POTD: Euglycemic DKA

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Today’s POTD comes from Dr. Buckingham.  Her clinical question: Can a patient present as a first time diabetic with euglycemic DKA? Hmmm... Let’s break question down.  

How do you diagnose diabetes in a patient?

  • Symptomatic hyperglycemia with classic symptoms of thirst, polyuria, weight loss with a random BGM≥200mg/dL
  • Fasting plasma glucose ≥126 mg/dL
  • Oral glucose tolerance test with two hour plasma glucose ≥200 mg/dL
  • HbA1C values ≥6.5%

 

What is euglycemic DKA?

Just as the name states, euglycemic DKA is diabetic ketoacidosis without the hyperglycemia.  Patients will have the serum/urine ketones and anion gap metabolic acidosis of DKA while glucose levels are normal/mildly elevated (<200mg/dL).  Patients that present with euglycemic DKA are usually those with poor carbohydrate intake, adequate hydration, use of insulin, alcohol intake, or use of sodium-glucose co-transporter 2 (SGLT2) inhibitors [Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance)].  Euglycemic DKA occurs more often in type 1 but can also occur in type 2 diabetes, and the most common symptom is vomiting.

**Check labs for patients with concerning story of DM, poor carbohydrate intake and/or taking SGLT2 inhibitor, c/o nausea/vomiting/fatigue/SOB**

 

So can someone present with no prior hx of diabetes and have euglycemic DKA?

Maybe, if they have been having poor carbohydrate intake but tolerating fluids.  However, also consider a broader differential diagnosis such as starvation ketoacidosis, alcoholic ketoacidosis, lactic acidosis, and drug toxicity.

 

Want to read more?

http://care.diabetesjournals.org/content/38/9/1638

https://emergencymedicinecases.com/euglycemic-dka/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4488998/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5592704/

http://rebelem.com/euglycemic-dka-not-myth/

https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-diabetes-mellitus-in-adults

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POTD: Neutropenic Fever Part II

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Clinical Scenario Continued: Your febrile neutropenic patient has been started on antibiotics with blood cultures sent and you are pending a return page from her oncologist.  The patient starts asking you if you could discharge her home because she feels a lot better and does not want to be in the hospital.  Her vital signs have improved and she is no longer tachycardic or febrile, she tolerated PO in the department and ambulated.  Your lab work and chest x-ray have been unremarkable other than neutropenia.
 
Question 1: Are neutropenic fever patients ever considered low risk?
Under the IDSA guidelines, most experts consider high risk patients to be those who have anticipated prolonged and profound neutropenia (>7 days with ANC≤100mm3 after cytotoxic chemotherapy), and/or have comorbid medical conditions like hypotension, pneumonia, neurological changes, or new abdominal pain.  Low risk patients are those whose neutropenic periods are anticipated to be brief (≤7 days) with few or no co-morbidities.
 
Question 2: Should you discharge a low-risk neutropenic fever patient home from the ED with oral antibiotics?
There are validated risk-stratification tools that help identify low-risk febrile neutropenic patients that could be sent home on oral antibiotics, used in the clinic and inpatient settings, two of which are the Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE).  You can find these calculators here:
There has been a recent retrospective study on these two tools on inpatients by Coyne et al. 2017: http://www.annemergmed.com/article/S0196-0644(16)31352-X/abstract
The CINSE was found to be highly specific in identifying low-risk patients (98.3% specific with 95% CI 89.7-99.9%) while MASCC was found to be much less specific (54.2% with 95% CI 40.8-67.1%).  However, this a retrospective study on inpatients and whether this can be extrapolated to discharged patients on oral antibiotics from the ED is still a question.  Prospective data is needed.
You can find the EM:RAP commentary on this study here: http://www.annemergmed.com/article/S0196-0644(17)30416-X/pdf
Want to read more?
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POTD: Trauma Tuesday! Hyperosmolar Solutions for Traumatic Brain Injury

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Clinical Scenario:  24 yo M BIBA after a MVC.  Patient was an unseatbelted passenger that was expelled from the vehicle.  Per EMS, patient had positive LOC at the scene, became more arousable on the way to the hospital, GCS13 with a hematoma on the left scalp.  While in the trauma bay, the patient loses consciousness with sluggish and dilated pupils.  He is bradycardic and hypertensive with irregular breathing (Cushing’s triad).  You are concerned that he is herniating with increased ICP and ask the nurse for a hypertonic solution while you prepare for intubation. Which hypertonic solution do you choose and how do you give it?
Two common choices are mannitol and hypertonic saline.
 
Mannitol is given as boluses of 0.25 to 1g/kg every 4-6 hours as needed.
Optimal dosing is not established for hypertonic saline; give in boluses through a central line, some protocols as per Uptodate include:
3%: 300mL given over 20 minutes when ICP >20mmHg (Huang 2006)
7.5%: 2mL/kg given over 20 minutes when ICP >25mmHg (Vialet 2003)
23.4%: 30mL given over 2 minutes (Ware 2005) or 30mL given over >30minutes when ICP values >20mmHg (Kerwin 2009)
 
So do you give mannitol or hypertonic saline?
A 2015 meta-analysis (Pelletier et al.) found no significant mortality benefit and no difference in neurologic outcome with giving hypertonic saline over other hyperosmolar solutions.  Mannitol has been the gold standard, but hypertonic saline’s volume expanding property over mannitol’s diuresis in a trauma patient has been a consideration.
 
Want to read more?

https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=353

http://pemcincinnati.com/blog/wwdwwd-hypertonic-saline/

http://thesgem.com/2016/03/sgem150-hypertonic-saline-for-traumatic-brain-injury/

https://www.uptodate.com/contents/management-of-acute-severe-traumatic-brain-injury?search=hypertonic%20saline%20cerebral%20edema&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H17

https://www.uptodate.com/contents/mannitol-systemic-drug-information?search=mannitol&source=search_result&selectedTitle=1~149&usage_type=default&display_rank=1

https://www.uptodate.com/contents/sodium-chloride-preparations-saline-and-oral-salt-tablets-drug-information?search=saline%20preparations&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Wright DW, Merck LH. Head Trauma. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109445450. Accessed January 23, 2018.

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