Diabetic Ketoacidosis

Question 1

Epidemiology

Answer 1

From poorly managed T1DM or from infection/illness.

Question 2

Characteristic px

Answer 2

10 years presents to A+E with severe dehydration + Hx of T1DM

Question 3

Pathophysiology

Answer 3

Complete absence of insulin = unrestrained lipolysis + gluconeogenesis
So much gluconeogenesis + lipolysis - not all glucose usable - increased FFA - oxidised to acetyl CoA - converted to ketones bodies (acidic = increase conc = KETOACIDOSIS) - inability of Hb to bind to O2 = kussmauls respirations, hyperkalaemia
Decreased peripheral glucose uptake = OSMOTIC DIURESIS - dehydration

Question 4

Risk Factors (ABCD…HI)

Answer 4

Acromegaly
Bariatric surgery
Cushing’s syndrome
Drug
- corticosteroids
- thiazide
- SGLT2 inhibitors
Hyperthyroidism
Hispanic or black ancestry
Inadequate insulin therapy
Infection

Question 5

Symptoms

Answer 5

Polyuria + dipsia
Nausea + vomiting
Breath smell of ketones
Drowsy/confused
Abdominal pain
Dry tongue
Reduced tissue turgor
Leg cramps
Headache
Inability to tolerate oral fluids

Question 6

Signs

Answer 6

Kussmaul’s breathing
- deep laboured breathing, to blow off CO2, compensation = signs of respiratory compensation
Pear drop breath
Abdo tenderness
Hyperglycaemia
Ketosis
Reduced tissue turgor, hypotension + tachycardia
DEHYDRATION (could kill)
METABOLIC ACIDOSIS (with low bicarbonate) - (could kill)
POTASSIUM IMBALENCE (could kill)

Question 7

Diagnosis

Answer 7

FIRST LINE
- Ketones (blood) > 3 mmol/L
- RPG = Hyperglycaemic > 11.1 mmol/L
- Acidosis (met) < 7.35 pH or <15 mmol HCO3-
= DIAGNOSTIC
Urine dipstick = glycosuria/ketonuria + hyperkalaemia
+ AKI from dehydration
Full blood count - raised CRP

Question 8

Treatment

Answer 8

ABCDE (emergancy)
Fluids (0.9% saline) - ALWAYS FIRST
Insulin (Actrapid)
Glucose (prevent hypoglycaemia)
Potassium
Infection
Chart fluid balance
Ketones (monitor)