Diabetic Ketoacidosis

Diabetic
Ketoacidosi
s
NIKETH HEBRON
ROLL NO : 67
Contents
01 02 03
Clinical
Precipitating Pathogenesis Features
Factors
04 05
Investigation Management
 DKA – hyperglycemic emergency
 Metabolic decompensation –
occurs – severe deficiency of
insuln
 More common – DM Type 1
 May also occur in DM Type 2
PRECIPITATING FACTORS
• Infections – Pneumonia, UTI, sepsis,
gastroenteritis
• Acute pancreatitis
• Alcohol intoxication
• Inadequate insulin
• Infarction – Cerebral, coronary, mesenteric,
peripheral
• Severe stress – Physical, emotional
• Hyperthyroidism, pheochromocytoma
• Drugs – thiazides, corticosteroids, cocaine
• Pregnancy
CARDINAL BIOCHEMICAL
FEATURES
Hyperglycaemia
Blood glucose ≥ 11.1 mmol/L
(200mg/dL)
Hyperketonemia
≥3.0 mmol/L on fingerprick or
Ketonuria more than 2+ on urine dipstick
Metabolic
acidosis
Venous bicarbonate <15mmol/L or
Venous pH < 7.3
Pathogenes
is
Stress, infection or
Absolute insulin deficiency
insufficient insulin intake
Counter regulatory hormones

Glucagon Catecholamines Cortisol GH
Lipolysis Glucose utilization Proteolysis Glycogenolysis

Protein synthesis
Gluconeogenic substrates
Gluconeogenesi
s
Hyperglycemia
Glucosuria
(Osmotic diuresis )
Loss of water and

electrolytes
Decreases fluid intake

Dehydration Hyperosmolarity
Impaired renal
function
CLINICAL FEATURES
Symptoms Signs
• Polyuria, • Dehydration
Polydipsia • Hypotension, reduced
• Weight loss JVP
• Weakness • Cold extremities
• Nausea, • Peripheral cyanosis
vomiting • Tachycardia
• Leg cramps • Air hunger (Kussmaul
• Blurred vision breathing)
• Abdominal pain • Smell of acetone
• Dyspnoea • Hyporeflexia,
hypotonia
• Hypothermia
• Delirium, drowsiness
•
COMPLICATIONS
●Acute gastric dilatation/erosive
gastritis
●Cerebral edema
●Hyperkalemia/hypokalemia
●Hypoglycemia
●Infections
●MI
●Mucormycosis
●ARDS
INVESTIGATIONS
● Plasma levels
Glucose – raised ( >250mg/dL)
Ketone bodies – raised ( >3mmol/L)
● Serum electrolytes
Potassium – normal or raised in initial stages – metabolic
acidosis – shift – potassium from
intracellular to extracellular cmpt – levels drop
once treatment started
Sodium – Low
Bicarbonate – Low ( < 15mEq/L )
Phosphorous – High
● Blood
Leukocytosis – Stress response
Arterial pH < 7.3
Blood urea nitrogen – raised (20-30 mg/dL) – prerenal failure
due to vol depletion
INVESTIGATIONS
● Infection screen
CBC
Blood and urine culture
CRP
Chest Xray
Serum amylase – elevated
● Urine examination – shows glucose and ketones
● ECG – Rule out MI
DIAGNOSTIC CRITERIA
● Plasma glucose > 250mg/dL
● Arterial pH < 7.3
● Serum Bicarbonate < 15mEq/L
● Ketonemia and/or ketonuria
● Anion gap > 12mEq/L
INDICATORS OF SEVERE DKA
Presence of one or more of these features :
● Blood ketones > 6mmol/L

● Bicarbonate < 5mmol/L
● Venous/arterial pH < 7 ( H+ >100nmol/L )
● Persistent hypotension/Oliguria
● Hypokalemia (<3.5mmol/L)
● GCS score < 12
● O2 Saturation < 92%
● Systolic BP < 90mmHg
● Heart rate >100 or <60 beats/min
● Anion gap > 16mmol/L
MANAGEMENT
Goals of therapy :
● Rehydration
● Reduction of hyperglycemia
● Correction of electrolyte imbalance
● Correction of acid-base imbalance
● Investigation and correction of precipitating
factors
● Treatment of complications
1) Fluid Replacement
● If systolic BP < 90mmHg – Rapid bolus 500ml NS for 10-15min
● BP > 90 mmHg - 0.9% NaCl at 1L per hour (4-14 ml/kg/hour)
● Introduction of 10% glucose infusion – when Blood glucose falls
below 252mg/dL – to prevent hypoglycemia
2) Insulin Replacement
● Regular insulin – 0.1 U/kg IV bolus followed by 0.1 U/kg/hr IV
Infusion
● When serum glucose reaches 250 mg/dL – Add 5% dextrose with
0.45% NaCl at 15-250 ml/hr with adequate insulin to keep serum
glucose between 150 and 200 ml/dL
● Response – Blood ketone conc falling by atleast 0.5mmol/L/hr
● Continue IV insulin until patient is able to eat
● When patient can eat – initiate SC insulin regimen
● Continue IV insulin infusion for 30-60min after SC insulin is begun
3) Potassium Replacement
● If Serum K+ is 3.3 - 5 mmol/L : Add 20-30 mmol/L KCl
to 2nd litre of IV fluid
● If Serum K+ > 5mmol/L : Potassium not given
● If serum K+ < 3.5 mmol/L : 40 mmol of K+ per hour till
the conc becomes > 3.5 mmol/L
4) IV Bicarbonate
● If pH < 6.9 : NaHCO3 100mmol diluted in 400 ml
distilled water infused at 200mL/hr with 20 mmol KCl.
● If pH > 6.9 : No NaHCO3
5) Phosphate correction
● A sharp drop of serum phosphorous can occur during

insulin treatment – no treatment necessary.
● But if levels < 0.6 mmol/L – Corrected – seen in
presence of resp or muscle weakness.
Criteria for Resolution of DKA
● Glucose < 200mg/dL

● Serum Bicarbonate ≥ 18mEq/L
● Venous pH of > 7.3
● Plasma osmolality < 315 mOsmol/kg
● Patient able to eat
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Diabetic Ketoacidosis

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Diabetic Ketoacidosis

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Diabetic

Counter regulatory hormones

Lipolysis Glucose utilization Proteolysis Glycogenolysis

Loss of water and

Decreases fluid intake

● Blood ketones > 6mmol/L

● A sharp drop of serum phosphorous can occur during

Criteria for Resolution of DKA

● Glucose < 200mg/dL

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