Diabetic ketoacidosis

Question 1

What is DKA

Answer 1

associated with type 1 diabetes mellitus

absolute lack of insulin leads to ketone production as fats are broken down for energy use

Question 2

What is the triad that is seen in T1DM

Answer 2

Hyperglycaemia
Ketonaemia
Metabolic acidosis

Question 3

What can cause DKA

Answer 3

infection /acute illness
non-adherence to diabetes medication

Question 4

What would someone with DKA present with

Answer 4

Nausea and vomiting

dehydration

polyuria and polydipsia

hyperventilation - Kussmaul breathing

Abdominal pain
Ketotic breath
collapse/confusion

Question 5

What else would be seen on a patient with DKA on examination

Answer 5

They will be intravascularly volume depleted with poorly perfused peripheries

• prolonged capillary refill time
  -low JVP
  -compensatory tachycardia to help maintain BP

Question 6

What investigations are needed to diagnose DKA

Answer 6

Raised blood glucose>11.1

ketonuria ++ or more on dipstick OR ketones >3mol/l

serum bicarbonate <15mmol/L

pH<7.3

Question 7

What other investigations should be carried out

Answer 7

capillary blood glucose test

Arterial blood gases

Question 8

What is the most important first management step for DKA

Answer 8

Obtain good IV access and run in 1 litre of 0.9% sodium chloride

Question 9

What are the other steps of management for DKA

Answer 9

-IV insulin (0.1unit/kg/hour) after fluids , only when K+ is not <3.5

• Include 10% dextrose in fluids once glucose falls <14mmol/L

– continue long-acting insulin, stop short acting insulin

• treat underlying cause – eg for infection antibiotics

–Subcutaneous insulin can be considered once patient is eating and has 1+ or less ketones in their urine

Question 10

How do you define DKA resolution ?

Answer 10

pH >7.3

blood ketones <0.6mmol/L

bicarbonate >15.0mmol/L

Question 11

How does the escalation of DKA management work

Answer 11

both the ketonaemia and acidosis should be resolved within 24 hours - if not patient requires senior review from an endocrinologist

If above criteria met , patient is eating and drinking switch to SC insulin

-patient should be reviewed by diabetes specialist nurse prior to discharge

Question 12

What are some complications associated with DKA or the treatment itself

Answer 12

-gastric stasis
-thromboembolism

• arrhythmias secondary to hyperkalaemia/iatrogenic hypokalaemia
• iatrogenic due to incorrect fluid therapy - cerebral oedema, hypokalaemia, hypoglycaemia

-ARDS
-acute kidney injury - so monitor urine output

Question 13

What should be considered for a patient with DKA for further monitoring

Answer 13

1. Urinary catheter should be passed if patient is oliguric/anuric

oligo-anuria is sign of inadequate intravascular fluid and may precede impending renal failure

2. Some may require assessment of central venous pressure

Question 14

When can one stop giving aggressive IV fluids

Answer 14

when both the acidosis corrects and the ketones are completely cleared

Question 15

Which findings are compatible with DKA

Answer 15

ketonuria 4+ on a dipstick

decreased levels of consciousness

succussion splash - sloshing sound heard through stethoscope during sudden movement of patient on abdominal auscultation

Question 16

What is seen on arterial blood gas for a patient with DKA

Answer 16

metabolic acidosis with high anion gap