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Y3 - Endocrine and metabolic > Diabetic ketoacidosis > Flashcards

Diabetic ketoacidosis Flashcards

1
Q

What is the definition of diabetic ketoacidosis?

A

A complication of diabetes mellitus caused by absolute or relative insulin deficiency

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2
Q

What are the 3 criteria that need to be met for diagnosing diabetic ketoacidosis?

A
  1. Hyperglycaemia >11 mM or known diabetes
  2. Ketonaemia >3 mM or ketonuria >2+
  3. Acidosis pH <7.3 and/or bicarbonate <15 mM
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3
Q

Does it usually occur in type 1 or type 2 diabetics?

A

Type 1

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4
Q

What are type 2 diabetics with diabetic ketoacidosis more likely to suffer from?

A

related condition hyperglycaemic hyperosmolar state (HHS)

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5
Q

What is the epidemiology of DKA?

A

Annual incidence of 1-5% amongst patients with type 1 DM
More common in women than men

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6
Q

What are 2 causes of diabetic ketoacidosis?

A
  1. Lack of compliance with insulin therapy
  2. Acute illness (eg infection, MI, trauma)
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7
Q

What is the pathophysiology of DKA?

A
  1. Insulin deficiency renders cells unable to take up and metabolise glucose
  2. Glucose remains trapped in the blood from where it is filtered by the kidney in concentrations that exceed renal reabsorption capacity
  3. Glycosuria causes a profound osmotic diuresis leading to severe hydration
  4. Unable to rely on carbohydrate metabolism, cells switch to fat metabolism and oxidise fatty acids to release acetyl coenzyme A (CoA) in concentrations that saturate the Kreb’s cycle
  5. Excess acetyl CoA is converted to the ketone bodies acetone, acetoacetate and beta-hydroxybutyrate, which are released into the blood causing a raised anion gap metabolic acidosis
  6. DKA mostly occurs in type 1 DM and is rare in type 2 DM because there is usually adequate levels of insulin to prevent ketogenesis
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8
Q

What are the symptoms of DKA?

A

Polyuria
Polydipsia
Light-headedness
Nausea and vomiting
Abdominal pain
Dyspnoea
Drowsiness
Loss of consciousness
Lack of compliance with insulin therapy
Symptoms of the precipitantc

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9
Q

Airway: DKA

A

May be compromised due to conscious level

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10
Q

Breathing: DKA

A

Kussmaul’s breathing - Hyperventilation to compensate for metabolic acidosis manifesting as ‘air hunger’

Acetone-smelling breath

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11
Q

Circulation: DKA

A
  1. Cold pale peripheries
  2. Prolonged cap refill times
  3. Decreased skin turgor
  4. Reduced JVP
  5. Sunken eyes
  6. Dry lips, mouth and tongue
  7. Tachycardia
  8. Postural hypertension
  9. Absolute hypotension
  10. Cardiac arrythmias precipitated by electrolyte disturbances
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12
Q

Disability: DKA

A
  1. Confusion
  2. Reduced conscious levels
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13
Q

Exposure: DKA

A

Signs of the precipitant

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14
Q

What are some differential diagnoses of DKA?

A

Hyperglycaemic hyperosmolar state (HHS)

Any cause of an acute abdomen (including medical causes) if presenting with abdominal pain

Other cause of raised anion gap metabolic acidosis
Alcohol
‘MUDPILES’: Methanol, uraemia, [DKA], paraldehyde, isoniazid, lactate, ethylene glycol, salicylates
Carbon monoxide/cyanide

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15
Q

What investigations can be carried out to investigate DKA?

A

Capillary blood glucose
Capillary blood ketones
VBG
Full bloods
Blood cultures
ECG
Urinalysis
Chest X-ray

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16
Q

What is the initial management of DKA?

A

Deliver high flow oxygen 15L/min via reservoir mask and titrate to achieve oxygen saturations (SpO2) 94-98% or 88-92% if known to have COPD

17
Q

What should be requested ASAP?

A

ECG - 12 lead
Chest X-ray
Bloods

18
Q

What should be be the next step after high flow oxygen?

A

Fluid resuscitation

19
Q

What volume of fluids should be given?

A

If systolic blood pressure (SBP) <90 mmHg, give 0.9% saline 500 ml IV stat and repeat as necessary until SBP >90 mmHg
If SBP >90 mmHg, give
0.9% saline 1 L IV over 1 hour
0.9% saline 1 L IV over 2 hours
0.9% saline 1 L IV over 2 hours
0.9% saline 1 L IV over 4 hours
0.9% saline 1 L IV over 4 hours
0.9% saline 1 L IV over 6 hours

20
Q

What should be infused?

A

Insulin infusion

Ask the nursing staff to draw up 50 units of actrapid in 50 ml of 0.9% saline (1 unit/ml) and run at 0.1 unit/kg/hour eg 7 units/hour for a 70 kg individual

21
Q

How quickly should ketone levels fall after insulin infusion?

A

Ketone levels should fall by 0.5 mM/hour

22
Q

What should be done if ketones do not fall adequately after insulin infusion?

A

increase the infusion rate by 0.1 unit/hour increments until this target rate is achieved

23
Q

What issues present when rates adequate to switch off ketogenesis are met?

A

ates adequate to switch off ketogenesis will usually render individuals hypoglycaemic so commence glucose 10% IV at 125 ml/hour once glucose <14 mM
Continue any long-acting insulin therapy at the usual dose and timing

24
Q

What will happen to potassium levels once insulin infusion has been given?

A

Although potassium levels may be high on arrival, they will fall rapidly once the fixed rate insulin IV infusion commences. The supplementation suggested below should be added to the resuscitation fluid.
Potassium >5.5 mM requires no supplementation
Potassium 3.5-5.5 mM requires supplementation of replacement fluid with potassium chloride (KCl) 40 mM
Potassium <3.5 mM requires supplementation of replacement fluid with KCl 60-80 mM and high dependency unit (HDU) care

25
Q

Should anticoagulation be given?

A

Yes
DKA is a hypercoagulable state so consider enoxaparin 1.5 mg/kg subcutaneously (SC)

26
Q

How often should tests be repeated?

A

Blood glucose and ketones should be checked hourly
VBG should be repeated at 1 hour, and 2 hourly thereafter
Aim for a urine output of >0.5 ml/kg/hour; insert a urethral catheter if necessary

27
Q

What clinical features in patients with DKA might you want to consider for a critical care referral?

A

Hypoxia
Hypotension
Reduced conscious level
Age >65 years
Significant cardiac or renal co-morbidities

28
Q

What biochemical features in patients with DKA might you want to consider for a critical care referral?

A

pH <7.1
Bicarbonate <5 mM
Ketonaemia >6 mM
Serum osmolalaity >320 mOsm/L
Potassium < 3.5 mM on admission

29
Q

What are 6 complications for DKA?

A
  1. Hyperkalaemia
  2. Hypokalaemia
  3. Hypoglycaemia from fixed rate insulin IV infusion without glucose supplementation
  4. Cerebral oedema
  5. Pulmonary oedema
  6. Death
30
Q

What molecule buffers ketones in the blood?

A

bicarbonate (produced by the kidneys)

31
Q

Summarise the management for diabetic ketoacidosis:

A

1) correct dehydration over 48 hours to dilute the hyperglycaemia and ketones
2) insulin infusion
3) once glucose falls to 14mmol/L, give IV dextrose to prevent hypoglycaemia

32
Q

What is a key complication in diabetic ketoacidosis treatment in children?

A

cerebral oedema

33
Q

Describe how cerebral oedema can manifest in children during treatment of diabetic ketoacidosis:

A

1) dehydration and hyperglycaemia cause water to move from the intracellular space in the brain to the extracellular space, causing brain cell to shrink
2) rapid correction of dehydration and hyperglycaemia causes a rapid shift in water from the extracellular to intracellular space which can cause the brain to swell and become oedematous
3) this can lead to brain cell destruction and death

Y3 - Endocrine and metabolic (20 decks)

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