1) Diabetic ketoacidosis (DKA) is a life-threatening complication that occurs most often in patients with type 1 diabetes and is characterized by hyperglycemia, ketoacidosis, and ketonuria. 2) Treatment for DKA involves IV fluids, insulin, potassium supplementation, and antibiotics. The goal is to rehydrate the patient and lower their blood glucose levels while correcting electrolyte imbalances. 3) Complications can include cerebral edema, acute renal failure, arrhythmias, and death. Prompt treatment is important to avoid complications and reduce mortality rates.

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.