The Curbsiders podcast

#25 Master hyperglycemia and DKA

February 6, 2017 | By

Master the management of hyperglycemia, DKA, and learn to avoid common pitfalls. This episode is packed with clinical pearls from repeat guest, Endocrinologist, Dr. Jeffrey Colburn.

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Clinical Pearls:

  1. Type 1 diabetes (DM1) occurs by autoimmune destruction of beta cells
    • occurs at any age
    • Typically lean body type and normal lipid profiles
  2. Type 2 diabetes (DM2)
    • Typically obese and insulin resistant
    • Eventually fat deposition in pancreas destroys insulin production 15-20 years after onset of DM2 leading to absolute insulin deficiency
  3. Triad of DKA = hyperglycemia, ketonemia, acidemia
  4. DKA occurs w/total lack of insulin leads to inability to utilize glucose (hyperglycemia)
    • Simulated starvation occurs
    • Counter regulatory hormones kick in
    • Free fatty acids are broken down for fuel
    • Keto acids are made as a by product (ketonemia)
    • Acidemia occurs
  5. DKA can occur in DM2 if overwhelming infection, or infarction (MI or CVA)
  6. Even just a little bit of insulin can keep patient out of DKA!
  7. Dehydration is a cardinal issue in DKA from osmotic diuresis
    • Often 6-8 liters depleted!
  8. Sick day rules for Type 1 diabetes
    • Early contact with healthcare team
    • Reduce, but do not discontinue insulin during the illness (see #9)
    • Check frequent fingersticks
    • Use antipyretics to manage fever
    • Push the fluids
    • Educate family members about signs/symptoms of DKA
  9. If sick, then drop basal insulin by 20% whether SQ or basal rate on insulin pump
    • Keep mealtime insulin dose the same, but skip if not eating
  10. Ketones
    • Beta hydroxybutyrate is the predominant ketone in DKA
    • Urine ketones measure acetoacetate (strongly) and acetone (weakly) NOT beta hydroxybutyrate
    • Serum ketones measure acetoacetate and acetone NOT beta hydroxybutyrate
    • Thus, check a direct blood beta hydroxybutyrate level if available
  11. Follow an algorithm when treating DKA!
  12. IVF fluids first line therapy in DKA, hyperglycemia
    • Make sure to replete potassium above at least 3.3 before giving insulin!
  13. Insulin drip – insulin out of system in minutes when drip stopped
  14. Subcutaneous insulin – lasts 4 hours and can “stack” if repeat doses given
  15. SGLT2 inhibitors can lower blood glucose in the absence of insulin leading to possible “euglycemic DKA”

Goal: Listeners will be able to confidently evaluate, and manage the patient with severe hyperglycemia and/or DKA.

Learning objectives:

By the end of this podcast listeners will:

  1. Differentiate between type 1 and type 2 diabetes
  2. Review the pathophysiology of DKA
  3. Utilize basic laboratory data to diagnose DKA and differentiate it from other common conditions
  4. Initiate management of hyperglycemia and/or DKA in the acute setting
  5. Formulate a plan for sick day management in type 1 diabetes
  6. Describe the mechanism of DKA in setting of SGLT2 inhibitor use


Dr. Colburn is a member of AACE and helped develop the AACE Algorithm for Type 2 Diabetes.

Time Stamps

00:00 Intro

02:06 Rapid fire questions

07:30 Definitions and classification of diabetes

10:12 DKA in type 2 diabetes?

11:16 Pathophysiology of DKA

13:00 Severe hyperglycemia mislabeled as DKA

14:22 Which type 2 diabetics get DKA?

15:40 The cardinal issue is dehydration

17:11 Starvation ketosis vs DKA vs other

18:33 How to handle severe hyperglycemia in outpatients

22:18 Sick day management in type 1 diabetes

27:48 Initial testing for diagnosis of DKA

31:00 Subcutaneous or IV insulin for DKA

33:35 Initial evaluation and management in ER

36:50 Fluids and electrolyte management

40:12 SGLT2 inhibitors and euglycemic DKA

Links from the show:

  1. Walden by Henry David Thoreau
  2. AACE Type 2 Diabetes Management Algorithm on iTunes.
  3. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care 2009

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  1. February 20, 2017, 1:31am Michaela Skelly MD writes:

    This was very helpful even though I am primarily an outpatient provider dealing with Type 2 diabetics. I love the way Matthew "confesses" his past mistakes. I do this with my students also and feel it is one of the best ways to teach. I think it unbelievable when he states that he is the "stupid one of the group". I think there are many physicians listening to the podcast that would love to be as "stupid" as him (me included). It takes confidence to admit when you did something less than perfect. I admire your modesty.

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The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit and search for this episode to claim credit.

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