final DKA emergency for medicine student c2.pptx

1. Diabetes ketoacidosis(DKA)
Dr. Chalachew T.(Emergency and Critical Care
Medicine Physician

2. Course outline
• Objectives
• Introduction
• Precipitating factors
• Clinical presentation
• Investigation
• Treatment
• Disposition
• Summary

3. Learning objectives
• By the end of this session, participants will be
able to:
– Define diabetic ketoacidosis
– Describe the clinical features of DKA
– Diagnose DKA
– Manage DKA according to the standard protocol

4. Introduction
• Diabetic ketoacidosis(DKA)
– A metabolic disorder characterized by the triad of
• Hyperglycemia
• Anion gap metabolic acidosis (increased anion gap)
• Ketonemia.
– serious complication of diabetes mellitus
– occurs when uncontrolled blood sugar rises and
the body can’t produce enough insulin to use the
glucose.

5. Precipitating factors
• The most common precipitating factors
– Infection
– Discontinuation of insulin treatment

6. Other precipitating factors
– Acute major illnesses such as MI, CVA, or
pancreatitis.
– New onset type 1 diabetes
– Drugs (glucocorticoids, higher dose thiazide
diuretics, sympathomimetic agents (e.g.,
dobutamine and terbutaline).
– Cocaine use ..etc

7. Clinical presentation
• Directly related to the three primary
metabolic derangements
– hyperglycemia,
– volume depletion
– acidosis.
• Symptoms
– Nausea/vomiting ,Thirst/polyuria, Abdominal pain,
Shortness of breath etc

8. Clinical presentation
• Physical Findings
– Tachycardia
– Dehydration/hypotension
– Tachypnea / Kussmaul respirations/respiratory
distress
– Abdominal tenderness (may resemble acute
pancreatitis or surgical abdomen)
– Lethargy/obtundation/cerebral edema/possibly
coma

9. Investigation
• Serum Glucose:
– The serum glucose will be elevated(>200mg/dl)
• Serum bicarbonate
– is frequently <10 mmol/L
• Arterial PH
– ranges between 6.8 and 7.3- depending on the
severity of the acidosis

10. Investigation…
– sodium, chloride, phosphorus, and magnesium are
reduced in DKA.
• are not accurately reflected by their levels in the serum
because of dehydration and hyperglycemia.
– Renal function test-
• Elevated blood urea nitrogen (BUN) and serum
creatinine levels
– reflect intravascular volume depletion.

11. Treatment
• Stabilize ABC of life
• Fluid management
• Insulin
• K+ repletion
• Treatment of precipitating factors
• Monitoring
• Long term management

12. Treatment
General measures
Stabilize the ABC of life
 Obtain IV access
Monitor RBS every hour ,urine ketone every 2-4
hrs
Identify and treat Precipitating cause of DKA

13. Treatment…
Repletion of fluid deficit
 The usual fluid deficit is about 3-6 liters
 Give as much NS/RL rapidly for a patient in shock
In general
 The first 2 L over 0 - 2 hours
 The next 2 L over 2 - 6 hours
 Then 2 L more over 6 -12 hours.
 Change the fluid to DNS when blood sugar falls to
below 250
 Replace ongoing fluid loss

14. Treatment..
Repletion of K+ deficit
 If baseline K+ is <3.3meq/L
avoid insulin and administer 20 to 30 mEq/hour K+ IV
until [K+] is above 3.3 mEq/L.
 If base line K+ is 3.3-5.3meq/L or is unknown
administer 40meq/L to run over 4-8 hrs after confirming
adequate urine output (≥50ml/hr)
 If baseline k+ is above 5.3meq/L
don’t administer k+
 The target is to keep it between 4-5meq/L

15. Treatment..
Insulin administration
 If perfuser and trained staff for monitoring of
the rate of infusion is available:
 Administer short-acting insulin: IV (0.1 units/kg),
then 0.1 units/kg per hour by continuous IV
infusion
 serum potassium is <3.3 mmol/L (3.3 meq/L),
do not administer insulin until the potassium is
corrected.

16. Treatment…
Insulin administration
 Give initial bolus of 10IU IV and 10 IU IM of regular
insulin (if there is no Perfuser)
 Then give 5 IU IV every one hour until blood sugar falls
below 250 and urine ketone is twice negative
 If RBS doesn’t drop by at least 50mg/dl or is
persistently above 350-400,double the dose of insulin
i.e. give 10 IU IV
 Overlap the last dose of regular insulin with the
standing dose of long acting insulin

17. DKA follow up chart..

18. Disposition
• Most patients with DKA require hospital
admission, often to the intensive care unit.
• Patients who have mild DKA may be
discharged from ED
– The underlying causes do not require inpatient
therapy
– Close follow-up is pursued.

19. Summary
• DKA is a metabolic disorder characterized by the triad
– hyperglycemia
– anion gap metabolic acidosis (increased anion gap)
– Ketonemia.
• The most common precipitating factors are
– infection
– discontinuation of insulin treatment
• The main principles of DKA management
– fluid replacement
– correction of electrolyte abnormalities
– Insulin administration
– treating the precipitating factors

20. Questions?

21. Thanks