Diabetic Ketoacidosis

Question 1

What is the goal for treatment in DKA cases?

Answer 1

To convert them back to normal diabetes mellitus- arent gonna cure them of the diabetes itself

Question 2

What is diabetes mellitus?

Answer 2

-A problem with the function of insulin in the body, either due to lack of production or lack of response of the cells to the presence of insulin
-characterized by hyperglycemia, but this is not the main problem

Question 3

What causes the clinical signs in diabetes patients?

Answer 3

Cells being starved of energy
-some tissues are insulin independent (like the brain), so these tissues are not affected

Question 4

What chemicals are transferred into cells the same way as glucose?

Answer 4

Potassium and phosphorus
- both can move into cells through the action of insulin
- insulin facilitates movement of glucose, phosphorus and potassium into cells

Question 5

What happens when the pancreas senses high blood sugar? What about when it senses low blood sugar

Answer 5

Pancreas releases insulin with high blood sugar, glucagon with low blood sugar

Question 6

What are ketones exactly?

Answer 6

Acids- specifically acetone, acetoacetate and beta-hydroxybutyrate

Question 6

Why does hyperglycemia result from diabetes?

Answer 6

Without functioning insulin, there is a lack of cellular uptake of glucose leading to hyperglycemia
- in addition, cells complain that they are starved leading to glycogenolysis and gluconeogenesis

Question 6

When does ketosis result?

Answer 6

Without insulin, or without a substrate for insulin, fatty acids will be converted to ketone bodies to act as a fuel source for cells (besides liver cells)
-not a problem until it gets excessive

Question 7

When do ketones become a problem?

Answer 7

When there are too many of them, acidemia results
-aka ketoacidosis
-varies from patient to patient how many ketones will result in acidemia (pH will be lower in these patients)

Question 8

How can you treat diabetic ketoacidosis?

Answer 8

Convert them back to a regular diabetic
- you do this with insulin- feed the cells so they stop complaining of starvation and they no longer encourage the formation of ketones

Question 9

Why do patients develop DKA?

Answer 9

-unmanaged or poorly managed diabetes mellitus (some diabetics arent recognized until they develop DKA)

OR

Previously well managed diabetic develops a co-morbidity
-comorbidity leads to worsened insulin resistance and dysregulation of DM
-could be a spontaneous new disease (ex: neoplasia, cushings disease, hyperthyroidism)
-or could be a consequence of DM itself (infections, or pancreatitis)

Question 10

What is the most common infection that patients get related to diabetes mellitus?

Answer 10

UTIs- due to lots of glucose in the urine

Question 11

What is the difference between “regular” insulin and intermediate or long acting insulin?

Answer 11

Regular- short acting, not used for maintenance therapy
- can be used in emergency management of diabetic crises
-similar to the insulin the pancreas creates

Intermediate or long acting
- used for maintenance therapy
- usually twice daily dosing
- occasionally can be used in DKA patients

Question 12

What is normal blood pH?

Answer 12

Around 7.4

Question 13

How can you easily measure serum ketones?

Answer 13

PCV tube spun down- dab serum on urine ketone strip

Question 14

What are some blood gas findings that would point towards a diagnosis of DKA?

Answer 14

Low pH, elevated lactate, significant elevated glucose

Question 15

What is recommended for a starting potassium dose for DKA patients?

Answer 15

.2 mEq/kg/hr= 100 mEq/L of NaCl

Question 16

What is the recommended product for measuring BG in DKA patients?

Answer 16

Freestyle libre monitor
- measures glucose in interstitium (lags by 10-15 min from blood glucose)
- try to measure every 1-2 hours after intake

Question 17

Why should you wait before immediately giving insulin in DKA patients?

Answer 17

Lots of moving pieces
- try to rehydrate first to see glucose drop from just rehydration
- electrolytes will change with fluids as well

*ideally start within a few hours (1-4)

Question 18

What are the options for insulin therapy in DKA patients?

Answer 18

Regular insulin CRI, Regular insulin q1-4 h IV or IM, or long-acting insulin every 12 hours sq (not predictably effective if still dehydrated)

Question 19

How can you determine if insulin dose needs to be adjusted in DM cases? DKA?

Answer 19

DM: Glucose curve
- trying to minimize the swing of the curve

DKA: Ketones, pH and CO2 on a blood gas
*rather than trying to avoid hypoglycemia, offer more substrate (dextrose)
-need to keep giving insulin until acidemia is reversed

Question 20

T/F: you can use “the chart” for calculating insulin rates

Answer 20

F
- encourages lack of thinking
- doesn’t separate insulin and fluid therapy
- doesnt have room for rapid changes in blood glucose
- doses are too low