DIABETIC KETOACIDOSIS

Question 1

What is DKA

Answer 1

a condition associated with high blood glucose (usually > 18 mmol/L), which nonetheless, is unavailable to the body tissues as a source of energy.

Question 2

Why are ketones produced in DKA

Answer 2

Fat is burned to produce energy generating ketones as a byproduct of

Question 3

Differences between DKA and Hyperosmolar Non-Ketotic state (HONK)

Answer 3

DKA is more common in Type 1 diabetes but HONK is more common in Type 2 diabetes

Ketones are absent or are in trace amounts in HONK but there is significant ketones in HONK

HONK presents with more severe dehydration compared to DKA

Question 4

Causes of DKA

Answer 4

Severe insulin deficiency
Interruption of antidiabetic therapy
Stress from illness

Question 5

Examples of diseases that precipitate DKA

Answer 5

Infection
MI
Stroke
Surgery
Complicated pregnancy

Question 6

Symptoms of DKA

Answer 6

Polyuria
Polydipsia
Nausea
Vomiting
Abdominal pain
Altered sensorium or collapse
Symptoms of infection or other underlying condition

Question 7

Signs of DKA

Answer 7

Signs of dehydration
Deep and fast breathing
Low BP
Fast and weak pulse
Fruity breath
Confusion, stupor or unconsciousness
Evidence of infection, recent surgery, surgery etc.

Question 8

What causes the fruity breath in DKA

Answer 8

Acetone

Question 9

Investigations in DKA

Answer 9

Random blood glucose (usually >18mmol/l)
Urine glucose (usually >3+)
Urine ketones (usually 2+)
BUE/Cr
FBC
Urine culture
Blood culture
Chest X-ray
Arterial blood gases
ECG

Question 10

Electrolyte abnormalities in DKA

Answer 10

Usually hypokaemia
Hyperkalemia and uraemia in renal failure

Question 11

Role of FBC in DKA

Answer 11

To rule out infection as precipitating factor

Question 12

Purpose of chest X-ray in DKA

Answer 12

Rule out pneumonia

Question 13

Purpose of ECG in DKA

Answer 13

To identify hypokalemia
To rule out acute MI as a precipitating factor in adults

Question 14

Treatment objectives in DKA

Answer 14

To replace the fluid losses
To replace the electrolyte losses, especially potassium
To replace deficient insulin
To seek the underlying cause and treat appropriately

Question 15

Three stages of DKA management according to STG

Answer 15

Initiating management
Maintaining management
Regular management

Question 16

What blood glucose and urine ketone level should DKA management be initiated

Answer 16

Blood glucose
>18 mmol/L
Or
Urine ketones
>2+

Question 17

Initiating management of DKA in adults

Answer 17

Monitor blood glucose hourly
Monitor urine ketones twice
daily

IV FLUIDS
0.45% N/S
1st litre over first 30 mins
2nd litre over next 1hour
3rd litre over next 4 hours
4th litre over next 4 hours
Subsequently, 1 litre every 6 hours or as required

Soluble or regular insulin
IV or IM, 10-20 units stat.
Thereafter, administer
Soluble/regular insulin,
IV Infusion 0.1 U/kg hourly
Or
5-10 units IM hourly
until blood glucose < 11 mmol/L

KCl Infusion
Start 2 hours after initiating insulin and Sodium Chloride Infusion
Check adequate urine output (>30 ml/hour)
Place 10-20 mmol KCl in 500 ml N/S
Run the IV infusion over at least one hour

Question 18

When is treatment of DKA moved from initial management to maintaining management

Answer 18

Blood glucose
< 13 mmol/L

Question 19

Regimen for maintaining management of DKA in adults

Answer 19

Monitor blood glucose every 4 Hours
Monitor urine ketones twice daily

IV FLUIDS
Glucose 5% to prevent subsequent hypoglycaemia
Continue Glucose 5% 1 litre every 6 hours or to meet requirements

Insulin
Regular insulin SC by ‘sliding scale’

KCL infusion
Repeat Potassium Infusion
after 2 hours if necessary
Check blood Potassium
level twice Daily
Withhold KCl if blood level
of potassium > 6 mmol/L

Question 20

When is management of DKA moved from maintaining management to regular management

Answer 20

Blood glucose 6-11
Urine ketones negative or trace

Question 21

Regular management of DKA in adults

Answer 21

Monitor blood glucose twice daily (pre-breakfast and pre-supper)

Fluids
Make sure patient is eating normally

Insulin
Change from ‘sliding scale’ to twice daily subcutaneous intermediate-acting or premixed insulin

Potassium chloride, oral, if required

Question 22

Initiating management for DKA in children

Answer 22

Monitor blood glucose hourly
Monitor urine ketones twice
daily

Fluids
Sodium Chloride 0.9%
1st hour 15 ml/kg
2nd hour 15 ml/kg
3rd Hour 7.5 ml/kg
4th hour and subsequently, adjust fluid rate to meet requirements

Soluble/ regular insulin,
IV or IM, 0.15 unit/kg stat
Thereafter, administer
Soluble/regular insulin, IV Infusion or IM 0.1 units/kg hourly
until Blood glucose
< 11 mmol/L

KCl
Start 2 hours after initiating
insulin and Sodium Chloride Infusion
Check adequate urine
output (>30 ml/hour)
Add KCl 0.2-0.4 mmol/kg (max. 10 mmol) in IV fluids. Run infusion over at least one hour

Question 23

Maintaining managment of DKA in children

Answer 23

Monitor blood glucose every 4 Hours
Monitor urine ketones twice daily

Sodium Chloride in 4.3%
Glucose to prevent subsequent hypoglycaemia
Set Infusion rate to meet requirements

Soluble/ regular insulin
subcutaneously by ‘sliding scale’

KCl
Repeat Potassium Infusion after 2 hours if necessary
Check blood Potassium level twice Daily
Withhold KCl if blood level
of potassium > 6 mmol/L

Question 24

Regular management of DKA in children

Answer 24

Monitor blood glucose twice daily (pre-breakfast and pre-supper)

Fluids
Make sure patient is eating normally

Insulin
Change from ‘sliding scale’ to twice daily subcutaneous intermediate-acting or premixed insulin

Potassium chloride, oral, if required

Question 25

Sliding scale

Answer 25

Monitor blood glucose and give corresponding insulin dose

6.0- No insulin
6.1 - 9.0: 4U in adults, 0.06U/kg in children
9.1 - 12.0: 6U in adults, 0.09U/kg in children
12.1 - 15.0: 8U in adults, 0.12U/kg in children
15.1 - 18.0: 10U in adults, 0.15U/kg in children

Question 26

How long on average does a patient have to be on sliding scale before until the patient is eating normally and the urine is free of ketones before changing to twice-daily intermediate or premixed insulin

Answer 26

12 to 72 hours

Question 27

Referra criteria for DKA

Answer 27

Inadequate resources for managing the patient

If the patient remains comatose or fails to pass adequate amounts of urine despite management, refer to a regional or teaching hospital for further care