Quick review on DKA and its management

1. DIABETICS
KETOACIDOSIS
Intern Anup
13TH Batch KUSMS

2. • DKA is an acute, life threatening medical emergency
• Occurs in both type1 (more common) and type 2 diabetic
patients
PRECIPITATING FACTORS:
-Infection (pneumonia, UTI, sepsis, gastroenteritis)
-inadequate insulin treatment or noncompliance
-infraction (cerebral, coronary, mesenteric, peripheral)
-severe stress (physical, emotional)
-hyperthyroidism, pheochromocytoma
-drugs( thiazides, steroids, cocaine)
-pregnancy

3. CARDINAL BIOCHEMICAL FEATURES
(triad of hyperglycemia, high anion gap metabolic acidosis
and ketonemia)

4. PATHOPHYSIOLOGY
- Occurs as a consequences of absolute or relative insuline
deficiency that is accompanied by an increase in counter-
regulatory hormones ( glucagon, cortisol, growth
hormone, epinephrine).
- This imbalance enhances hepatic gluconeogenesis,
glycogenolysis, lipolysis and ketogenesis.
- Two ketone bodies namely acetoacetic acid and B-
hydroxybutyric acid are strong acid and are responsible
for acidotic state.

8. INVESTIGATIONS
Investigations shouldnot delay the institution of IVF and
insulin replacement.
URINE TESTS:
-Urine R/E (shows glucose in urine)
-Urine Ketone
BLOOD TESTS:
-Blood glucose, RFT( Ur, Cr, Na, K)
-Arterial Blood Gas Analysis
INFECTION SCREEN:
-Full blood count, blood and urine culture, CRP, C-XR

9. TREATMENT OF DKA
The goals of therapy:
1. Improvement of circulatory volume and tissue perfusion
2. Gradual reduction of serum glucose and osmolality
3. Correction of electrolyte imbalance
4. Identification and prompt treatment of co-morbid
precipitating causes
5. Frequent monitoring of patients by clinical and
laboratory parameters

11. Fluid Therapy
• DKA is volume-depleted states with total body water
deficit of approximately 6 L
• Use of isotonic saline at the rate of 15–20 ml /kg body
weight per hour or 1–1.5 L during the first hour
• hypernatremic or eunatremic condition 0.45% NaCl is
infused
• Recommended schedule:
- administer 1-3 litre over 1st hour
- 1 litre during second hour
- 1 litre during following 2 hour
- 1 litre every 4 hours depending on the degree of
dehydration state and CVP

12. Insulin Therapy
-Insulin should only be started after serum potassium value is >
3.3 mmol/L
-IV bolus of regular insulin (0.1 u/kg body weight) followed by a
continuous infusion of regular insulin at the dose of 0.1u/kg/hr.
-The optimal rate of glucose reduction is between 50-70 mg/hr. If
desirable glucose reduction is not achieved in the first hour, an
additional insulin bolus at 0.1 u/kg can be given
-when plasma glucose reaches 200-250 mg/dL , insulin rate
should be decreased to 0.05 U/kg/hr and IVF is changed to D5
½ NS.
-Revert to S/C insulin after patient begins to eat (iv insulin
infusion is continued for 1-2 hrs)

13. Potassium Therapy
-If the initial serum potassium is below 3.3 mEq/L, IV
potassium chloride is started with saline (20-40 mEq/hour)
-if the initial serum potassium is between 3.3 and 5.3
mEq/L, IV KCL (20-30 mEq) is added to each litre of Iv
replacement fluid and continued until serum potassium
concentration has increased to 4.0-5.0 mEq/L range
-If the serum potassium is initially >5.3 mEq/L, then
potassium replacement should be delayed

14. CORRECTION OF ACIDOSIS
-The use of bicarbonate in treatment of DKA remains
controversial (A/E- hypokalemia, decreased tissue oxygen
uptake and cerebral edema)
-If arterial pH < 6.9 bicarbonate should be given :100 mmol
sodium bicarbonate in 400 ml isotonic solution over 2
hours and repeat dose until pH>7.0

15. MONITORING
• capillary blood glucose and ketone: hourly
• Venous bicarbonate and potassium: after 1 and 2 hrs then
every 2 hrly
• Plasma electrolytes: every 4 hrly
• Clinical monitoring of O2 saturation, pulse, BP, RR and
urine output every hourly

16. ADDITIONAL
• Treatment of any precipitating factors
• Catheterisation if no urine passed after 3 hrs
• Measure ABG and repeat C-XR if O2 saturation < 92%
• ECG monitoring in severe case

17. HYPERGLYCEMIC HYPEROSMOLAR STATE
-severe hyperglycaemia (>600 mg/dl or 30 mmol/l)
-Hyperosmolality (serum osmolality >320 mOsm/kg)
-Dehydration
Absence of significant hyperketonaemia (<3 mmol/l) or
acidosis (PH>7.3, bicarbonate >15 mmol/l)
Onset is insidious, presents with a several week history of
polyuria, weight loss and diminished oral intake (dka <24
hrs)

19. Management
FLUID REPLACEMENT:
1-3 litres of NS over first 2-3 hours
After the patient is hemodynamically stable free
water defecit (9-10 litre) is reverse over next 1-2
days with 0.45% saline
When blood glucose reaches 250 mg/dl IVF is
changed to D5 ½ NS.

20. INSULIN:
IV bolus of regular insulin (0.1 u/kg body weight) followed
by a continuous infusion of regular insulin at the dose of
0.1u/kg/hr
when plasma glucose reaches 200-250 mg/dL , insulin rate
should be decreased to 0.05 U/kg/hr
Infusion is continued until patient has resumed eating and
can be transferred to a S/C regimen
PPT agents should be treated
Potassium correction