Diabetic Ketoacidosis

1. MRS. ARUNA MANO
MSC (N),MEDICAL SURGICAL NURSING
LECTURER
GANGA COLLEGE OF NURSING
COIMBATORE

3. ABSTRACT :
• Introduction
• Definition
• Epidemiology
• Triad
• pathophysiology
• Causes
• Signs and symptoms
• Investigation
• Management
• Complication

4. Diabetic Ketoacidosis is an
acute, major, life-threatening complication of
Diabetes. It mainly occurs in patients with
Type 1 Diabetes but it is not uncommon in
some patients with Type 2 diabetes

5. DKA is an extreme metabolic state
caused by insulin deficiency it is defined
as an acute state of severe uncontrolled
diabetes associated with keto
acidosis that requires emergency
treatment.

6. CONT…
It is a state of absolute or relative insulin deficiency
aggravated by ensuing hyperglycemia, dehydration and
acidosis- producing derangements in intermediary metabolism
Diabetic keto acidosis is a Medical Emergency and remains a
serious cause of morbidity in type 1 diabetes. Mortality
remains high in developing countries.
Mortality – in children by cerebral edema.
– in adult by hypokalemia, ARDS, co-morbidities

7. BASIC DEFINITION :
• Hyperketonaemia (>3 mmol/L ) and ketonuria
(>2+ on urine sticks)
• Hyperglycemia (blood glucose>200 mg/dl )
• Metabolic acidosis ( venous PH< 7.3 and or
venous bicarbonate <15 mmol/L)

8. EPIDEMIOLOGY :
• DKA accounts for 14% of all hospital admissions of patients
with diabetes and 16% of all diabetes-related fatalities.
• The overall .DKA is frequently observed in diagnosis of type 1
diabetes and often indicates this diagnosis (3%)
• mortality rate for DKA is 0.2-2%, being at the highest in
developing countries..
• The incidence of DKA in developing countries is higher.
• It is far more common in young patients.

9. CONT….
Case-fatality rate of DKA varies according to the
geographic region and ranges from a low of less than
1000 per 100,000 individuals (USA and Scotland) to a
high of 30,000 per 100,000 individuals (India).
The prevalence of DKA varies with age and is more
common in children.

10. TRIAD

14. CAUSES :
• Pneumonia
• UTI ,Age
• Infection : (35%)
• Drugs :
Steroids and thiazides
• New onset of DM (20%)
• Medical surgical emotional stress
• No cause (5%)

15. CONT ..
Recurrent episode of DKA in young
patients :
– Eating disorder
– Cocaine or alcohol abuse
– Dosage skipping

18. MNEMONIC :
DKA Patients first
go To Hospital

19. D – Dehydration :

20. K - Kussmal respiration

21. A – Acidosis :

22. Cold extremities and cyanosis

23. T – Tachycardia :

24. H – Hypotension :

25. H – Hypothermia :

26. Coma

27. MANAGEMENT
M

28. Based on ,
• History
• Physical examination
• Investigation

29. History :
• can develop over several days, Symptoms mostly occur within
24hr.
• Ask about symptoms of hyperglycemia
e.g. -polyuria, polydipsia, nocturia,weight loss, muscle pains &
cramps
• Symptoms of acidosis & dehydration:
-abdominal pain, SOB, confusion, coma
• Other symptoms
-vomiting, signs of infection(UTI,RTI), weakness, nonspecific malaise

30. Physical examination:

31. CONT ..
• BP is usually normal until last stage
• Tachycardia
• Capillary refill is maintained
• Patient have a smell of acetone
• Impaired consciousness 20%
Level of consciousness depends on serum osmolality &not on
acidosis >320mosm/l
osmolality-2(Na)+K+glucose/18
• Coma 10% patients
• Abdominal tenderness

32. Investigation :
Blood glucose level

33. Urine analysis :
ketones

34. Blood analysis :

35. ABG :

36. EKG

38. Due to dehydration, blood flow to the kidney is decreased and
leads to acute renal failure which causes disturbed kidney

39. INFECTION SCREEN
• Complete blood count
• Blood and urineculture
• Crp
• Chest x ray

42. M
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44. Insulin :
• Fixed rate iv insulin infusion of 0.1
u/kg/hr is recommended.
• Glucose should done by 55-110mg/dl per
hour or blood ketone should fall by
0.5mmol/l/hr
• When glucose has fallen,10% dextrose
infusion is introduced

45. Fluid replacement :
• Rapid fluid replacement in the first few
hours recommended.
• Mostly 0.9%NACL is used(isotonic
saline)
• If the plasma sodium is >155mmol/l,
0.45% saline may be used.

46. Potassium :
• are full monitoring needed, because both
hypo and hyperkalemia can occur.
Plasma potassium(mmol/l) Potassium replacement (mmol/l of
infusion)
>5.5 Nil
3.5 – 5.5 40
<3.5 Senior review-additional potassium
required

47. Bicarbonate :
• Adequate fluid and insulin should
resolve the acidosis.
• Use of bicarbonate is not
recommended.

49. ADDITIONAL MEASURES

50. Catheterization if no urine passed after 3 hrs.

51. Central venous line if cardiovascular system
compromised, severe DKA, renal or cardiac failure,
other serious comorbidities

52. Measure arterial blood gases and repeat x ray if
oxygen saturation <92%

53. Thrombo prophylaxis with low molecular weight
heparin