Diabetic ketoacedosis

1. Diabetic Ketoacidosis
(DKA)
Prepared by :
Rasti Hussein Mohammed
Supervised by :
Dr. Alan Abdulla Abdulrahman

2. Diabetic Ketoacidosis :
Diabetic ketoacidosis (DKA) is an acute, major, life-threatening
complication of diabetes that mainly occurs in patients with type 1
diabetes, but it is not uncommon in some patients with type 2
diabetes. This condition is a complex disordered metabolic state
characterized by hyperglycemia, ketoacidosis, and ketonuria.

3. Criteria for DKA :
1-hyperglycemia (>200 mg/dL)
2-acidosis: bicarbonate < 15mmol/L)
3-evidence of an accumulation of ketoacids in the blood
(measurable serum or urine)

4. When DKA happen :
When the clinical features of new-onset DM1 are not detected
In diabetic patients with known DM1 if insulin injections are omitted
During an intercurrent illness

5. Polyuria
Polydipsia
Nausea, and vomiting
Abdominal pain
Dehydration (all cases of DKA should be considered as having
8.5% dehydration )
Kussmaul respiration
The fruity odor
Altered mental status can occur, ranging from disorientation to
coma
Fever is unusual
Clinical manifestations :

6. Laboratory studies :
Hyperglycemia (serum glucose concentrations ranging from 200
mg/dL to >1000 mg/dL)
Arterial pH is below 7.30
Serum bicarbonate less than 15 mEq/L
Serum sodium concentrations may be low
Blood urea nitrogen (BUN) can be elevated
Phosphate depletion

7. Treatment :
DKA is one of the emergencies , so if the patient has disturbed level
of consciousness or is in coma establish basic life support:
1. Airway, breathing, circulation (put 2 cannulas, 1 for insulin and 1
for fluid)
2. Urinary catheter
3. Give 20 mL/kg N/S in 1 hour

8. Generally treatments include :
1. IV fluid
2. Insulin
3. Potassium
4. Antibiotic

9. 1- IV fluid
Total amount = (85 mL/kg + maintenance)/24 hr , ½ of this is given
within 12 hr – bolus given in basic life support , the other ½ is given
within the next 12 hr.
If the patient is hypernatremic they should be rehydrated slowly
over 48 hr.
Continue on N/S or ½ N/S , if available till blood sugar is < 250
mg/dL then add 5% dextrose.

11. 2- Insulin
Blood sugar
(mg/dL)
Unit/kg of
insulin
> 600 0.1
300-600 0.05
Give immediately with IV fluid by infusion per 1 hr.
Note: Mix 25 units of insulin with 250 mL N/S. In this way each
mL will contain 0.1 unit. Thus you can give 1 cc/kg/hr .

12. 3-Potassium
Potassium should be added after the 1st hr of treatment by giving 1 mEq/kg
of potassium phosphate if available.
If this is not available then give KCl as follows :
Serum K+ 3.5-5 → give 20 mmole/L.
Serum K+ < 3 → give 40 mmole/L and do an ECG.
If the patient is hyperkalemic , potassium should not be given and they
should be followed up.

13. 4-Antibiotic
 Give ceftriaxone or amoxiclave to cover
underlying infections.

14. Follow up :
1- If there is improvement
2-If there is no improvement

15. 1- If there is improvement :
Which mean (no emesis, improved consciousness, can take orally,
acidosis corrected)
Blood sugar
(mg/dL)
Unit/kg soluble
insulin
< 100 0
100–200 0.1 u/kg
200–300 0.2 u/kg
300–400 0.3 u/kg
400–500 0.4 u/kg
> 500 0.5 u/kg
1. Stop IV fluid and start oral feeding.
2. Stop IV insulin and change to sliding scale.
 Measure blood sugar every 6 hr then given insulin accordingly. Continue on
IV insulin untill ½ hr after subcutaneous insulin has been restarted.

16. 2-If there is no improvement
1. Exclude hypoglycemia.
2. Are there signs of ↑ ICP (e.g. apnea, bradycardia, seizure, papilledema,
deterioration, ↓ LOC)? Consider cerebral edema and send for a CT scan.

17. Treat ↑ ICP:
1. Elevate head
2. Mannitol 0.5–1 g/kg/hr
3. Intubate & hyperventilate
4. NaHCO3 is indicated only if severe acidosis (pH 6.95)

18. Complications :
1. Cerebral edema
2. Intracranial thrombosis or infarction
3. Acute tubular necrosis with acute renal failure
4. Arrhythmias
5. Pulmonary edema
6. Peripheral edema
7. Death

19. Prognosis :
 The reported mortality rates is 0.15 to 0.3%
 Once cerebral edema develops, death occurs in some 20–80%
 Pituitary insufficiency, occurs in 10 –25% of survivors
 Overall, cerebral edema accounts for 60–90% of all DKA-related
deaths in children.