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Diabetic ketoacidosis

Definition
 Acute metabolic complication of diabetes – potentially fatal
 Characterised by absolute insulin deficiency
 Most common acute hyperglycaemic complication of diabetes
4 signs of DKA: Acidosis (metabolic, raised anion gap), ketosis, dehydration and hyperglycaemia

Aetiology
 (Supplement from internship book)  Drugs that affect carbohydrate
 2 most common precipitating events: metabolism
o Inadequate insulin therapy o Corticosteroids
o Infection o Thiazides
 Underlying medical conditions o Sympathomimetic agents (e.g.
o Myocardial infarction dobutamine, terbutaline)
o Stroke/cerebrovascular accidents o Second generation antipsychotic
o Acromegaly agents
o Hyperthyroidism  Underlying medical conditions provoke the
o Cushing’s syndrome release of counter-regulatory hormones
o Pancreatitis that are likely to result in DKA in patients
o Pneumonia with diabetes

Classification
Mild Moderate Severe Resolved
Plasma glucose >13.9mmol/L <11.1
Arterial pH 7.25-7.30 7.00-7.24 <7 >7.3
Serum bicarbonate 15-18 10-15 <10 >18
Urine ketone Positive Negative
Serum ketone Positive Negative
Effective serum osmolality Variable
Anion gap >10 >12 <10
Mental status Alert Alert/drowsy Stupor/coma Alert
Symptoms
 Signs and symptoms
o Hyperglycaemia (polyuria, polydipsia, abdominal pain), polyphagia
o Weight loss
o Weakness
o Volume depletion/dehydration/poor skin tugor/sunken eyes/dry mucous membranes
 Obs
o Tachycardia
o Hypotension
o Hypothermia
 On examination
o Generalised abdominal pain, no peritonitic pain
o Kussmaul respiration (acidotic)
o Acetone breath
o Changes in mental status

Investigations
 Bedside:
o Urinalysis – including urine ketones, consider UTI
o ECG
o pO2
 Normal: 80-100 on room air
 4L: 120 and above
 FiO2: 21% on room air
 Nasal prongs: 30%  FiO2 >120
 FiO2 x 4 = pO2
 Bloods
o FBE (raised WBC), UEC biochemistry panel (including sodium, potassium, Cl, Mg, phosphate)
 Low sodium, chloride, magnesium, calcium
 High potassium, high phosphate
o BSL and blood ketones
o ABG/VBG – pH, anion gap calculation
 VBG range: 7.32-7.42
 ABG range: 7.35-7.45
 Elevated anion gap metabolic acidosis:
 Low HCO3, normal lactate, high potassium (potassium not in cells)
 Causes LTKR: Lactate, Toxins Ketones, Renal failure
o Serum urea, creatinine – elevated
o LFTs (usually normal)
o Serum amylase/lipase (pancreatitis)
o Troponins/CKMB
o Blood, urine, sputum cultures (Septic screen)
 Imaging
o CXR (?pneumonia)

Management
 Prevention: Education
o Ketone/BSL monitoring, insulin use, nutrition during illness, GP/endocrinologist monitoring
 Acute management (DRSABCD NBM)
o Restore volume deficit (Fluid resuscitation first via 2 large bore cannulas)
 Fluid therapy – normal saline at 1/1,5L/h 0.9& NaCl to also correct low sodium
o Correct electrolyte abnormalities’
 Potassium, bicarbonate therapy
o Resolve hyperglycaemia, acidosis and ketosis
 Insulin i/v infusion – do not stop IV insulin until 30min after s/c insulin is given
 Aim BSL level 5-12mmol
o Treat precipitating aetiology of DKA
 Normal management (not severe enough to cause DKA – mild hypoglycaemia)
o Normally cognition
o 6-7 diabetic jellybeans or 200ml of non-diet soft drink (e.g. fruit juice)
o Reassess BSL every 15min
o Once BSL goes back to normal (>5), give long-acting carbohydrate (e.g. sandwich)
 Severe hypoglycaemia
o Unconscious, confused
o i.v. glucose 50% (but I.m. or sc glucagon?)

SPIDER step-by-step mnemonic: Acute management


 S: Saline
o Risk – cerebral oedema
o Give mannitol, transfer to ICU
 P: Potassium (3.5-5) – give potassium because insulin causes hypokalaemia
 I: Insulin (short acting, IV)
o Give bolus 10% dextrose if hypoglycaemia
 D: Dextrose (once serum levels drop to 12-13mmol, then give until 5-12mmol)
 E: Electrolytes (Correct any electrolyte disturbance) – lactate, potassium, HCO3, Na+
 R: Resolve underlying issue
o E.g. non-compliance to drugs/insulin
o Concurrent infection (e.g. sick people don’t eat or follow regimens)
 Regular monitoring
o 1x every hour – vital signs, GCS, BSL, ketones, potassium
o every 2h – VBG, UEC
o Anticoagulation/heparin (risk of VTE)
o Fluid balance chart +/- catheter

Fluids (crytalloids)
Urea (check it)
Creatinine (check it)/ Catheterize
K+ (potassium)
Insulin (5u/hour. Note: sliding scale no longer recommended in the UK)
Nasogastic tube (if patient comatose)
Glucose (once serum levels drop to 12)