DKA w/o anion gap?

[iish]

I was recently admitting a pt for a new diagnosis of DM2 w/ hyperglycemia to the mid 500s and when speaking to the admitting team was asked if the pt was in DKA. It kind of took me by surprise based on the rest of my sign-out as I had indicated that the pt was walk, talky, arguing, very with it, and especially when I mentioned they had a gap of 14. I was pressed on why serum ketones weren't ordered, which while I'm still very early in my training, I see more as an inpatient test. I simply told the admitting team that last I recall from medical school to be in DKA you have to be acidotic w/ a gap, which a gap of 14 does not support in conjunction with the pt's clinical picture.

Am I missing something or is the admitting team just being tough w/o reason?

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[Bostonredsox]

I was recently admitting a pt for a new diagnosis of DM2 w/ hyperglycemia to the mid 500s and when speaking to the admitting team was asked if the pt was in DKA. It kind of took me by surprise based on the rest of my sign-out as I had indicated that the pt was walk, talky, arguing, very with it, and especially when I mentioned they had a gap of 14. I was pressed on why serum ketones weren't ordered, which while I'm still very early in my training, I see more as an inpatient test. I simply told the admitting team that last I recall from medical school to be in DKA you have to be acidotic w/ a gap, which a gap of 14 does not support in conjunction with the pt's clinical picture.

Am I missing something or is the admitting team just being tough w/o reason?

Yes you can have DKA without a gap if there is a secondary metabolic acid base disorder going on which alters the serum bicarbonate. Also, you didn't post a ph or bicarbonate level so we don't know if this pt is acidotic or not, which IS something I would want to know. The reason I want to know is a new diagnosis of DM2 with a sugar of 500 is something that can be seen and in fact often times is first discovered in clinic. Hyperglycemia by itself does not warrant admission to the hospital, unless severely dehydrated which you did not put in your post. If the pt is acidotic, in DKA or HHNK, then they would warrant an admission hence I would ask you the ph/bicarbonate.

I have never asked an ER doc for a serum ketone level however as I cannot see how it would change my management from and admission or triage perspective,

 

[WilcoWorld]

There are three components of DKA 1) BGL>250 2) Ketosis 3) Acidosis

If I'm worried about DKA I get a chemistry, VBG and serum ketones - all in the ED. If I'm not worried about DKA, and I'm planning on discharging this "CC: High Sugars, sent from clinic" I'll use a chemistry and urinalysis to rule out. If their bicarb isn't low and they're non-ketotic on UA (and don't look sick otherwise) I won't chase it further.

 

[EM4life]

I get the feeling that the admitting team maybe giving you crap because they are trying to figure out why this patient warrants admission - if not in DKA and not severely dehydrated and the patient appears well - like Bostonredsox said - does not warrant admission. Unless you have other reasons like, this patient does not have a PMD and does not have anyway to get reasonable follow up or there are other significant comorbidities. I find that in general, I get a lot more questions when I'm admitting a "gray" area patient or a soft call. If it is a soft call admission, it has served me well to be up front with admissions and letting the hospitalist know exactly why they are unsafe for discharge. This usually cuts down on the questions and allows them to understand why you didn't do the 5 million dollar workup. Unfortunately, what you are describing will never go away, even as an attending, different admitting docs will ask you to do different, sometimes unreasonable things, and it's all apart of our job. Sometimes a quick response like "you know what, I don't think the patient's clinical picture and resultant labs suggested DKA, but I'm happy to add on serum ketones for you" will do.

 

[iish]

PH and bicarb were unremarkable. Reason for admission is more cultural than anything else, all new DM2 get admitted at the joint

 

[gman33]

Were there ketones in the urine?
If not, from what you described it sounds like a weak admission.
Admitting them all might the culture of the ED, but I doubt that's what IM wants.
They would probably rather you give the patient an appointment in the clinic.
Don't know if you have a mechanism to get that done.

A separate issue is how to sell a weak admission that your attending wants.
Think about what IM wants.

My usually hyperglycemia workup is as follows.
Accucheck and urine.
If high BG and ketones in urine, check some labs.
Usually VBG, BMP and serum ketones.

Every once in a while IM will tell you they want an albumin to correct the anion gap for hypoalbuminemia.
Corrected AG = AG + [2.5 x (4 - albumin)]

This is usually a block move where they want to call the patient DKA so they have to go to the Unit on an insulin gtt.
Then the patient is somebody else's problem.

 

[Rendar5]

If you are unable to find appropriate follow-up in the next few days, sure admit. If this is an age where you suspect it to be type I DM, sure admit. Otherwise, it doesn't warrant admission in my mind. I lost the ability to do serum ketones a couple years ago when the reagents were on back order, and I haven't gotten them since. I do get vbg's, check ketones in urines (although not the best way) and check a bmp. Also, I do remark on my HPI if I can smell ketones or not. Never could as a resident, now for some reason I can smell them down the hallway, even on starvation and alcohol ketoacidosis.

 

[dotcb]

It sounds like your patient had hyperglycemia without DKA, which is probably why the admitting MD was giving you some push-back. In the absence of an anion gap, the serum ketones are unlikely to alter the patient's management, and I prolly wouldn't even check that test. Urine ketones are basically useless, except to determine that someone may be dehydrated (which you already knew). I personally feel the BMP is the best test to rule in or rule out DKA. In the low suspicion patient, it's the only test I may do to rule them out. It depends on the culture of your hospital as to whether this patient would require admission. I would put them in observation status, hydrate, insulin boluses, probably turn them around in 4-8 hrs, DC w/ metformin and close follow up by a PCP or in our urgent care clinic.

 

[xaelia]

My current practice is to offer admission to newly-diagnosed, grossly uncontrolled type II diabetics – i.e., the dude with the glucose >500 who is clearly not going to be controlled on metformin. An observation status stay with diabetic teaching, initiation on insulin, scheduled follow-up, etc. is probably going to benefit that patient.

The other, various, usually non-compliant hyperglycemias get made euvolemic-ish and sent home to continue making Good Life Decisions.

 

[ORL10]

The odd thing is you really only need two things to have DKA and one of them is not acidemia and the other is not hyperglycemia. Patients with elevated GFR's (pregnant patients) who take insulin but rapidly clear it can go into DKA with blood glucose less than 250. The defining characteristics of all patients with DKA are they WILL HAVE AN ANION GAP, and they WILL HAVE KETONEMIA.

The bicarb is is not helpful and neither is the pH for defining DKA only triaging. Say a patient has been vomiting significantly they will have both a contraction alkalosis and have been vomiting, both of which increase serum bicarbonate. If they have ketonemia they will still have a gap (we are electrically neutral), but pH could be normal and so could the bicarb. Good point on the albumin and phosphorus corrections for anion gap, as these are often forgotten because a cirrhotic may have a normal gap of 7 on a good day and a gap of 14 is twice their normal.

Remember these are the exceptions and not the rules, and most patients in DKA will have an elevated anion gap, acidosis, low serum bicarb, hyperglycemia and ketonemia.

 

[jdh71]

The odd thing is you really only need two things to have DKA and one of them is not acidemia and the other is not hyperglycemia. Patients with elevated GFR's (pregnant patients) who take insulin but rapidly clear it can go into DKA with blood glucose less than 250. The defining characteristics of all patients with DKA are they WILL HAVE AN ANION GAP, and they WILL HAVE KETONEMIA.

The bicarb is is not helpful and neither is the pH for defining DKA only triaging. Say a patient has been vomiting significantly they will have both a contraction alkalosis and have been vomiting, both of which increase serum bicarbonate. If they have ketonemia they will still have a gap (we are electrically neutral), but pH could be normal and so could the bicarb. Good point on the albumin and phosphorus corrections for anion gap, as these are often forgotten because a cirrhotic may have a normal gap of 7 on a good day and a gap of 14 is twice their normal.

Remember these are the exceptions and not the rules, and most patients in DKA will have an elevated anion gap, acidosis, low serum bicarb, hyperglycemia and ketonemia.

Of course they will have a gap, but it may be "hidden" at first blush. Use the delta-delta gap to find the mixed disorder.

All of it taken together is helpful bicarb and pH, you just have to know how to put them all into context.