Diabetic Ketoacidosis

Question 1

What is Diabetic Ketoacidosis?

Answer 1

This is a serious complication of diabetes that can be life-threatening and is caused by high blood glucose as a result of a lack of insulin.

Because the body cannot use the glucose for energy, it begins to breakdown other tissues for an alternative energy source. Ketones are a by-product of this and if these ketones build up, the body becomes acidotic.

Most common is type 1 diabetes but an occur in type 2

Question 2

What are the clinical features of Diabetic Ketoacidosis?

Answer 2

1. High blood glucose (not always present though)
2. Ketones in the blood or urine

Question 3

What are the symptoms of Diabetic Ketoacidosis?

Answer 3

 Increased frequency of urination
 Increased thirst
 Tiredness/ lethargy
 Blurred vision
 Abdominal pain
 Nausea and vomiting
 Smell of ketones on the breath
 Collapse/ unconsciousness

Question 4

What are the risk factors for Diabetic Ketoacidosis?

Answer 4

 Concurrent illness
 Missing insulin doses
 During a growth spurt or puberty
 Pregnancy
 Binge drinking
 Using illegal drugs

Question 5

What are the treatments for Diabetic Ketoacidosis?

Answer 5

 Rehydrate with intravenous fluids
 Replace electrolytes with intravenous electrolytes
 Administer intravenous insulin - via a fixed rate insulin infusion

Question 6

Explain Intravenous fluids with Diabetic Ketoacidosis?

Answer 6

If patients have a systolic BP less than 90 mmHg a fluid bolus of 500mL sodium chloride 0.9% should be given over 10-15 minutes, this can be repeated if BP remains low.
When the BP is over 90 mmHg sodium chloride 0.9% is given at a rate that replaces deficit and provides maintenance.

Question 7

Explain Intravenous electrolytes with Diabetic Ketoacidosis?

Answer 7

Potassium chloride should be given in the fluids unless the patient is suspected of being anuric. This should be adjusted according to plasma-potassium concentration.

Question 8

Explain Intravenous insulin with Diabetic Ketoacidosis?

Answer 8

Soluble insulin should be given by intravenous injection.

It is diluted with sodium chloride 0.9% to give a final concentration of 1 unit/mL.
Initially infuse at a fixed rate of 0.1 units/kg/hour.

• If on a long acting insulin this should be continued alongside the intravenous insulin infusion.
• If on a short acting insulins, e.g. Novorapid should NOT be given whilst the patient is receiving a fixed rate insulin infusion.

Question 9

What monitoring should be done for Diabetic Ketoacidosis?

Answer 9

The patient should have their plasma potassium monitored initially after 60 minutes of commencing treatment, then at 2 hours after treatment started and then every 2 hours thereafter.

If level is outside of the normal range recheck every hour until back in normal range.

Blood-ketone and blood glucose concentrations need to be checked hourly, the rate of the intravenous insulin infusion can be adjusted accordingly - the ketones should fall by at least
0.5 mmol/litre/hour and glucose by at least 3 mmol/litre/hour.

Question 10

What is the next step for Diabetic Ketoacidosis after starting treatment and motioning?

Answer 10

When blood glucose concentration is less than 14 mmol/litre the patient should be started on a glucose 10% infusion at a rate of 125 mL/hour. This needs to be given in addition to sodium chloride 0.9% infusion.

The insulin infusion can be stopped when the blood ketone concentration is less than 0.3 mmol/litre and blood pH is greater than 7.3 as long as the patient can eat and drink normally.

When stopping the insulin infusion the patient should be given a subcutaneous fast acting insulin and a meal and the infusion stopped one hour later.