Diabetic ketoacidosis
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This document describes a case of diabetic ketoacidosis (DKA) in a 32-year-old male patient presenting with vomiting, drowsiness, abdominal pain, fever and cough. On examination, the patient showed signs of dehydration and mild abdominal tenderness. Laboratory findings confirmed hyperglycemia, acidosis, ketonemia and electrolyte abnormalities. The patient was diagnosed with DKA and treated with IV fluids, insulin, electrolyte replacement, and antibiotics for the concurrent infection, with the goals of correcting dehydration, hyperglycemia, acidosis and electrolyte disturbances. Complications of DKA and the importance of patient education are also discussed.
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Diabetic ketoacidosis
- 2. Diabetic Ketoacidosis DR TARIQUE AHMED MAKA
- 3. Case Scenario • Name: XYZ • Age: 32 yrs • Gender: Male Presenting complaint: Vomiting , drowsiness and pain abdomen― 6 hrs Fever and cough ― 2 days
- 4. Examination Findings Pulse: 104/min B.P: 100/70mmHg Temp: 102.2⁰ F R/R: 24/min BSR: Hi
- 5. Examination Findings Dry mucous membranes and poor skin turgor Slightly confused Chest: Rales in right lower chest Abdomen: Mild generalized tenderness
- 6. Lab Findings TLC: 18x10⁹/L BSR: 450mg/dl Na+: 152mEq/L K⁺: 5-8mEq/L Urea: 10.2mmol/L Creatinine: 1.4mg/dl
- 7. Contd. ABGs: pH: 6.9 pO2 : 95mmHg pCO2: 28mmHg HCO3 : 9mEq/L SpO2: 98% Urine Ketones: +++
- 9. DKA Essentials of diagnosis: • Hyperglycemia : BSR > 250mg/dl • Acidosis with pH < 7.3 • Serum Bicarbonate < 15 mEq/L • Serum positive for ketones
- 10. Mortality rates • < 5 % in individuals under 40 years • > 20 % in elderly with poor prognosis
- 11. Precipitating Factors • Infection • Trauma • Surgical procedure • MI
- 12. Signs and Symptoms Symptoms: • Polyuria • Polydipsia • Fatigue • Nausea • Vomiting • Abdominal pain • Stupor • Coma
- 13. Signs: • Ill appearance • Dehydration • Rapid deep breathing • Fruity breath • Hypotension • Tachycardia • Fever • Abdominal tenderness
- 14. Lab Findings • Plasma Glucose: 350 to 900 mg/dl • Serum Ketones : positive • Hyperkalemia (K⁺= 5-8 mEq/L) • Slight Hyponatremia (Na⁺= 130 mEq/L) • Acidosis (pH: 6.9-7.2)
- 16. Differential Diagnosis Hyperglycemic Hyperosmolar state Lactic Acidosis Septic shock
- 17. Pathophysiology
- 18. Management General Management: • NG intubation • Foley's catheterization • CVP catheterization • Vital signs, input and output monitoring • BSR monitoring ― Hourly • Electrolytes and pH ― 2-3 hourly
- 19. Management Specific Management: Goals : • Correction of fluid loss (ē IV fluids) • Correction of hyperglycemia (ē insulin) • Correction of electrolyte disturbances (particularly K⁺ loss) • Correction of acid-base balance • Treatment of concurrent infection
- 20. Correction of fluid loss Fluid deficit: 4-5L (approx.) 0.9% saline solution is the solution of choice. Recommended schedule : • 1-3 L in first 1 hr • 1 L during second hr • 1 L in following 2 hrs • 1 L every four hrs *When BSR decreases to 250 mg/dl replace isotonic saline with 5-10 % dextrose
- 21. Correction of Hyperglycemia • Follow a low dose insulin regimen • Only short acting insulin • Use IV routes (preferably)
- 22. Dose : Loading dose: 0.1U/kg bolus Continuous IV insulin infusion @ 0.1U/kg/hr Optimal rate of glucose decline is 100mg/dl/hr Do not allow blood glucose levels to fall below 200mg/dl during first 4-5hrs of treatment
- 23. Correction of electrolyte disturbances If K⁺ > 5 mEq/L― Do not administer K⁺ If K⁺ 4 - 5 mEq/L ― Add 20 mEq/hr If K⁺ 3 - 4 mEq/L ― Add 30 mEq/hr If K⁺ <3 mEq/L ― Add 40 mEq/hr • Monitor electrolytes hourly • K⁺ replacement should be started with initial fluid replacement • If K⁺ < 3.5 mEq/L withhold insulin therapy until K⁺ > 3.5 mEq/L
- 24. Contd. ECG can be helpful in monitoring K⁺ • High peaked T waves in Hyperkalemia • Flattened T waves in Hypokalemia Hyperkalemia Hypokalemia
- 25. Correction of acid-base disturbances The use of Sodium Bicarbonate in management of DKA is questioned because of following potentially harmful consequences • Hypokalemia (from rapid shift of K⁺ into the cells) • Tissue anoxia (from decreased Hb-O₂ dissociation) • Cerebral acidosis (from decreased CSF pH)
- 26. Contd. Therefore Sodium bicarbonate is administered to DKA patients when pH ≤ 7 It should be administered in half saline soln. It can be repeated until pH reaches 7.1 It should not be given if pH ≥ 7.1 (risk of rebound alkalosis)
- 28. Transition to s/c insulin S/C insulin therapy can be initiated once DKA is controlled Dose: 0.6 U/kg/day Half of this dose can be given as long acting basal insulin and other half as short acting pre-meal insulin
- 29. Complications • Cerebral edema Mannitol 0.5 – 1 g/kg IV over 20 mins Dexamethasone 2 - 4 mg every 6 - 12 hrs • Cardiac dysrhythmias Correction of cause • Pulmonary edema Diuretics and O₂ therapy • Hypoglycemia • Hypokalemia
- 30. Patient’s education Seek doctor’s advice when BSR is raised and when they have unexplained nausea or vomiting. Educate patients to understand the importance of close and careful monitoring of BSR levels during infection, trauma and other periods of stress
- 31. Take home message DKA is a life-threatening medical emergency which can be treated with prompt and meticulous management and prevented through patient’s education about early recognition of symptoms and adherence to therapy.