INITIAL fluid of choice in resuscitation of DKA

[DrQuinn]

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So I had MICU last month, and my attending and resident were blasting the ED on using NS as the initial fluid choice, saying that it can precipitate hyperchloremic acidosis. Anyways, I did a little pubmed searching, textbook searching, mdconsult searching, and UTDOL searching, and could not find any evidence to substantiate what they're talking about.

Any thoughts?

My attending even stopped me in the hallway to tell me his three "mantras:" No Levaquin for pneumonia/sepsis, always calculate the PF ratio, and use 1/2NS as the initial fluid for DKA resus.

I can see switching from NS to 1/2NS after the first litre or two, as not only are patient's e'lytes out of whack but they're also just plain hypovolemic. Shoot, find anyone in FL who isn't a litre down in the summer.

My next rotation in the ED is in August, so I won't have any time to see any of the DKA stuff first hand until then, just thought I'd see any other opines out there.

Q, DO

 

[DocWagner]

Mine is NS...this has been discussed in our conferences and EACH academic attending uses NS as the initial fluid. If there is no evidence to the contrary then it is purely conjecture. We live in a fishbowl and those same attendings would crack under the pressure of the ED.
If you have a subscription to www.empractice.net it has a great EBM approach...it clearly states .9% NaCl fluids. I suggest showing this to your pals rounding in the MICU. Perhaps a refresher is needed.

 

[ERMudPhud]

I couldn't find much in medline or cochrane. Its not like anyone has done a randomized trial of various IV solutions in DKA. Most of the arguments are based on theoretical concerns--the fluid lost in DKA tends to be Hyponatremic resulting in significant total body free water losses but that argument has been extrapolated to recommendations of resuscitation using everything from colloid to 1/2NS to NS. Certainly reviews by experts support the use of NS. See http://www.emedicine.com/med/topic548.htm
as an example although I'm betting MDconsult and UTDOL will have similar recommendations.

What's a PF ratio?

 

[drewpydog]

Not to hijack the thread, but P/F ratio is PaO2/FiO2. Different people use different values, but at my old hospital we used <300 = acute lung injury, <250 = ARDS. I've only used it in an ICU setting.

 

[Ponyboy]

Isn't anyone worried about cerebral edema when they're using 1/2NS? How fast can you give 1/2NS when you're watching the serum Na?

 

[DocWagner]

This is rapidly turning into a IM discussion...the mainstay of EM recussitation fluids in DKA is NS. D51/2 NS can be given later when glucose has come down after multiple liters of IVF. Ideally I don't want to see a DKA patient for 6 hours.

 

[tonem]

Amen!!!

 

[A little elf]

NS: it can precipitate hyperchloremic acidosis...wwwhhhoooo cares? I haven't heard of anyone dying of hypercholoremic acidosis (or even having big issues with it). I agree with DocWagner...NS initially, then D5 1/2 NS when the bs reaches about 250 (don't forget K). I really doubt that all of the textbooks are wrong in this debate.

Elf

 

[Sessamoid]

So I had MICU last month, and my attending and resident were blasting the ED on using NS as the initial fluid choice, saying that it can precipitate hyperchloremic acidosis. Anyways, I did a little pubmed searching, textbook searching, mdconsult searching, and UTDOL searching, and could not find any evidence to substantiate what they're talking about.

Any thoughts?

You could take the innocent route, and ask them for edification. Say you'd really appreciate it if they could produce some references to clinical trials that indicate that NS is harmful as an initial resuscitation fluid in DKA, because you--as nothing but a dumb ER resident--were unable to find such an article after a long literature search. That tends to shut people up pretty quickly.

My attending even stopped me in the hallway to tell me his three "mantras:" No Levaquin for pneumonia/sepsis,

Nice. All the ID specialists at the last two hospitals I worked at included quinolones in their protocols for CAP. I also think that the American Thoracic Society considers quinolones as a reasonable first line treatment (they do. I just looked it up).

If you're feeling gutsy, tell em to complain about the weather if they must have something to complain about. That's what I always did in Florida.

 

[docB]

All the ID specialists at the last two hospitals I worked at included quinolones in their protocols for CAP. I also think that the American Thoracic Society considers quinolones as a reasonable first line treatment (they do. I just looked it up).

We used quinolones up to a few months ago and stopped because our local surveilance showed that on our bugs rocephin + azithro worked better. This is just a local thing though.

 

[NaeBlis]

So I had MICU last month, and my attending and resident were blasting the ED on using NS as the initial fluid choice, saying that it can precipitate hyperchloremic acidosis. Anyways, I did a little pubmed searching, textbook searching, mdconsult searching, and UTDOL searching, and could not find any evidence to substantiate what they're talking about.

Any thoughts?

My attending even stopped me in the hallway to tell me his three "mantras:" No Levaquin for pneumonia/sepsis, always calculate the PF ratio, and use 1/2NS as the initial fluid for DKA resus.

I can see switching from NS to 1/2NS after the first litre or two, as not only are patient's e'lytes out of whack but they're also just plain hypovolemic. Shoot, find anyone in FL who isn't a litre down in the summer.

My next rotation in the ED is in August, so I won't have any time to see any of the DKA stuff first hand until then, just thought I'd see any other opines out there.

Q, DO

I had this same issue in MICU during internship. Intensivist said to transition to 1/2 ns to prevent hyperchlorimic acidosis. When I asked him to explain how this was possible, he drew a blank. I then disscussed it with a nephrologist and endocrinologist, who in tern discussed it with other collegues. The end decision was that the whole concept was BS. Yes you can get hyperchloremia, but the acidocis would be incidental, remanant of the DKA. This is one of those dinosaurs like renal dose dopamine, that IM people love to pimp on but don't understand or question. There is no issue with using NS with regards to hypercholomic acidosis.

 

[MBK2003]

As an IM resident in the land of Mycobacterium Tuberculosis, Levaquin is a big "no-no" since it some activity against TB. If you are admitting a pt for CAP and you have even a tiny amount of suspicion for TB (immigration to US within last 5 yrs, unsafe sexual practices, h/o autoimmune dz), avoid that dose of Levaquin 500 in the ER. Otherwise, once we get them on the floor, they spend a week in the hospital on Ceftriaxone/Azithro sending multiple sputums for AFB smears, just to make sure that we aren't sending home someone who has active pulmonary TB. Thanks!

MBK2003

 

[DocWagner]

If one admits a patient for uncomplicated CAP use the antibiotics recommended by the American College of Chest Physicians http://www.cmecorner.com/macmcm/accpchest/accp2003_06.htm

Treat with Levaquin or Azith/rocephin combo...follow those guidelines only. The rest is conjecture until proven otherwise. Treating inflated egos generally is what happens when admitting to medicine...rather than treating disease.

 

[ERMudPhud]

As an IM resident in the land of Mycobacterium Tuberculosis, Levaquin is a big "no-no" since it some activity against TB. If you are admitting a pt for CAP and you have even a tiny amount of suspicion for TB (immigration to US within last 5 yrs, unsafe sexual practices, h/o autoimmune dz), avoid that dose of Levaquin 500 in the ER. Otherwise, once we get them on the floor, they spend a week in the hospital on Ceftriaxone/Azithro sending multiple sputums for AFB smears, just to make sure that we aren't sending home someone who has active pulmonary TB. Thanks!

MBK2003

Not that I'm a big user of levaquin for pneumonia but I'm confused about how a single dose of levaquin changes your workup of a potential TB patient. It doesn't make their PPD negative and I can't imagine it makes their initial AFB smears less sensitive so it would seem to me you would be doing the same workup (back when I was in NYC it was 3 negative AFB's) regardless of levaquin exposure.

 

[MBK2003]

For most people who meet Port Criteria and are admitted for CAP, Levaquin is fine, but at our institution, people with TB risk factors who receive a dose of Levaquin in the ER are subject to more than the standard 3 negative AFBs before respiratory isolation can be d/c'ed. It may be just that we were at the center of the TB epidemic in the 80s, so the ID folks are hypervigilant. During my ID/Pulm Dz rotation, I can tell you that everytime we got a CAP, R/O TB admission who had received CFTZ/Azithro in the ER, we wanted to run down to the ER and kiss the ER resident because 3 negative AFBs later respiratory isolation was d/c'ed and the pt was sent on their merry way. Just a small request from your friendly IM resident.

MBK2003

 

[DrQuinn]

For most people who meet Port Criteria and are admitted for CAP, Levaquin is fine, but at our institution, people with TB risk factors who receive a dose of Levaquin in the ER are subject to more than the standard 3 negative AFBs before respiratory isolation can be d/c'ed. It may be just that we were at the center of the TB epidemic in the 80s, so the ID folks are hypervigilant. During my ID/Pulm Dz rotation, I can tell you that everytime we got a CAP, R/O TB admission who had received CFTZ/Azithro in the ER, we wanted to run down to the ER and kiss the ER resident because 3 negative AFBs later respiratory isolation was d/c'ed and the pt was sent on their merry way. Just a small request from your friendly IM resident.

MBK2003

I'm not familiar with "Port Criteria," but as far as I recall, as DocWagner said, most big name think tanks allow either Cef/Zithro OR Levaquin. IDSA, ATS, CDC...

I usually use Cef/Z but depending on my mood and the level of ink in my pen I may throw the drug reps a bone and give them a Levaquin.

Q, DO

 

[margaritaboy]

For most people who meet Port Criteria and are admitted for CAP, Levaquin is fine, but at our institution, people with TB risk factors who receive a dose of Levaquin in the ER are subject to more than the standard 3 negative AFBs before respiratory isolation can be d/c'ed. It may be just that we were at the center of the TB epidemic in the 80s, so the ID folks are hypervigilant. During my ID/Pulm Dz rotation, I can tell you that everytime we got a CAP, R/O TB admission who had received CFTZ/Azithro in the ER, we wanted to run down to the ER and kiss the ER resident because 3 negative AFBs later respiratory isolation was d/c'ed and the pt was sent on their merry way. Just a small request from your friendly IM resident.

MBK2003

I'm still confused like ElMURPHUD above. Why are patients that recieve levaquin at your institution subject to more than the traditional 3 AFB smears? PPD would presumably be unaltered, as would the sensitivity of the AFB smears. Workup would seem to be the same irrespective of what antibiotic they recieved.

Is the reasoning that your ID docs think levaquin would kill AFB in the sputum before it can be visualized on a smear, much like systemic antibiotics given before blood cultures were drawn could kill your blood cultures??

 

[roja]

In all my vast years of experience 😉 I say NS. So many reasons, these people are severly dehydrated (up to 6 L or more) and need intravascular volume. and as many have said, who cares about hyperchloremic acidosis...


And for CAP pnuemonia, I tend to go with Ceftriaxe/azithromax. But that's because they have the best pens. 😉

 

[jashanley]

I'm not familiar with "Port Criteria,"
Q, DO

Port criteria is a scale created to decide which patients were at increased mortality from pneumonia and was designed to aid in determination of disposition and location of admission. Multiple factors are included into the Port criteria

"Patient Outcome Research Team (PORT) investigators validated a risk scale for mortality in community-acquired pneumonia, assigning point values based on patient characteristics, comorbid illness, physical examination, and basic laboratory findings"

http://www.clevelandclinicmeded.com...isease/communitypneumonia/table5community.htm

"Patients less than 50 years of age without comorbid illness or significant vital sign abnormalities (risk class I) were found to have a low risk for mortality. The authors suggested that such patients might be eligible for outpatient antibiotic therapy without extensive laboratory evaluation. All others were evaluated with the laboratory testing listed in Table 5 and assigned to risk classes by point totals (Table 6).

Classes I and II are considered excellent candidates for outpatient oral therapy, assuming no hemodynamic instability, no chronic oxygen dependence, immunocompetence, and ability to ingest, absorb, and adhere to an oral regimen. Patients in risk class III may be considered for either outpatient or brief inpatient therapy, depending on clinical judgment. Patients in risk categories IV and V are recommended for hospital admission. Ultimately, each decision to admit must be individualized."

 

[ERMudPhud]

For most people who meet Port Criteria and are admitted for CAP, Levaquin is fine, but at our institution, people with TB risk factors who receive a dose of Levaquin in the ER are subject to more than the standard 3 negative AFBs before respiratory isolation can be d/c'ed. It may be just that we were at the center of the TB epidemic in the 80s, so the ID folks are hypervigilant. During my ID/Pulm Dz rotation, I can tell you that everytime we got a CAP, R/O TB admission who had received CFTZ/Azithro in the ER, we wanted to run down to the ER and kiss the ER resident because 3 negative AFBs later respiratory isolation was d/c'ed and the pt was sent on their merry way. Just a small request from your friendly IM resident.

MBK2003

That really makes no sense. Is everyone in NYC doing this now or just your institution? Even patients on appropriate anti-TB regimens take days to usually weeks to have AFB negative smears. Even if the levaquin was killing the TB it should still be visible on an AFB smear. The smear isn't a culture and doesn't depend on growth. I cant' believe there is any evidence that a single dose of Levaquin decreases the sensitivity of a correctly induced sputum for AFB over the next few days. Have you asked your ID docs for where the evidence is for the increased stringency in screening levoquin exposed patients?

 

[roja]

As a NYC resident I can attest that we do NOT do this (even ran it by my own friendly medicine residents...)

In general, we use ceftriaxone/azithro.. its just easier and on our formulary...

 

[Annette]

To get back to the OP, I'm just glad that a: the ED recognizes DKA, b: you have started any fluids at all, and c: am truely amazed if you gave any insulin 😀 😛

Hey, Mods- why don't we have a tongue-in-cheek smile thingie?

 

[roja]

To get back to the OP, I'm just glad that a: the ED recognizes DKA, b: you have started any fluids at all, and c: am truely amazed if you gave any insulin 😀 😛

Hey, Mods- why don't we have a tongue-in-cheek smile thingie?

It is rather amazing that we bafoons in the ED recognize ANYTHING. It actually amazes me when I not only manage to recognize an obvious disease process but then figure out how to manage it.


And the mainstay of initial treatment in DKA is FLUIDS. Not insulin. You have to at least have a K back before you give insulin. It could have potentially been really disasterous to give my pt with a glucose of 1800 and a K of 1.8 a huge bolus of insulin and driven what ever K was left in his body into his cells...

😀

 

[Tenesma]

hmmm... what patient will be hperglycemic (BS=1800) and hypokalemic (k=1.8)???? never saw that before 🙂

 

[jawurheemd]

hmmm... what patient will be hperglycemic (BS=1800) and hypokalemic (k=1.8)???? never saw that before 🙂

Ever draw labs off a patient's arm who's got D10W or D5W infusing into the same arm?

 

[Tenesma]

Ever draw labs off a patient's arm who's got D10W or D5W infusing into the same arm?

I, personally, haven't - but I know quite a few nurses who have - but for some reason they were also very concerned about the acute anemia/neutropenia and thrombocytopenia as well 😀