What happens if you lower blood glucose too fast in a patient with DKA?

[Emyst]

Hi, so in a patient with diabetic ketoacidosis (DKA), it is recommended to not let their blood glucose drop less than 120 at my hospital. I was wondering why is this?

For example, if a patient came in and had a BG > 300, and I slowly got them to ~120 using the sliding insulin scale, why wouldn't I want to go lower?

My preceptor asked me, why is it bad to lower BG too fast in a patient with DKA, and why? If someone can explain this to me, I'd greatly appreciate it! Thank you.

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[zero0]

I'm guessing because rapid decrease in blood osmolarity will result in increased intracellular fluid in brain cells and cause cerebral edema. The brain needs time to adjust to changes in osmolarity so you have to taper any drastic corrections in glucose, electrolytes, protein, etc. I forget the exact rate off the top of my head.

 

[Osteoth]

I also assume if you hit them with a big bolus of insulin to drop their glucose then their K+ would drop precipitously, which could cause arrythmia, seizure, possible death.

 

[jhamaican]

Because you don't want your patient hypoglycemic?!


Serious: it's less about the glucose levels and more the fact that you need continued insulin to metabolize the ketones. This is why u switch to d5w at around glucose of 200 and titrate the d5w to prevent hypoglycemia rather than touching the insulin.

Issues with rate of decrease have to do with electrolytes primarily the potassium shifts. Also rapid decrease increases chance for hypoglycemia.

Google Iowa dka protocol. It is the bomb

 

[zero0]

I also assume if you hit them with a big bolus of insulin to drop their glucose then their K+ would drop precipitously, which could cause arrythmia, seizure, possible death.

Kinda assumed they'd be giving the standard protocol of saline, insulin, potassium, and glucose, but yeah if they left out the potassium that'd be a no-no

 

[sliceofbread136]

Most mortality in dka is related to cerebral edema. Rapid decrease in glucose levels contribute to this

Also hypoglycemia