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Diabetic Ketoacidosis Guide: Symptoms, Treatment & Prevention
- 2. Characteristics Uncontrolled hyperglycaemia (generally >13.9 mmol/L) Metabolic acidosis (arterial blood ph <7.3) and plasma bicarbonate <15 mmol/L High anion gap acidosis of >12 ± 2 Increase in circulating total body ketone concentration (β- hydroxybutyric and acetoacetic acid) and ketonuria.
- 3. Precipitating causes Infection New-onset diabetes Cessation of insulin Myocardial infarction Pancreatitis Shock and hypovolaemia Stroke Other medical diseases No precipitating event
- 4. Symptoms Nausea and vomiting Thirst and polyuria Weakness and/or anorexia Abdominal pain Visual disturbances Somnolence
- 5. Signs Tachycardia Hypotension Dehydration Warm, dry skin Hyperpnoea or Kussmaul breathing Impaired consciousness Fruity odour of ketones
- 6. Initial laboratory investigations Immediate urine test for glycosuria and ketonuria Plasma sample for: ∘ Glucose ∘ Electrolytes ∘ Bicarbonates ∘ Chloride ∘ Urea ∘ Creatinine Arterial blood samples for blood gas analysis Blood count (leucocytosis is frequent) Urine culture Blood culture if indicated X-ray chest Electrocardiogram (ECG)
- 8. How does the body dispose of ketones? Extrahepatic tissues have the capacity to utilize ketone bodies but this is impaired in uncontrolled diabetes. Oxidation of ketone anions during treatment neutralizes the acidosis by generating bicarbonate ions. Increased excretion of ketone bodies through the kidneys and lungs is important in ketone body elimination.
- 9. What are the effects of acidosis? Negative inotropic effect on cardiac muscle. Systemic hypotension. Peripheral vasodilatation. Risk of ventricular arrhythmia. Respiratory depression.
- 10. What is the impact of acute illness on glucose metabolism? Increased production. Decreased tissue utilization. Decreased renal clearance.
- 11. Effect of Hyperglycaemia in DKA
- 12. Broad-line management Fluid replacement. Insulin replacement. K+ replacement.
- 13. Rules for fluid replacement Which fluid should be used? ∘ Isotonic saline: 0.9% normal saline. ∘ In severe hypernatraemia: 0.45% saline. ∘ In case of shock: volume expander. How to replace fluid? ∘ There are several protocols based on the fact that volume depletion is significant. ∘ The initial fluid of choice is isotonic saline at the rate of 15-20 ml/kg body weight per hour or 1-1.5 L in adults during the first hour. ∘ Further repletion depends on the hydration status, serum electrolyte levels and urine output.
- 14. Insulin replacement DKA is a state of marked insulin resistance. Only short- acting (regular) insulin should be used initially. The optimum route of administration is intravenous. A low-dose insulin regimen is given: 5–7 units of short- acting insulin hourly through continuous intravenous infusion till plasma glucose falls to 13.9 mmol/L. The expected rate of decrease in plasma glucose is 4–5 mmol/L per hour. Plasma glucose concentration should not be allowed to drop to ≤11 mmol/L in the first 6–8 hours.
- 15. Rationale for low-dose insulin therapy Low-dose insulin raises the circulating insulin level to 10– 20 times the normal fasting level and provides near- maximal stimulation of each action of insulin, as follows: inhibition of hepatic glucose production inhibition of lipolysis stimulation of glucose uptake by the peripheral tissues.
- 16. Potassium replacement In established DKA, total body K+ deficits amount to 200–400 mmol or 3–5 mmol/kg body weight. The initial plasma K+ value may be low, normal or high. During the treatment of DKA, plasma K+ concentration will drop because of: rehydration (dilution) correction of acidaemia continued renal excretion insulin-mediated cellular uptake.
- 17. Bicarbonate administration There is no evidence that administration of bicarbonate (HCO3) is either necessary or safe in DKA. Bicarbonate should not be used in the initial resuscitation procedure. The potential hazards of HCO3 therapy include: paradoxical exacerbation of central nervous system acidosis hypokalaemia and altered calcium ionization excessive osmolar load and volume overload tissue hypoxia.
- 18. Persistent acidosis is likely to be caused by: Inadequate insulin effect Sepsis.
- 19. Indications for considering bicarbonate therapy pH <7.0 or HCO3 – <5.0 mmol/L Severe left ventricular failure Hyperkalaemia (K+ >6.5 mmol/L) Respiratory depression Hypotension unresponsive to fluid replacement Late hyperchloraemic acidosis
- 20. DKA resolution criteria Blood glucose ≤11.1 mmol/L. Serum HCO3 ≥15.0 mmol/L. Venous pH ≥7.3. Calculated anion gap ≤12 mmol/L.
- 21. Clinical observations and monitoring Monitoring Interval Clinical Mental status 1 h Vital signs (temperature; pulse; respiratory rate; blood pressure) 1 h ECG As indicated Weight As indicated Therapy Fluid intake and output (mL/h) 1–4 h Insulin (unit/h) 1–4 h Potassium (mmol/L) 1–4 h Bicarbonate (mmol/L) 1–4 h Laboratory Glucose (bedside) 1 h Potassium, pH 1–2 h Sodium, chloride bicarbonate 2–4 h BUN or creatinine 4–6 h Urine ketones 2–4 h Calcium As indicated Haematocrit As indicated
- 22. Other considerations Type and cross-match if necessary. Take blood (and other) cultures if necessary. Aspirate stomach contents if comatose. Catheterize if needed for accurate urine output measurement. Keep patient nil by mouth.
- 23. Complications Attributable to the Treatment of DKA Premature discontinuation of insulin may result in persistence and worsening of ketoacidosis. Cerebral oedema may occur, particularly in children: ∘ Rapid correction of hyperglycaemia ∘ Excessive amounts of hypotonic fluid. Early feeding may lead to vomiting and aspiration pneumonia. Too aggressive fluid replacement may induce congestive heart failure.
- 24. Mortality Mortality from DKA when there is a delay in treatment still remains high and may reach 5%. Major causes of mortality are associated with medical co- morbidities that precipitate DKA. Prevention of DKA and sick day guidelines remain the most important aspects of management.
- 25. Prevention Patients should be given the following advice: Measure blood glucose at least four times a day. Depending on blood glucose results, take an extra-short- acting insulin. Replace food with plenty of sugar-free liquids. If blood glucose persists at ≥17 mmol/L, contact your doctor.