Diabetic Ketoacidosis

Vanessa Ting Ching Ching

 Introduction
• DKA is a serious acute complication of
diabetes.
• Characterised by hyperglycaemia, anion
gap metabolic acidosis & ketonaemia
Pathogenesis
 Precipitating Factors
• Inadequate/non-compliance with insulin therapy
• Infection
• Acute major illnesses (MI, CVA)
• New onset Type 1 diabetes
• Drugs affecting carbohydrate metablosim
(glucocorticoids, high dose thiazides,
sympathomimetic agents (dobutamine,
dopamine), 2nd-generation antipsychotic agent
• Cocaine use
 Clinical Presentation
• Rapid progression (usually over a few days)
• Initially polyuria, polydipsia, nocturia & weight loss
• Progress to Kussmaul respirations (compensatory
hyperventilation for low arterial pH), fruity (acetone)
breath, abdominal pain, vomiting
• Hypovolaemia (dehydration, decreased skin turgor, dry
axillae and oral mucosa, hypotension)
• Drowsiness, lethargy & coma (neurologic disturbances
due to plasma hyperosmolality)
• Fever is rare even in infection due to peripheral
vasoconstriction caused by hypovolaemia
 Diagnosis
• Hyperglycaemia (>14mmol/L)
• Anion gap metabolic acidosis (pH<7.3, HCO3<15mmol/L)
• Other investigations
– Serum potassium: usually high (K+ movement into ECF & insulin
deficiency)
– Serum sodium: normal or low (usually of no concern)
– WCC: raised; may be unrelated to infection (hypercortisolaemia)
– Urea & creatinine: raised (dehydration
• Ketonaemia/ Ketonuria
– 3 ketone bodies produced (beta-hydroxybutyric acid, acetoacetic
acid, acetone)
 Laboratory Findings
• Hyperglycaemia
• Hyperosmolality
• ↑blood urea &
creatinine (due to
↓GFR)
 Fluid Replacement
• For the 1st 24 hours, 6-8L may need to be given.
Normal saline (0.9%) is initially used
• Switch to half saline (0.45%) when Na>145mmol/L.
Care must be taken not to reduce plasma osmolality
too rapidly (cerebral oedema may occur)
• Dextrose saline or 5% dextrose should be used
when glucose level<15mmol/L
• Blood urea, serum electrolytes and serum creatinine
must be concurrently monitored.
Potassium Supplementation
Complications of Treatment
 Patient Education
• Insulin
– compliance, skipped doses
– Condition of insulin – cloudy, frosted vial, proper storage
– Increased requirements due to illness/stress (infection,
pregnancy, pancreatitis, trauma, hyperthyroidism, MI)
• Signs & symptoms
– Hyperglycaemia – thirst, excess urination, fatigue, blurred vision
– Acidosis – fruity breath, deep & difficult breathing
– Dehydration – dry mouth, warm dry skin, fatigue
– Stomach pain, nausea, vomiting, decreased appetite
• Action to be taken
– Drink plenty of fluids, continue taking insulin dose
– Seek medical attention immediately