diabetic ketoacidodis is a complicaton which is seen in type 1 patient.

1. MANAGEMENT OF DIABETIC
KETOACIDOSIS
KEERTHIKA.V
1 ST YEAR
PERIODONTICS AND IMPLANTOLOGY

2. CONTENTS
 Introduction
 Causes
 Pathophysiology
 Symptoms
 Diagnosis
 Management

3. DIABETIC KETOACIDOSIS
 Diabetic ketoacidosis is an acute, major, life-threatening complication of
diabetes.DKA mainly occurs in patient with type I diabetes, but it is also not
uncommon in some patients with type 2diabetes.
 Also it can be the very initial presentation of the previously undiagnosed pt with
type 1 diabetic mellitus.
 This condition is a complex disordered metabolic state characterized by
hyperglycemia, ketoacidosis, and ketouria.

4. CAUSES OF DKA
TYPE I DIABETIC MELLITUS
 In 25% of patients, DKA is present at
diagnosis of type 1 diabetes due to
acute insulin deficiency.
 Poor compliance with insulin.
 Bacterial infection and recurrent
illness[eg,urinary tract infection[UTI],
vomiting]
 Medical,surgical, or emotional stress.
 Idiopathic
TYPE II DIABETIC
MELLITUS
 Intercurrent illness [eg.myocardial
infarction,pneumonia,prostatitis,UTI].
 Medication[eg,corticosteroids,pentami
dine,clozapine.]

8.  Diabetic ketoacidosis[DKA] usually evolves rapidly, over 24-hr period.
 The earliest symptoms of marked hyperglycemia are polyuria, polydipsia, and
weight loss

9.  Dehydration
 Acidotic [Kussmaul’s]breathing, with a fruity smell[acetone].
 Abdominal pain or distension.
 Vomiting.
 An altered mental status ranging from disorientation to coma.
 Blood pressure and pulse.
 Temperature.

10. TO DIAGNOSE DKA ,THE FOLLOWING CRITERIA MUST BE FULFILLED.
The American Diabetes association diagnostic criteria for DKA are as follow:
 Elevated serum glucose level
 An elevated serum ketone level.
 A PH less than 7.3 and
 A serum bicarbonate level less than 18 mEq per L

12. MANAGEMENT
PRINCIPLES OF MANAGEMENT OF DIABETIC
KETOACIDOSIS
 Rapid correction of dehydration.
 Rapidly acting regular insulin,early and enough.
 Correction of acidosis.
 Treatment of precipitating cause, if found.
 Correction of hypokalemia and hypophosphatemia.
 Nursing management.
 Measure capillary glucose every 1-2 h and electrolytes every 4h for 24h.

13. DKA
INSULIN
BICARBONATES
INFUSION
ELECTROLYTES FLUIDS

14. FLUID
REPLACEMENT

15. FLUID REPLACEMENT
 Determine hydration status:
Hypovolemic shock
Administer 0.9% saline, Ringer’s lactate or a plasma expander as a bolus dose of
15-20 ml/kg. This can be repeated if the state of shock persists.

16.  Dehydration without shock ;
1. Adminster 0.9% Saline4-14 ml/kg/hr for an initial hr, to restore blood volume and
renal perfusion.
2. If serum sodium is high or normal start with 0.45% saline.
When serum glucose reaches 250mg/dl change fluid to 5% dextrose with 0.45% saline,at a
rate that allow complete restoration in 48 hrs, and to maintain glucose at 150-250
mg/dl.

17. INSULIN THERAPY

18.  Start regular insulin 0.5 unit/kg as IV Bolus.
 Start infusing regular insulin at a rate of 0.1%/kg/hr using a syringe pump.Optimally,
serum glucose should decrease in a rate no faster than 100mg/dl/hr.
 If serum glucose falls <200 prior to correction of acidosis, change IV fluid from D5 to
D10, but don’t decrease the rate of insulin infusion.

19. CORRECTION OF ELECTROLYTE IMBALANCE
 Regardless of K conc.at presentation,total body K is low.So, as soon as the
urine output is restored potassium supplementation must be added to Iv fluid at
a conc. Of 20-40 mmol/l, where 50% of it given as KCL, and the rest as
potassium phosphate, this will provide phosphate for repalcement, and avoids
excess phosphate[may precipitate hypocalcaemia].

20. POTASSIUM AND PHOSPHATE
 If k conc.<3.3mEq/l,administer 40mEq/l of KCL in IV saline over 1
hr.Withhold insulin until K conc.becomes >3.3mEq/l and moniter K
conc.hourly.
 If serum potassium is 5 or more,do not give potassium recheck in every2 hrs.
 If initial potassium is > 3.3 but < 5mEq/l give 20-30mEq/l of K in each liter in
each liter of Iv fluids[2/3 as KCL and 1/3 as KPO4 to keep K to 4-5mEq/l].

21. BICARBONATE
 If ph<6.9
Bicarbonate [100 osmol] dilute in 400 ml of H2O.infused at 200 ml/h.
 If ph <6.9-7.0
Bicarbonate [50 osmol] dilute in 200ml of H2O.
Infused at 200ml/h
 If ph >7
No bicarbonate.

22. MONITORING
 A flow chart must be used to moniter fluid balance and lab measures.
 Serum glucose must be measured hourly.
 Electrolyte also 2-3 hourly.
 Ca,Mg,and phosphate must be measured initially and atleast once during
therapy.
 Neurological and mental state must examined frequently and any complaints of
headache or deterioration of mental status should prompt rapid evaluation for
possible cerebral edema.

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