2. INTRODUCTION
• 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.
• Described by Dr. Julius Dreschfeld in 1886.
3. DEFINITION
• DKA is an extreme metabolic state caused by insulin deficiency. It is
defined as an acute state of severe uncontrolled diabetes associated
with ketoacidosis that requires emergency treatment.
• It is a state of absolute or relative insulin deficiency aggravated by
ensuing hyperglycemia, dehydration and acidosis-producing
derangements in intermediary metabolism.
4. DIAGNOSIS
• Triad of hyperglycemia, high anion gap metabolic acidosis and
ketonemia.
ADA(2009)
• Glucose> 13.9 mmol/L (250 mg/dl).
• Bicarbonate< 18mmol/L; pH< 7.3.
• Ketones positive result for urine or serum ketones by nitroprusside
reaction.
JBDS (2013)
• Glucose> 11 mmol/L (200 mg/dl) or known Diabetes.
• Bicarbonate< 15mmol/L or pH< 7.3 or both.
• Ketones> 3mmol/L or (++) in urine dipstick.
5. EPIDEMIOLOGY
• DKA accounts for 14% of all hospital admissions of patients with
diabetes and 16% of all diabetes-related fatalities.
• DKA is frequently observed in diagnosis of type 1 diabetes and often
indicates this diagnosis (3%).
• The overall mortality rate for DKA is 0.2-2%, being at the highest in
developing countries.
• The incidence of DKAin developing countries is higher.
• It is far more common in young patients.
6. PATHOPHYSIOLOGY
• DKA is a complex disordered metabolic state characterized by
hyperglycemia, ketoacidosis and ketonuria.
• It usually occurs as a consequence of absolute or relative insulin
deficiency that is accompanied by an increase in counter-regulatory
hormones (i.e, glucagon, cortisol, growth hormone, epinephrine).
• This imbalance enhances hepatic gluconeogenesis, glycogenolysis,
lipolysis and ketogenesis.
9. CLINICALPRESENTATION:SYMPTOMS
• DKAusually evolves rapidly, over a 24 hour period.
• Earliest symptoms are polyuria, polydipsia and weight loss.
• Nausea, vomiting and abdominal pain are usually present.
• Malaise, generalized weakness and fatigability.
• As the duration of hyperglycemia progresses, neurologic symptoms,
including lethargy, focal signs, and obtundation can develop. Frank
coma is uncommon in DKA.
11. LABORATORYEVALUATION
• Blood test for glucose every 1-2 hour.
• ABG/ VBG.
• Serum electrolytes (includes phosphate)
• Renal function test.
• Urine dipstick test (acetoacetate).
• Serum ketones (3-hydroxybetabutyrate).
• CBC.
• Anion gap.
• Osmolarity.
• Cultures.
• Amylase.
Repeat lab investigations are key!
12.
13. MANAGEMENT
• Correction of fluid loss with intravenous fluids.
• Correction of hyperglycemia with insulin.
• Correction of electrolyte disturbances, particularly potassium loss.
• Correction of acid-base balance.
• Treatment of concurrent infection, if present.
15. CORRECTIONOFFLUIDLOSS
• It is a critical part of treating patients with DKA.
• Use of isotonic saline.
• 15-20mL/kg/hour for the first few hours.
• Recommended schedule:
• Administer 1-3 L during first hour.
• Administer 1 L during second hour.
• Administer 1 L during the following 2 hours.
• Administer 1 L every 4 hours, depending on the degree of dehydration and
CVP.
• When patient becomes euvolemic, switch to 0.45% saline is
recommended, particularly if hypernatremia exists.
16.
17. INSULINTHERAPY
• Insulin therapy to be initiated only if potassium levels are above 3.3 mEq/L.
• Intravenous regular insulin preferred.
• Initiated with IV bolus of regular insulin (0.1 units/kg) followed by continuous
infusion of regular insulin of 0.1 units/kg/hour.
• SC route may be taken in uncomplicated DKA (0.3 U/kg then 0.2 U/kg one
hour later).
• When serum glucose reaches 200 mg/dl, reduce insulin infusion to 0.02-0.03
U/kg/hour and switch the IV saline solution to dextrose in saline.
• Revert to SC insulin, after patient begins to eat (continue IV infusion
simultaneously for 1 to 2 hours).
18. POTASSIUMREPLACEMENT
• If the initial serum potassium is below 3.3 mEq/L, IV potassium chloride
is started with saline (20 to 40 mEq/hour).
• If the initial serum potassium is between 3.3 and 5.3 mEq/L, IV KCl (20
to 30 mEq) is added to each liter of IV replacement fluid and continued
until the serum potassium concentration has increased to the 4.0 to 5.0
mEq/L range.
• If the serum potassium is initially greater than 5.3 mEq/L, then
potassium replacement should be delayed.
19. CORRECTIONOFACIDOSIS
• Bicarbonate therapy is a bone of contention among physicians and still
remains a controversial subject, as clear evidence of benefit is lacking.
• Bicarbonate therapy is only administered if the arterial pH is less than
6.9.
• 100 mEq of sodium bicarbonate in 400 mL sterile water is administered
over two hours. Repeat doses until pH rises above 7.0.
• Bicarbonate therapy has several potential harmful effects.
21. TOPICSOFDISCUSSION
• ABGor VBG?
• Bicarbonate therapy: to use or not to use?
• Insulin when?
• Utility of insulin bolus.
• Which Insulin?
• Insulin How?
• Transition from IV to SC insulin.
• Euglycemic DKA: It’s not a myth.
• Which fluid?
22. ABGORVBG?
THECASEFORVENOUSRATHERTHANARTERIALBLOODGASESINDIABETIC
KETOACIDOSIS- KellyAMet al (2006).
• There is reasonable evidence that venous and arterial pH have sufficient
agreement as to be clinically interchangeable in patients with DKA who are
hemodynamically stable and without respiratory failure.
ARTERIALBLOODGASRESULTSRARELYINFLUENCEEMERGENCYPHYSICIAN
MANAGEMENTOFPATIENTSWITHSUSPECTEDDIABETICKETOACIDOSIS-
Ma OJ et al (2003).
• ABG results rarely influenced emergency physicians' decisions on diagnosis,
treatment, or disposition in suspected DKA patients. Venous pH correlated
well and was precise enough with arterial pH to serve as a substitute.
23. ABGORVBG
Other Reasons:
• ABGs can cause radial artery spasm, infarct, and/or aneurysms
• ABGs are painful to patients, even more so than IV access
• By the way, when is the last time you checked a Modified Allen’s
Test before doing a radial ABG?
The VBG-electrolytes were 97.8% sensitive and 100% specific for the
diagnosis of DKAin hyperglycemic patients (Menchine M et al., 2011).
24. BICARBONATETHERAPY
BICARBONATEINDIABETICKETOACIDOSIS:ASYSTEMATICREVIEW-Chuaetal
(2011).
• Transient improvement in metabolic acidosis.
• No improved glycemic control.
• Risk of cerebral edema in pediatric patients.
• No studies with pH <6.85.
INTRAVENOUSSODIUMBICARBONATETHERAPYINSEVERELYACIDOTIC
DIABETICKETOACIDOSIS- Duhonet al (2013).
• No Difference In: Time to resolution of acidemia, time to hospital discharge,
time on IV insulin, potassium requirement in first 24hrs.
• Subgroup Analysis of pH < 6.9 showed no statistical difference in time to
resolution of acidemia.
27. UTILITYOFINSULINBOLUS
UTILITYOFINITIALBOLUSINSULININTHETREATMENTOFDIABETIC
KETOACIDOSIS– Goyal et al (2010).
• Insulin bolus at the start of an insulin infusion IS EQUIVALENT to no
insulin bolus at the start of an insulin infusion in several endpoints
including:
• Decrease normalization of glucose
• Affect the rate of change of anion gap
• Reduce ED or hospital length of stay
• Insulin bolus at the start of an insulin infusion DOES:
• Increase hypoglycemic events by 6 fold (6% vs 1%).
29. INSULINHOW?
DIABETICKETOACIDOSIS:LOW-DOSEINSULINTHERAPYBYVARIOUS
ROUTES- Fisher JN et al (1977).
• Intravenous infusion of Insulin is superior to subcutaneous route.
TREATMENTOFDIABETICKETOACIDOSISWITHSUBCUTANEOUSINSULIN
ASPART- Umpierrez et al (2004).
• The use of subcutaneous insulin Aspart every 1 or 2 h represents a safe
and effective alternative to the use of intravenous regular insulin in the
management of patients with uncomplicated DKA.
30. INSULINHOW?
EFFICACYOFSUBCUTANEOUSINSULINLISPROVERSUSCONTINUOUS
INTRAVENOUSREGULARINSULINFORTHETREATMENTOFPATIENTSWITH
DIABETIC KETOACIDOSIS- Umipierrezet al (2004).
• Treatment of uncomplicated DKA with SC lispro every hour in a non-intensive
care setting may be safe and more cost-effective than treatment with IV
regular insulin in the intensive care unit.
SUBCUTANEOUSLISPROANDINTRAVENOUSREGULARINSULINTREATMENTS
AREEQUALLYEFFECTIVEANDSAFEFORTHETREATMENTOFMILDAND
MODERATEDIABETICKETOACIDOSISINADULTPATIENTS-Ersozetal(2006).
• Treatment of mild and moderate DKA with SC insulin lispro is equally effective
and safe in comparison with IV regular insulin.
31. TRANSITIONFROMIVTOSC
BRIDGEOVERTROUBLEDWATERS:SAFEANDEFFECTIVETRANSITIONSOFTHE
INPATIENTWITHHYPERGLYCEMIA- O’Malley et al (2008).
• First dose of SC insulin to be given atleast 1 hour prior to discontinuation of IV insulin
infusion, failing which allows development of rapid rebound hyperglycemia.
TRANSITIONFROMINTRAVENOUSTOSUBCUTANEOUSINSULIN:EFFECTIVENESSAND
SAFETYOFASTANDARDIZEDPROTOCOL-Avanziniet al (2011).
• Stable blood glucoses which are less than 180 mg/dL for at least 4–6 h consecutively
(Some studies suggest 24 hours).
• Normal anion gap and resolution of acidosis in DKA.
• Stable clinical status; hemodynamic stability.
• Not on Vasopressors.
• Stable nutrition plan or patient is eating.
• Stable IV drip rates (low variability).
32. EUGLYCEMICDKA:IT’SNOTAMYTH!
• It is essentially DKAwithout hyperglycemia (Glucose< 200).
• Euglycemic DKA is a rare entity that mostly occurs in patients with Type
1 Diabetes, but also in Type 2 Diabetes.
• It has been associated with partial treatment of diabetes, carbohydrate
food restriction, alcohol intake, and with Sodium-Glucose Cotransporter
2 (SGLT-2) inhibitor medications [Glifozins].
• The exact mechanism of euDKA is not entirely known.
35. WHICHFLUIDTOUSE?
PLASMA-LYTE148VS0.9%SALINEFORFLUIDRESUSCITATIONIN
DIABETICKETOACIDOSIS- Chuaet al. (2012)
• PL had faster initial resolution of metabolic acidosis and less
hyperchloremia, with a transiently improved blood pressure profile and
urine output.
RESUSCITATIONWITHBALANCEDELECTROLYTESOLUTIONPREVENTS
HYPERCHLOREMICMETABOLICACIDOSISINPATIENTSWITHDIABETIC
KETOACIDOSIS- Mahleret al (2011).
• Resuscitation of DKA patients with BES results in lower serum
chloride and higher bicarbonate levels than patients receiving NS,
consistent with prevention of hyperchloremic metabolic acidosis.