This document discusses diabetic ketoacidosis (DKA), providing information on its pathophysiology, causes, symptoms, diagnosis, complications and management. DKA is a serious complication of diabetes characterized by hyperglycemia, acidosis and ketonemia. It occurs due to insulin deficiency and increased counter-regulatory hormones, leading to altered glucose and lipid metabolism. Common causes include missed or irregular insulin doses. Treatment involves fluid replacement, insulin therapy, and monitoring for and correcting acid-base disturbances and electrolyte imbalances to prevent complications like cerebral edema. Nursing responsibilities include close monitoring of vital signs, labs, intake/output and providing supportive care.

1. DIABETIC KETO-ACIDOSIS
MEANING ,
COMPLICATIONS,TYPES&
MANAGEMENT FOR NURSES
MURUGESH H J ,RN
KFCH ICU 02 JIZAN
SAUDI ARABIA

2. DIABETIC KETO-ACIDOSIS …..
Diabetic ketoacidosis (DKA) is a serious and
potentially life threatening complication of diabetes
(Joint British Diabetes Societies, 2013).
***It is a complex disordered metabolic state
characterised by hyperglycaemia (elevated blood
glucose), acidosis (pH imbalance) and ketonaemia
(excess ketones in the blood)…
KETONE + ACIDOSIS = ALTERERD HOMIOSTASIS

3. PATHOPHYSIOLOGY ….
Pathophysiology ….
DKA results from a dysregulation of carbohydrates,
protein and lipid metabolism (Yehia et al, 2008) and
usually occurs as a consequence of absolute or relative
insulin deficiency accompanied by an increase in
counter-regulatory hormones (glucagon,
catecholamine, cortisol, growth hormones and
epinephrine), which contribute to increased blood
glucose levels and insulin resistance…
INSULIN DEFICIENCY----ALTERED HORMONAL
FUNCTION----INSULIN RESISTANCE---
HYPERGLYCEMIA

4. CAUSES..
IMPORTANT CAUSES ARE
*** SKIP OR IRREGURARLY INSULIN INTAKE
*** TYPE 01 OR TYPE DIABETIS MELLITUS
*** KINK OR SUDDEN STOPPING OF INSULIN INFUSION
***SECONDARY TO RESPIRATORY INFECIONS example ARDS OR SEPSIS OR
CARDIAC PROBLEMS SUCH AS MI, ANGINA ETC…

5. IMPORTANT POINTS….
*** The majority of patients presenting with diabetic ketoacidosis have type 1
diabetes…
***Patients with type 2 diabetes can develop DKA, especially during acute illnes
..
*** Infection is the most common precipitating factor for DKA
***Clinical signs of DKA include polyuria, polydipsia, weakness, fatigue, weight
loss, vomiting and abdominal pain
***DKA is a medical emergency
Norma values
● Ketonaemia ≥3mmol/L (normal values: 2+ on standard urine dipstick)
● Blood glucose >11mmol/L (normal values: 3.5-7.8mmol/L) or known diabetes
● Bicarbonate blood levels (HCO3) <15
PH <7.3, ACIDOSIS

6. HOW IT OCCURS …
***The combination of insulin deficiency and increased
counter-regulatory hormones leads to alteration in glucose
production and use, increased lipolysis (breakdown of fatty
acids to form alternate source of energy) and production of
ketone bodies (Umpierrez et al, 2002)
****An increase in hepatic gluconeogenesis (production of
glucose from non-carbohydrate sources) and
glycogenolysis (breakdown of glycogen to glucose), renal
glucose production and impaired glucose use in peripheral
tissues leads to severe hyperglycaemia (JBDS, 2010). ..

7. HOW IT OCCURS…
***An increase in free fatty acids in circulation as a result of
lipolysis enhances hepatic production of ketone bodies, which
result in ketonaemia and metabolic acidosis (Kitabachi et al,
2004)…
Dehydration and electrolyte imbalances occur in DKA as a result
of several mechanisms. Hyperglycaemia causes fluid and
electrolytes to shift from the intracellular to the extracellular
space, leading to cellular dehydration and electrolyte imbalance
example hypokalemia . Both hyperglycaemia and high ketone
levels also cause osmotic diuresis, resulting in further
dehydration; vomiting is commonly associated with DKA and
contributes to fluid depletion and electrolyte imbalances (JBDS,
2013).

8. COMMON SYMPTOMS OF DKA …
Symptoms of DKA can appear quickly and may include:
•** frequent urination **extreme thirst
•** high blood sugar levels ** high levels of ketones in the urine
•** nausea or vomiting ** abdominal pain
•** Confusion **fruity-smelling breath
** a flushed face ** fatigue
•**rapid breathing **dry mouth and skin

9. Pathophysiology, Signs and Symptoms of DKA
Conditions associated with diabetic ketoacidosis are….
. ● Diuresis: High serum glucose causes an osmotic diuresis. U/O >
200-400ML/HR
● Electrolyte disturbances: Osmotic diuresis, nausea, and vomiting
cause loss of calcium, magnesium, phosphate, and potassium.
Metabolic acidosis causes potassium to move from the intracellular
space to the extracellular space…
● Increased metabolic rate: The increased metabolic rate of DKA is
caused by increased/excessive glycogenolysis and gluconeogenesis,
increased respiratory rate, dehydration, elevated levels of circulating
catecholamines, and other physiologic demands of DKA.
● Increased respiratory rate: Compensation for metabolic acidosis. ●
Metabolic acidosis: Breakdown of ketone bodies.
● Nausea and vomiting: Caused by metabolic acidosis, worsens
dehydration.

10. BASED ON SEVERITY TYPES OF
DKA ….
01.MILD DKA
Glucose: > 250 mg/dL Ketones: Positive Arteria
l pH: 7.25-7.30 Bicarbonate: 15-18 mEq/L
Anion gap: >10 Elevated serum osmolality ………..
02.MODERATE DKA
Glucose: > 250 mg/dL ,, Ketones: Positive ,, Arterial pH: 7.00-7.24
,,,Bicarbonate: 10 - < 15 mEq/L ,,, Anion gap: >12 Elevated serum
osmolality ……..
03.SEVERE DKA
Glucose: > 250 mg/Dl,,, Ketones: Positive ,,,Arterial pH: < 7.00
Bicarbonate: < 10,,,, Anion gap: >12 Elevated serum osmolality…..

11. DIAGNOSIS…..
**URINE KETONE DIPSTICK STUDY
**URINE ANALYSIS
*** LAB STUDIES● HBA1c level ● Serum glucose ● Serum ketones ●
Urine ketones ● Arterial or venous blood gas ● Serum electrolytes ●
Bun and creatinine ● Serum lactate level ● Serum osmolality ● Serum
calcium, magnesium, and phosphate
***12-LEAD ECG ELECTROLYTES CHANGES
*** CT scan of the head TO IDENTIFY CEREBRAL EDEMA

12. COMPLICATIONS & MANAGEMENT
…
EARLY DETECTION & PROMPT MANAGEMENT IS VITAL TO AVOID
COMPLICATIONS OF DKA …..
EXAMPLES ARE Complications of DKA (aside from those
previously discussed) include, but are not limited to cerebral
edema, renal failure, rhabdomyolysis, QTc prolongation, and
stroke. Many of these are more common in children than adults,
i.e., cerebral edema.Cerebral edema is a particularly serious
complication of DKA.
The primary complications of DKA treatment are hypoglycemia,
hyperkalemia, and fluid overload. These can be prevented with
conscientious monitoring of serum glucose, serum potassium,
and the patient’s fluid status

13. TREATMENT FOR DIABETIC
KETOACIDOSIS….
Treatment of DKA should be focused on
1) fluid replacement,
2) insulin therapy,
3) monitoring for and correcting acid-base disturbances, electrolyte
imbalances, and complications
4) the assessment for, and treatment of comorbid conditions and
precipitating factors.

14. PROTOCAL FOR MANAGING DKA…

15. NURSING RESPONSIBILITIES..
***MONITOR VITAL SIGNS , INTAKE OUTPUT CHART & STRICT GCS
ASSESSMENT
****HOURLY RBS , 4TH HOURLY ABG , 6TH SERUM ELECTROLYTES LAB
INVESTIGATION, URINE KETONE DIPSTICK STUDY 6TH HOURLY
***FLIUD REPLACEMENT , INSULIN ADJUSTMENT , ELECTROLYTES
CORRECTION AS PER PHYSICIAN ORDER
****NUTRITION MANAGEMENT
*** PSYCHOLOGICAL & FAMILY SUPPORT

16. THANK YOU
ALL