Management of diabetic Ketoacidosis Nelson 21st Ed.

Source of the Video: https://www.youtube.com/watch?v=raEKXVfuWTo
Link also in Description.

• Lethargy for last 4 day
• Decreased acceptance of feeds for last 2 days
• Pain abdomen for last 2 day
• Fast Breathing for last 1 day
• Tachypnea
• Tachycardia
• Feeble peripheral pulses
• BP – 60/34
• Patient had a typical fruity odour
• B/L air entry was equal, no added sounds,
along with rapid deep breathing
• CVS and P/abd examination was WNL
• On CNS exam patient was drowsy, GCS was 11/15,
DTR were normal planters were downward
RBS= 359 mg/dl
• Provisional Diagnosis of
Diabetic Ketoacidosis was
kept

• Lethargy for last 4 day
• Decreased acceptance of feeds for last 2 days
• Pain abdomen for last 2 day
• Fast Breathing for last 1 day
• Tachypnea
• Tachycardia
• Feeble peripheral pulses
• BP – 60/34
• Patient had a typical fruity odour
• B/L air entry was equal, no added sounds along
with rapid deep breathing
• CVS and P/abd examination was WNL
• On CNS exam patient was drowsy, GCS was 11/15,
DTR were normal planters were downward
RBS= 359 mg/dl
• Provisional Diagnosis of
Diabetic Ketoacidosis was
kept
Management???

Source: Nelson pediatrics 21st Ed

•

FASTING BREAKFAST FASTING LUNCH FASTING DINNER FASTING
INSULIN LEVELS
Insulin Levels

Insulin Levels Glucose levels

•
•
•

Insulin Levels Glucose

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•
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STRESS!!!!

STRESS!!!!
•

•
Impairing insulin secretion
(epinephrine)
Antagonize Insulin action
(epinephrine, cortisol, growth hormone
Promote glycogenolysis, gluconeogenesis, lipolysis,
and ketogenesis
(glucagon, epinephrine, growth hormone, and cortisol)
Decrease glucose utilization and glucose
clearance (epinephrine, growth hormone, cortisol).
KETOACIDOSIS

Promote glycogenolysis, gluconeogenesis, lipolysis,
and ketogenesis
(glucagon, epinephrine, growth hormone, and cortisol)
Principally β-hydroxybutyrate and acetoacetate
is formed which exceeds the capacity for
peripheral utilization and renal excretion
Accumulation of these keto acids
results in metabolic acidosis (DKA)
KETOACIDOSIS

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• https://www.youtube.com/watch?v=raEKXVfuWTo
• Daily losses of water and glucose 5 L
and 250 g

The progression of
symptoms may be
accelerated by the
stress of an
intercurrent illness or
trauma, when
counterregulatory
(stress) hormones
counter the limited insulin
secretory capacity.

NORMAL MILD MODERATE SEVERE
CO2
(mEq/L,
venous)
20-28 16-20 10-15 <10
pH
(venous)
7.35-7.45 7.25-7.35 7.25-7.15 <7.15
Clinical No change Oriented, alert but
fatigued
Kussmaul respiration,
Oriented but Sleepy,
Arousable
Respiratory failure or
depressed sensorium
to coma
Severe hypernatremia (corrected Na >150 mEq/L) would also be
classified as severe diabetic ketoacidosis.
Major form of CO2 in
blood is in the form of
Bicarbonate (HCO3
-)

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1. what dose
3. titrate
2. glucose

1. what dose

2. glucose
300 mg/dl 200 mg/dl
# Hourly in Severe DKA
# 3-4 hourly in mild
and moderate DKA

300 mg/dl 200 mg/dl

cerebral
edema

3. titrate
DON’T

Insulin
↓Glucose

1. Timings
2. Calculation of fluids
3. Types of fluids

1. Timings

Shock
deficit
maintenance

Shock
deficit
maintenance
10-20 ml/Kg
20 min
• Deficit
• Maintenance
2. Calculation of fluids

10-20 ml/Kg
20 min
• Deficit
• Maintenance
2. Calculation of fluids 3. Types of fluids
0.9%
0.45%

10-20 ml/Kg
20 min
• Deficit
• Maintenance
0.9%
0.45%
.

Insulin Rehydration
↓Glucose

1. How
2. What to do

1. How 2. Wha

2. What to do
• 0.5-1.0
• 80 mEq/L

Insulin Rehydration
↓Glucose
↓K+

4. Bicarbonate
1. When
3. does not get corrected
2. Ketonuria

1.
• fatty acid substrates
• Bicarbonate buffers ketone bodies

cid substrates
ketone bodies
2. Ketonuria
• β-
hydroxybutyrate
• β-
hydroxybutyrate converts to acetoacetate
•
degree of clinical
improvement.

1.
2.
3.
4.

1.
2.
3.
4.
4. Bicarbonate
No
•
hypokalemia cerebral edema
•
unresponsive

Insulin Rehydration
↓Glucose
↓K+
Ketoacidosis

1. relation
2. ‘true’
3. relevance

1. relation
1.6 mmol/L
100 mg/dL

2. ‘true’
‘true’
.

3. relevance
•
• greater than 150 mmol/L

Insulin Rehydration
↓Glucose
↓K+
Na+
Ketoacidosis

1.
2.

1.
1.
2.
3.
4.
5.
6.
7.
8.
9.

2.
9.
1.
2.
3. mannitol

• Pancreatitis is occasionally seen with DKA.
• Serum amylase and lipase may be elevated.
• If the serum lipase is not elevated, the amylase is
likely nonspecific or salivary in origin.
Important Points to Note

When DKA has resolved
??????

• CO2 > 15 mEq/L
• >7.30
• Sodium
• Anion gap
• No emesis

• A dose of long-acting insulin is given.
• The insulin drip is discontinued
approximately 30 min later.
• Frequent (every 2-3 hr) short-acting insulin
bolusing may need to be given until
ketosis resolves.

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Management of diabetic Ketoacidosis Nelson 21st Ed.

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