Diabetic Ketoacidosis

Question 1

what is it?

Answer 1

a disordered metabolic state which occurs in the context of absolute or relative insulin deficiency accompanied by an increase in the counter regulatory hormones e.g. glucagon, adrenaline, cortisol and growth hormone

Question 2

what causes the relatively high mortality risk?

Answer 2

hypokalaemia
aspiration pneumonia
cerebral oedema in children

Question 3

pathogenesis

Answer 3

insulin deficiency leads to lipolysis causing increased ketogenesis leading to acidosis
side thing - insulin deficiency can also lead to to hyperglycaemia causing dehydration and increased lactate which also causes acidosis

Question 4

what are the biochemical results of DKA?

Answer 4

Blood glucose >11.0 mmol/L or known DM
Ketonaemia >3 mmol/L or significant ketonuria (>2+ on a standard urine stick)
Bicarbonate <15 mmol/L or venous pH <7.3
K+ can be > 5.5mmol/L but after insulin there can be hypokalaemia so needs monitored
Creatinine – often raised
Na – often low
Lactate – normally raised
Amylase – often raised but rarely the cause of this is pancreatitis – normally it returns to normal

Question 5

what triggers DKA?

Answer 5

insulin deficiency - poor management of DM or can be a 1st presentation of T1DM
increased insulin demand - infection, inflammatory, intoxication or iatrogenic
associated conditions -underlying sepsis or gastroenteritis

Question 6

how does it present?

Answer 6

•	Osmotic related
Thirst and polyuria 
Dehydration 
•	Ketone body related 
Flushed 
Vomiting 
Abdominal pain and tenderness
Breathlessness – Kussmaul’s respiration – there isn’t always a smell

Question 7

how is it managed?

Answer 7

close monitoring
replace losses
- fluids (3L by the end of hour 4 - NaCl)
- insulin
- potassium (once it has dropped)
- rarely other electrolytes need replaced

Question 8

potential complications of DKA?

Answer 8

ventricular fibrillation (cardiac arrest) because of electrolyte disturbance
cerebral oedema
adult respiratory distress syndrome
gastric dilatation - risk of aspiration

Question 9

how to prevent DKA recurrence?

Answer 9

find out why it happened e.g. new case - educate on management
if due to non-compliance - re-educate and support in treatment
‘sick day’ rules - lots of people don’t know about taking their insulin and flushing their system with fluids even if not eating because body is under stress. Monitor glucose and ketones
provide ketone meter if don’t already have
arrange follow up

Question 10

what is the characteristic DKA patient?

Answer 10

younger 
type 1 
insulin deficiency 
insulin omission precipitates 
mortality <2% 
insulin treatment