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Endocrinology > Diabetic ketoacidosis > Flashcards

Diabetic ketoacidosis Flashcards

1
Q

What is DKA?

A

Disordered metabolic state that usually occurs in the context of an absolute or relative insulin deficiency accompanied by an increase in the counter-regulatory hormones e.g. glucagon, adrenaline, cortisol and growth hormone

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2
Q

What type of diabetes is DKA most common in?

A

Type 1

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3
Q

What are some infections that can increase insulin demand, leading to DKA?

A

Pneumonia
UTIs
Cellulitis

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4
Q

What are some inflammatory disorders that can increase insulin demand, leading to DKA?

A

Pancreatitis
Cholecystitis

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5
Q

What are some forms of intoxication that can increase insulin demand, leading to DKA?

A

Alcohol
Cocaine
Salicylate
Methanol

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6
Q

What are some infarction that can increase insulin demand, leading to DKA?

A

Acute MI
Stroke

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7
Q

What are some iatrogenic factors that can increase insulin demand, leading to DKA?

A

Steroids
Surgery

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8
Q

Describe the formation of ketone bodies in DKA?

A
  1. Ketone bodies are formed from acetyl-CoA in the mitochondria (From ß-oxidation of fats)
  2. These are useful in energy metabolism, and are usually converted back into acetyl-CoA, which enters the TCA cycle
  3. If glycolysis is reduced and glucose limited, the excess acetyl-CoA remains as ketones
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9
Q

What is another non-diabetic condition that can lead to ketoacidosis?

A

Starvation

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10
Q

How does starvation cause ketoacidosis?

A

Oxaloacetate is consumed for gluconeogenesis and when glucose is not avaliable fatty acids are oxidised to provide energy; the excess acetyl-CoA will be converted into ketones

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11
Q

What are some of the consequences of high ketone levels in the blood?

A

Acidosis
Osmotic diuresis due to high glucose excretion
Decreased renal function
Coma
Death

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12
Q

What are some osmotic related symptoms of DKA?

A
  • Thirst and polyuria
  • Dehydration
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13
Q

What are some ketone body related symptoms of DKA?

A
  • Flushed
  • Vomiting
  • Abdominal pain and tenderness
  • Increased respiratory rate
    • Kussmaul’s respiration
  • Distinctive smell on breath (not present in all individuals)
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14
Q

What is meant by Kussmaul’s respiration?

A

deep, rapid breathing pattern associated with severe metabolic acidosis

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15
Q

How do ketone bodies cause nausea and vomiting?

A

Ketone bodies can stimulate chemotrigger zone receptors in the brain causing nausea and vomiting

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16
Q

How do ketone bodies cause acidosis?

A

Ketone bodies can give off H+ ions, causing acidosis

17
Q

How do ketone bodies cause arrhythmia and ileus (Abdominal pain)?

A

H+ moves into the ICF, but K+ leaves, causing an increase in K+ in ECF

This can lead to arrhythmia and ileus (Abdominal pain)

18
Q

How do ketone bodies cause increased respiratory rare and fruity breath?

A

Increased protons stimulates peripheral chemoreceptors located to the certodi and aortic bodies, connected to vagus nerve

This causes increase in respiratory rate to get rid of CO2, causing Kussmaul’s respiration and breathing off of acetone (Fruity breath)

19
Q

What are some conditions associated with DKA?

A
  • Underlying sepsis
  • Gastroenteritis
20
Q

What tests are required in diagnosis of DKA?

A

Ketone measurement
Blood glucose levels
Bicarbonate levels

21
Q

What ketone level provides diagnosis of DKA?

A

Ketonaemia ≳3 mmol/L, or significant ketouria (≳2 on standard urine stick)

22
Q

What blood glucose level provides diagnosis of DKA?

A

Blood glucose > 11.0/L or known DM

23
Q

What bicarbonate level provides diagnosis of DKA?

A

Bicarbonate <15 mmol/L and/or venous pH <7.3

24
Q

What are some other biochemistry signs of DKA?

A

Potassium >5.5mmol/L
Raised creatinine
Low sodium
Raised amylase
Raised WCC

25
Q

What are the 5 stages of DKA management?

A
  1. Correction of dehydration - IV fluids
  2. Correction of hyperglycaemia - IV insulin
  3. Electrolyte imbalance
  4. Indentification of comorbid precipitating events
  5. Very frequent monitoring and observations
26
Q

Why do DKA patients in management require constant potassium level measurement?

A

Insulin can further decrease K+ levels

27
Q

What is the fluid replacement strategy used in DKA?

A
  • 1000mL NaCl 0.9% in the first hour
  • 20000mL NaCl by end of hour 2
  • 30000mL NaCl by end of hour 4
  • Once blood-glucose concentration falls below 14 mmol/litre, IV glucose 10% should be given in addition to the sodium chloride 0.9% infusion
28
Q

What is the electrolyte replacement strategy used in DKA?

A
  • NaCl 0.9% as above
  • IV Potassium
  • Phosphate rarely replaced
29
Q

How is acid-base balance restored in DKA management?

A

Bicarbonate rarely replaced as once the circulating volume is restored the metabolic acidosis is rapidly compensated

30
Q

What is the insulin replacement strategy used in DKA?

A
  • IV insulin 0.1 units/kg per hour to suppress ketogenesis, lower the glucose and correct the electrolyte disturbance
  • Continue ‘usual’ SC daily basal insulin
  • Continue IV insulin until ketoacidosis has been resolved; to prevent hypoglycaemia give 10% glucose IV alongside the 0.9% NaCl once blood-glucose concentration falls below 14 mmol/L
31
Q

What monitoring is required after DKA management?

A
  • Monitor blood-ketone and blood-glucose concentrations hourly
  • Blood gas and electrolytes every 2-4 hours
32
Q

What are some other management strategies used in some DKA cases?

A
  • Seek underlying cause e.g. infection if suspected
  • Patient may aspirate vomit so consider NG tube
  • Dehydration, increased blood viscosity and coagulability of DKA increase risk of thromboembolism - all patients should receive prophylactic LMWH
33
Q

How can recurrence of DKA be prevented?

A
  • Education and support before discharge
  • Provide patient with ketone meter
  • Arrange DSN follow-up and inform GP
34
Q

What are some possible complications of DKA?

A
  • Cerebral oedema - mostly happens in children/YAs
  • Hypokalaemia can cause cardiac arrest and paralytic ileus
  • Aspiration pneumonia
  • ARDS
35
Q
A

Endocrinology (42 decks)

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