euvolemia and electrolyte levels as much as possible before going to the operating room.

Table 1. Classifications
MildModerateSevere
pH7.25–7.37.0–7.25<7.0
HCO3 (mEq/L)15–1810–15<10
Mental statusAlertAlert/DrowsyStupor/Coma

Treatment ⬆ ⬇

PREOPERATIVE PREPARATION

Premedications

In emergent surgeries, intensive therapy with volume resuscitation, insulin infusion, and electrolyte replacement should be continued en route to the operating room.

INTRAOPERATIVE CARE

Choice of Anesthesia

Guided primarily by the procedure except in cases of altered mental status when intubation is required for airway protection

Monitors

  • Standard ASA monitors
  • Arterial line may be useful for frequent lab checks as well as to monitor beat-to-beat blood pressure in patients who are hypovolemic or in septic shock.
  • Foley catheter: Ins and outs should be carefully monitored.
  • Central line access may be useful to guide fluid administration.

Induction/Airway Management

  • Consider rapid-sequence induction/intubation if a full stomach is suspected or there is risk for aspiration.
  • Patients are hypovolemic and may become unstable with induction medications. Consider etomidate and/or ketamine if appropriate.
  • Induction agents may have effects on glucose homeostasis but are clinically insignificant.

Maintenance

  • Intensive care therapy should be continued in the operating room in the same manner.
  • Labs:
    • Blood glucose ~ hourly
    • pH
    • Electrolytes (potassium)
    • Intraoperative monitoring of -hydroxybutyrate may help trend the response to therapy and indicate resolution.
  • Volume resuscitation:
    • 0.9% NaCl: 15–20 mL/kg for the first hour
    • 0.45% NaCl: 4–14 mL/kg/hr if serum sodium is within or elevated above normal values (institution-based).
    • D5 0.45% NaCl should be started when the serum glucose level is <200 mg/dL.
    • Lactated Ringers (LR) may also be used and may be preferable given its pH (or effect on pH). It should also be noted that LR contains 4 mEq/L of potassium.
    • Fluid replacement alone may drop the serum glucose level ~50 mg/dL/hr.
    • Adjust accordingly for cardiac and renal pathology
    • Resuscitation should also factor in insensible and surgical blood loss.
    • If packed red blood cells are administered, the use of washed cells may be beneficial as acid citrate dextrose may worsen hyperglycemia.
  • Insulin therapy:
    • Regular insulin: 0.1–0.2 U/kg initial IV bolus
    • Insulin infusion: 0.1 U/kg/hr, with the goal of decreasing serum glucose by 50–75 mg/dL/hr. If glucose does not decrease as expected, consider doubling the infusion rate.
    • Continue infusion until serum glucose <200 mg/dL then reduce infusion to 0.02–0.05 mg/kg/hr and consider changing to SC management.
  • Potassium replacement:
    • If [K+] <3.3 mEq/L hold insulin and replete potassium
    • If [K+] >5.3 mEq/L continue insulin and monitor every 2 hours
    • If [K+] = 3.3–5.3 mEq/L continue to administer 20–30 mEq in each liter of fluids
  • Sodium bicarbonate: Controversial and is usually not indicated; may be considered in cases of refractory acidosis (serum pH <7.15 and [HCO3-] <10 mEq/L)
  • Normothermia: Hypothermia decreases the response to insulin.

Extubation/Emergence

Emergence/extubation should be based on mental status, volume status, and hemodynamic stability.

Follow-Up ⬆ ⬇

Bed Acuity
Medications/Lab Studies/Consults
Complications

References ⬆ ⬇

  1. Hirsch I , McGill JB , Cryer PE , et al. Perioperative management of surgical patients with diabetes mellitus. Anesthesiology. 1991;74:346–359.
  2. Kitabchi A , Umpierrez GE , Murphy MB , et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2006;29(12):2739–2748.
  3. McAnulty G , Robertshaw HJ , Hall GM. Anaesthetic management of patients with diabetes mellitus. Br J Anaesth. 2000;85(1):80–90.
  4. Milaskiewicz R , Hall GM. Diabetes and anaesthesia: The past decade. Br J Anaesth. 1992;68:198–206.

Additional Reading ⬆ ⬇

See Also (Topic, Algorithm, Electronic Media Element)

Codes ⬆ ⬇

ICD9
ICD10

Clinical Pearls ⬆ ⬇

Author(s) ⬆

Matthew V. Satterly , MD

Ori Gottlieb , MD