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    DKA Concepts and Management

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    Mohammad Ali
    1) Diabetic ketoacidosis (DKA) results from a lack of insulin leading to hyperglycemia, ketone production, and metabolic acidosis. Common causes include new-onset type 1 diabetes, infection, and insulin omission. 2) Diagnosis of DKA requires hyperglycemia, ketonemia, and acidosis with a blood pH below 7.3 and bicarbonate level below 15 mmol/L. 3) Treatment goals are to rehydrate by replacing fluids, administer insulin to halt ketosis while simultaneously giving dextrose to avoid hypoglycemia, and correct electrolyte and acid-base imbalances through potassium and bicarbonate replacement.

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    DKA Concepts and Management

    Uploaded by

    Mohammad Ali
    105 views22 pages
    1) Diabetic ketoacidosis (DKA) results from a lack of insulin leading to hyperglycemia, ketone production, and metabolic acidosis. Common causes include new-onset type 1 diabetes, infection, and insulin omission. 2) Diagnosis of DKA requires hyperglycemia, ketonemia, and acidosis with a blood pH below 7.3 and bicarbonate level below 15 mmol/L. 3) Treatment goals are to rehydrate by replacing fluids, administer insulin to halt ketosis while simultaneously giving dextrose to avoid hypoglycemia, and correct electrolyte and acid-base imbalances through potassium and bicarbonate replacement.

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    DKA Concepts and Management

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    1) Diabetic ketoacidosis (DKA) results from a lack of insulin leading to hyperglycemia, ketone production, and metabolic acidosis. Common causes include new-onset type 1 diabetes, infection, and insulin omission. 2) Diagnosis of DKA requires hyperglycemia, ketonemia, and acidosis with a blood pH below 7.3 and bicarbonate level below 15 mmol/L. 3) Treatment goals are to rehydrate by replacing fluids, administer insulin to halt ketosis while simultaneously giving dextrose to avoid hypoglycemia, and correct electrolyte and acid-base imbalances through potassium and bicarbonate replacement.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    105 views22 pages

    DKA Concepts and Management

    Uploaded by

    Mohammad Ali
    1) Diabetic ketoacidosis (DKA) results from a lack of insulin leading to hyperglycemia, ketone production, and metabolic acidosis. Common causes include new-onset type 1 diabetes, infection, and insulin omission. 2) Diagnosis of DKA requires hyperglycemia, ketonemia, and acidosis with a blood pH below 7.3 and bicarbonate level below 15 mmol/L. 3) Treatment goals are to rehydrate by replacing fluids, administer insulin to halt ketosis while simultaneously giving dextrose to avoid hypoglycemia, and correct electrolyte and acid-base imbalances through potassium and bicarbonate replacement.

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    Dr Samreen Sheikh

    MANAGEMENT OF
    DIABETIC
    KETOACIDOSIS
    Pathophysiology of DKA
    A collection of severe and potentially life-
    threatening metabolic disturbances:
    • Hyperglycemia  Osmotic diuresis
    » Urinary loss of fluids & electrolytes
    » ECFv contraction
    » Depletion of total body K+ stores
    (even though may be hyperkalemic 2° to cell
    shift d/t insulin deficiency and acidosis)
    • Ketone production  Metabolic acidosis
    » Compensatory Respiratory alkalosis (hopefully)

    • Uncontrolled lipolysis  severe  TG


    DKA risk factors

    • Type 1 DM
    • 1st presentation
    • Acute-illness
    • Insulin omission (inappropriate sick-day management,
    noncompliance, Eating Disorders)
    • Type 2 DM
    • During stress
    • Ethnicity: African-American, Hispanic
    • Extremes of age
    • Poor glycemic control
    DKA: Precipitating Factors

    Acute illness
    (MI, trauma,
    10-20% pancreatitis)
    20-38%
    New-onset DM

    5-39% Insulin omission

    33%
    Infections
    DKA: Diagnosis

    • Symptoms & Signs:


    • Polyuria, polydipsia
    • Fatigue
    • Nausea,vomitting, abdominal pain(may simulate
    acutevabdomen)
      ECFv(increase heart rate,hypotention,dry mucous
    membran decrease skin turgor,
    • Kussmaul’s( deep) respiration, Acetone (fruity) breath, mild
    impairment in cognition
    1 Step: Confirm diagnosis
    st

    • Diabetes: RBS > 250 mg% (occasionally


    normal or only mild  BS)

    • Ketones: Raised serum ketones (and urine


    ketones)

    • Acidosis: pH < 7.3, serum HCO3 < 15


    mEq/L, AG > 14 mM
    2nd Step: Admit

    • Admit to hospital

    • Intensive-care setting may be necessary


    for frequent monitoring or if pH < 7.00 or
    unconscious
    3rd Step: Assess & Manage

    • Serum electrolytes (K+, Na+, Mg2+, Cl-,


    bicarbonate, phosphate)
    • Acid-base status—pH, HCO3-, PCO2, Beta-
    hydroxybutyrate
    (Acetone is volatile & expired via lungs;
    Ketones may become negative after prolonged
    duration between sampling and testing)
    • Renal function (creatinine, urine output)
    Goals of DKA Management

    1. Replace Fluids
    2. Halt Ketogenesis and Correct Acidosis
    3. Maintain Acid-Base and Electrolyte
    Balance
    4. Identify & Treat Underlying Cause(s)
    Note: Maintainance of euglycemia is not the
    sole target of Insulin Infusion in DKA
    1st Goal of Management:
    Repletion of ECV and ICV
    Why?

    • There is Extracellular and Intracellular


    volume loss due to Osmotic Diuresis
    1st Goal of Management:
    Repletion of ECV and ICV
    • Choice of Fluids:
    – 2–3 L of 0.9% saline over first 1–3 h (10–15
    mL/kg per hour)
    – subsequently, 0.45% saline at 150–300 mL/h
    – change to 5% glucose and 0.45% saline at
    100–200 mL/h when plasma glucose reaches
    250 mg/dL (14 mmol/L).
    2nd Goal of Management:
    Halt the Process of Ketosis; Role
    of Insulin and Simultaneous
    Dextrose Infusion
    • Administer short-acting insulin: IV (0.1 units/kg) or IM (0.3
    units/kg)
    • Then 0.1 units/kg per hour by continuous IV infusion,
    increase 2- to 3- fold if no response by 2–4 h
    • Adjust rate of Insulin to achieve 30 - 50 mg% / hour
    decrase in RBS
    3rd Goal of Management:
    Maintain Acid-Base and Electrolyte
    Balance
    • Maintenance of Normokalemia
    • Correction of Acidosis via Bicarbonate
    Replacement
    3rd Goal of Management:
    Maintenance of Normokalemia
    • K+ defecit: 3-5 mEq/Kg (350 mEq for 70Kg)
    • Normal to high serum K+

    Ketoacidosis
    H+ H+

    K+ K +

    Insulin
    DKA: Potassium
    • Overall, K+ deficit 3-5 mEq/kg (350 mEq in 70kg)
    • Need K+ with initial IV fluid & insulin Rx unless:
    • Anuric
    • K > 5.5 mEq/L or hyperkalemic ECG changes

    Initial [K] Replacement > 20 mEq/h:


    > 5.5 mEq/L nil (initially) •With Cardiac monitor
    • Via Central line
    5.2-5.5 mEq/L 10 mEq/h
    4-5.2 mEq/L 20 mEq/h
    3-4 mEq/L 30 mEq/h
    < 3 mEq/L 40 mEq/h
    Additional electrolyte replasement

    PHOSPHATE
    • Required only if phosphate<1.5mg%
    • Replase with potassium phosphate
    MAGNESIUM
    • For mild hypomagnesemia( 1-1.5mg%) give16-
    24mEq magnesium sulfate over 8 hours in IV fluids
    • For severe hypomagnesemia (<1.0 mg%) give 32-48
    mEq magnesium sulfate over 24 hours in IV fluids
    3rd Goal of Management:
    Correction of Acidosis via
    Bicarbonate Replacement
    • The ADA advises bicarbonate [50 mmol/L (meq/L) of
    sodium bicarbonate in 200 mL of sterile water with 10
    meq/L KCl over 1 h if pH = 6.9–7.0

    • or 100 mmol/L (meq/L) of sodium bicarbonate in 400 mL


    of sterile water with 20 meq/L KCl over 2 h if pH < 6.9].
    Monitoring via Flow Chart

    time VS UOP pH HcO AG keto Glc K PO4 IVF insu


    3 nes lin
    Transition from insulin infusion to
    subcutaneous insulin
    • Can consider switch to SC insulin when:
    • AG normalized
    • BS < 270 mg%
    • Insulin IV requirements < 2U/h
    • Patient able to eat
    • Overlap insulin IV infusion with 1st SC insulin by
    2-4h to avoid recurrent ketosis
    • Type 2 DM patients with DKA:
    • Don’t necessarily have to be d/c on insulin SC (Type I DM
    do require Insulin for life)
    • Once acute stress resolved, many do well on Oral Anti-
    Diabetic medictaions
    4th Goal of Management:
    Identify & Treat Underlying
    Cause(s)
    • Antibiotics for infection
    • Appropriate Cultures and Infection screen
    • Look for Occult Abscess
    • Rule out ACS
    4th Goal of Management:
    Identify & Treat Underlying
    Cause(s)
    • Counselling for:
    – Non-compliance
    – Appropriate monitoring of blood glucose
    during stress
    – Adequate increase in Insulin, if in any stress
    – Addressing cost issues
    – Proper storage and insulin administration
    technique
    Thank You

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