DIABETIC KETOACIDOSIS

Question 1

Essentials of diagnosis of a patient with Diabetic Ketoacidosis.

Answer 1

(1) Hyperglycemia > 250 mg/dL
(2) Acidosis with blood pH  7.3
(3) Serum bicarbonate  15 mEq/L
(4) Serum positive for ketones

Question 2

Diabetic Ketoacidosis may be the initial manifestation of

Answer 2

both type 1 or type 2 diabetes but Commonly occurs with poor compliance in type 1 diabetics,

Question 3

bullet points

Answer 3

(3) Develops in type 1 and type 2 diabetics with increased insulin requirements
during infection, trauma, myocardial infarction, or surgery
(4) May develop in type 2 diabetics under severe stress such as sepsis or trauma

Question 4

Clinical Findings of a patient with Diabetic Ketoacidosis.

Answer 4

(1) May begin with a day or more of polyuria, polydipsia, marked fatigue,
nausea and vomiting and, finally, mental stupor that can progress to coma
(2) Dehydration, possible stupor
(3) Rapid deep breathing and a “fruity” breath odor of acetone
(4) Hypotension with tachycardia indicates profound fluid and electrolyte depletion
(5) Mild hypothermia usually present; elevated or even a normal temperature may
suggest infection
(6) Abdominal pain and tenderness in the absence of abdominal disease;
conversely, cholecystitis or pancreatitis may occur with minimal
symptoms and signs

Question 5

Treatment of a patient with Diabetic Ketoacidosis.

Answer 5

(a) Insulin:
1) Initially Insulin plus fluid and electrolyte replacement is the mainstay of
therapy - Consult Medical Officer prior to Insulin Administration
2) Begin with loading dose of 0.15 unit/kg as IV bolus, followed by 0.1
unit/kg/h, continuously infused or given hourly as an IM injection
3) Recheck blood glucose before repeat insulin injection(s).
4) “Piggy-back” insulin into the fluid line so the rate of fluid
replacement can be changed without altering the insulin delivery rate
5) If plasma glucose level fails to fall at least 10% in the first hour, give
repeat loading dose
(b) Fluids:
1) Volume repletion is an initial management priority. Fluid deficit is
usually 4-5 L. In the first hour, give at least 1 L of 0.9% normal saline
to re-expand contracted vascular volume (lactated ringer’s is fluid of
choice if available).
2) When blood glucose falls to 250 mg/dL or less, use 5% glucose
solutions to maintain blood glucose 200-300 mg/dL while continuing
insulin to clear serum ketones.
3) Once improvement is noted in vital signs and hyperglycemia (>250
mg/dL or less) and adequate urine output of at least 30 to 50 mL/h is
ensured, intravenous fluids may be reduced to maintenance levels or
discontinued if the patient is taking oral fluids well.
4) The cornerstone of therapy for acute hyperglycemia is restoration of
intravascular volume and reperfusion of vital organs, especially the
kidneys.
5) Electrolytes will need to be carefully monitored. Often potassium is
elevated initially due to metabolic acidosis, however with correction
of acidosis and insulin-mediated transfer of potassium into the cells,
serum potassium may rapidly fall and require aggressive repletion.
6) Be careful to avoid fluid overload in patients with cardiac disease.
7) Excessive fluid replacement (more than 5 L in 8 h) may contribute
to acute respiratory distress syndrome or cerebral edema

Question 6

Disposition of a patient with Diabetic Ketoacidosis.

Answer 6

MEDEVAC

Question 7

Complications of a patient with Diabetic Ketoacidosis.

Answer 7

(1) Acute myocardial infarction and infarction of the bowel following
prolonged hypotension
(2) Renal failure, especially with prior kidney dysfunction
(3) Cerebral edema occurs rarely
(a) Best prevented by avoiding sudden reversal of marked hyperglycemia
(b) Maintaining glycemic levels of 200-300 mg/dL for the initial 24 h after
correction of severe hyperglycemia reduces this risk