DIABETIC KETOACIDOSIS

  

A metabolic emergency in which hyperglycemia is associated with metabolic acidosis due to greatly raised ketone levels Hyperglycemia : > 13 mmol/L Acidosis : pH < 7.30, HCO3 < 15mmol/L Ketonemia or ketonuria

Diabetic ketoacidosis
 

Occur MAINLY in DM type 1 Manifestation of a state of absolute or relative insulin bankcuptcy

Peviously undiagnosed diabetes  Interruption of insulin therapy  The stress of intercurrent illness


Precipitating factor

- infection,
- myocardial infarction - trauma - omission of Insulin -stroke -surgery

Clinical features:
         

Polyuria, polydipsia, nocturia Weight loss HyperventilationHyperventilation- Kussmaul respiration Ketotic breath Abdominal pain Nausea, vomiting Dehydration Hypotension Drowsiness coma

progress over a short period of time

Relevant investigations:
      

Blood glucose (RBS) Full blood count (FBC) Blood urea serum electrolytes (BUSE) Blood gases (VBG) ECG Cardiac enzymes (CE) Ix for underlying cause


Eg: CXR, ECG, urine microscopy, sepsis workout, etc

Management


Goal, to correct:
1. 2. 3. 4. 5.

Fluid loss Hyperglycemia Electrolyte loss Acidosis Precipitating cause

Goal 1: correct dehydration



Start iv fluid of 0.9 NS 1L/hr initially (15-20ml/kg/hr. (15average of 6-8 liter was given 6in 24 hrs) Suggested regime
     

1l in 1 hr Then 1L in 2 hrs Then 1L in 4hrs Then 1L in 6hrs Then 1L in 8hrs Then 3L NS/24h

(replacement must be done with close monitoring of pts clinical state)

When blood glucose <15mmol/l, change to fluid cointaining glucose such as dextrose saline or 5%5%-10% dextrose

Goal 2 : correct hyperglycemia

      

By insulin therapy- start on sliding therapyscale Continuous iv insulin infusion is the tx of choice Soluble insulin is diluted in NS at concentration of 1U/ml Bolus: 10U (0.15u/kg) followed by 6u/hr(0.1u/kg) by infusion pump Monitored blood glucose hourly Aim: 10% drops (~3mmol/L/hr) Sc/IM route if no infusion pump

 

When the blood glucose<15, the insulin infusion rate. Change IVD NS to dextrose Maintain glucose level at 8-12mmol/L Iv insulin infusion with iv dextrose should be continue until acidosis resolved and patient metabolic state normalized

Goal 3 :correct electrolyte

 

DKA usually have low total body k+ following insulin tx Administration should begin:
  

ECG no sign of hyper K+ Ample urine output Plasma K+ <5mmol/l

 

Add 1gm KCl in each pine NS. Adjust K+ replacement according to serum potassium level BUSE done 4-6hrly n ECG 4Maintain b/w 4-5mmol/L 4-

Goal 4: correct acidosis



After adequate fluid resuscitation when:

 

pH 7.0 Severe hyperK with ECG changes

Usually NaHCO3 given mixed with normal saline Aim pH 7.1. should not been given if pH 7.1

Goal 5 : Tx of precipitating cause

 

Treat the precipitating fators If sepsis suspected, treat with broad spectrum antibiotics until culture results return. Then switch to appropiate antibiotics

Complication
 

 

  

Hypoglycemia Cerebral edema - if too rapid lowering of plasma glucose Aspiration pneumonia Hypokalemia - due to loss of K+ in urine from osmotic diuresis Hypomagnesemia Hypophosphatemia Thromboembolism - due to immobilization