3. INTRODUCTION
Diabetic ketoacidosis ( DKA ) is acute,life
threatining complication of diabetes
mellitus.
DKA Occurs in Predominantly in Type 1
DM
10% to 30 % in Newly diagnosed Type 2
DM.
4. PATHOPHYSIOLOGY
DKA is complex relation between insulin and
counterregulatory hormones.
Counter regulatory hormone include glucagon
catecholamine, cortisol , growth hormone.
It is a response to cellular starvation brought on
by relative insulin defeciency and
counterregulatory or catabolic hormone excess.
16. Laboratory Testing
Rapid bedside glucose determination - For hyperglycemia
Urine test strip - For ketone
ECG - For hyperkalemia
CBC - For Hb
Serum electrolytes - For electolytes imbalance
BUN and creatinine – For kidney function
Urine analysis - For osmolarity and ph , infection
Venous blood gas - For acid base disoder
Calculate anion gap - For electolyte imbalance
Blood cultures - For infection managment
ABG - For acid base balance
17. Treatment of DKA
The goals of therapy
A second IV line with 0.45% normal saline at minimal rate to keep the line open .
Begin at least one large bore IV infusion of NS / collect lab sample
Place patients on a cardiac monitor ,ECG ,Urine/serum ketones
Aggressive fluid therapy should be initiated before receiving results
The diagnosis of DKA should be suspected at triage,brief h/o/exa
18. The goals of therapy
1. Volume replacement
2. Correction of hyperglycemia
3. Correction if electrolyte and
acid-base imbalances
4. Recognition and treatment of
causes
5. Avoidance of complication
21. 0 to 1 hour
Brief history / examination
Monitor , glucose,ECG,Urine/serum
ketones
iv #1 NS 15-20 ml/kg/h for first hour
# 2 0.5 NS to keep vein open
send electrolytes,VBG, blood/urine
culture
Comments
if glucose >
250,urine +
ketones assume
DKA search for
precipitant,
infection
Check ECG for
hyperkalemia ,
infraction
Foly
catheter as
needed
Begin flow
sheet of vital
signs mental
Status , BS
lytes , AG
venous ,Ph,i/o
.
22. 1 hour to 2 hour
If initial [k+] > 5.2 initial IV infusion of
regular insulin at 0.1-0.14 units/kg/hr
if initial [k+] >3.3to <5.2 and urine outout
add 20-30 mEq of k+ to each liter of fluid
and insulin drip as above
if initial [k+]<3.3 hold insulin drip and give
k+ @ 20-30 mEq/h until [k+]>3.3 than
insulin drip as above
Comments
Initial lytes;-check
osmolarity,AG,BS,
corrected
[Na+],potassium
Initial [k+]
determinee further
therapy adequate
urine output is
essential before
initial K+ therapy
Repet glu,lytes AG -
If AG > 25 OR
GLUCOSE >800 OR
Significants
comorbidity
,consider ICU
disposition
23. 2 hours to 3 hours
After NS bolus give 0.45 NS @
25-500ml/h with k+ supplement
as above if hyponatremia
continue NS 250-500 ml
if ph <6.9 may give NaHCO3
Comments
Rate of hydration
depends on
hemodynamics,hy
dration status ,
urine output
If ph > 6.9
do not
require
NaHCO3
Check glu ,
lytes , ABG
,VBG ,mental
status, urine
o/p
24. 3 to 4 hours
Active -- adequate fluid infusion
Goal -- insulin infusion
-maintain [k+] 3.3-5.2
-lower glu by 75 mg/dl/h
-maintain adequate lytes.
When CBG apporaches 200 change iv
D5 NS WITH 20-40 mEq kcl / L and
decrease insulin rate to 0.2-0.05
units/kg/h
Comments
If blood sugar does
not decrease by 10%
after 1 hour insulin
therapy,give 0.14
units/kg bolus then
resume previos rate
If blood sugar
decreased faster
than 50-75 mg/dl/h
,decreased insulin
drip
Check glucose
hourly
25. 4-12 hours to 12-24 hours
maintains serum glu 180-200 and
continue insulin drip for at least 12
hours or until DKA resolves : glu < 200
and AG normal ph > 7.3 and HCO3 >15
Patient able to eat give sc short and
long acting insulin.
Comments
In young and new
onset diabetes avoid
excess free water ,
monitor carefully for
devlopments of
cerebral edema and
have manitol bedside
Recheck lytes , glu ,
AG , repet 4 hourls
Complications-
Refractory acidosis
,cerebral
edema,vascular
thrombosis,ARDS
26. Related to acute disease Related to therapy
Complication
Loss of
airway
Sepsis
Myocardial
infraction
Hypovolemic
shock
Hypokalemia
Hypophosp
hatemia
Acute
respiratory
distress
syndrome
Cerebral
edema
Hypoglyce
mia
OSMATIC DIAURSIS –increased the urination rate caused by the presence of certain substance in the small tubes of the kidney such as glucose enter in tubules and cannot be reabsorbed.
Prerenal azotemia –is the most common cause of renal failure due to lack of blood flow to the each kidney
Anion gap – difference b/n cation and anion in the serum , plasma or urine ( na+k)-(cl+hco3) normal
Normal saline is the most frequently recommended fluid
Fluid helps restore intravascular volume and normal tonicity , perfuse ,vital organ , improve GFR and lower serum glucose and ketone level.
Normal saline does not provides “free water to correct intracellular fluid loss but it does prevent the rapid fall in extracellular osmolarity.
After initial NS replacement change the fluids to 0.45% NS once the corrected serum Na is normal.
Based on clincal finding and before electrilyte results give the iv bolus
of isotonic saline -15 to 20 ml / kg / h during first hour.
