Eric Felner, MD, Associate Professor of Pediatric Endocrinology and Director of the Pediatric Endocrine Fellowship Program at Emory University
Espousing a “3-Bag Theory of DKA management,” Dr. Eric Fellner presented an update of the inpatient management of diabetes mellitus at SHM 2014. This approach to dKA involves maintenance IV fluids based on BSA after fluid resuscitation, with variable proportions of ½ NS and D10 ½ NS with potassium chloride/potassium phosphate, and insulin given intravenously. This approach can reduce costs by avoiding multiple changes in IV fluid solution bags, and avoids multiple mistake-prone calculations. He recommends all patients with DKA under the age of 5 years be admitted to the PICU. Constant monitoring of lab values, glucose, vital signs, and clinical condition is also required. In general, insulin boluses do not provide a benefit over insulin drip alone, and use of bicarbonate remains controversial.
Although it is somewhat controversial as to whether all new type 1 diabetics need to be admitted, Dr. Felner favored admission due to improved teaching of patients/families, evaluation of the proposed insulin and carbohydrate regimen, and identification of potential insurance and social problems. Type 2 diabetics rarely get admitted for diabetic complications, but there are increasing numbers admitted for hyperglycemic hyperosmolar state.
Dr. Chang is a pediatric hospitalist with the University of San Diego Medical Center and Rady Children's Hospital, San Diego, and the pediatric editor for The Hospitalist.