DIABETIC KETOACIDOSIS Flashcards
What is DKA
a condition associated with high blood glucose (usually > 18 mmol/L), which nonetheless, is unavailable to the body tissues as a source of energy.
Why are ketones produced in DKA
Fat is burned to produce energy generating ketones as a byproduct of
Differences between DKA and Hyperosmolar Non-Ketotic state (HONK)
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
Causes of DKA
Severe insulin deficiency
Interruption of antidiabetic therapy
Stress from illness
Examples of diseases that precipitate DKA
Infection
MI
Stroke
Surgery
Complicated pregnancy
Symptoms of DKA
Polyuria
Polydipsia
Nausea
Vomiting
Abdominal pain
Altered sensorium or collapse
Symptoms of infection or other underlying condition
Signs of DKA
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.
What causes the fruity breath in DKA
Acetone
Investigations in DKA
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
Electrolyte abnormalities in DKA
Usually hypokaemia
Hyperkalemia and uraemia in renal failure
Role of FBC in DKA
To rule out infection as precipitating factor
Purpose of chest X-ray in DKA
Rule out pneumonia
Purpose of ECG in DKA
To identify hypokalemia
To rule out acute MI as a precipitating factor in adults
Treatment objectives in DKA
To replace the fluid losses
To replace the electrolyte losses, especially potassium
To replace deficient insulin
To seek the underlying cause and treat appropriately
Three stages of DKA management according to STG
Initiating management
Maintaining management
Regular management
What blood glucose and urine ketone level should DKA management be initiated
Blood glucose
>18 mmol/L
Or
Urine ketones
>2+
Initiating management of DKA in adults
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
When is treatment of DKA moved from initial management to maintaining management
Blood glucose
< 13 mmol/L
Regimen for maintaining management of DKA in adults
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
When is management of DKA moved from maintaining management to regular management
Blood glucose 6-11
Urine ketones negative or trace
Regular management of DKA in adults
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
Initiating management for DKA in children
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
Maintaining managment of DKA in children
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
Regular management of DKA in children
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
