Diabetic Ketoacidosis Flashcards
What is the definition of Diabetic Ketoacidosis (DKA)
DKA is a metabolic state characterised by hyperglycaemia, acidosis and ketonuria
It is severe uncontrolled diabetes requiring emergency treatment with insulin and IV fluids
What is the annual incidence rate per 100 type 1 diabetic patient
1-5 episodes per 100
What age does it usually occur?
<19 but may occur at any age. Most common cause of death in Uk for people with diabetes <20
Is it more common in males or females?
Twice as common in females
What is the average mortality of DKA?
5-10%
Does the mortality rise or lower with age?
Rises with age. 50% >80 years
What are the precipitating factors?
Infection New case of type one diabetes Insulin error Myocardial infarction Stressful events Pregnancy
What problems would the patient face?
Tiredness/lethargic Hyperglycaemia Glycosuria Polyuria Dehydration Ketonuria Ketones on breath Weight loss Nausea/vomiting Abdo pain
What is the progression of DKA?
Drowsy- semi conscious- unconscious
Dehydration- hypovalaemic shock Low bp- tachycardia- higher resp rate Oliguria Dry skin Hyperglycaemia Kyperketonaemia Metabolic acidosis
Breathlessness- kussmals
Loss of potassium- effect on t wave- arrhythmias
Loss of sodium
Signs of infection
What are the priorities?
Airway Unconscious patient Treat shock Reduce blood sugar Replace loss of sodium and potassium Find cause
What observations are needed?
Neuro obs Bp, temp, Hr, RR Hourly bms Hourly urine output Hourly cvp Cardiac monitor Blood gases Urea and electrolytes
What would you do with regards to airway/breathing?
Assessment Position Nil orally Naso gastric tube and aspirations Oxygen Pulse oximetry
What would you do for shock?
Monitor/ obs
Catheterise and hourly urine output
Fluid balance chart
Fluids IVI 500mls stat, then saline 1000 over one hour, 1000 over two hours then 1000 over four hours
Change to 6% dextrose when BG below 15mmol
What would you do for hyperglycaemia?
Monitor/ hourly bms and 2 hour venous sample
Soluble insulin via a pump
Possible sliding scale
Aim to reduce glucose by 3mmol/h
Short acting insulin (humulin s/actrapid)
50 mil sodium chloride 0.9% via a syringe driver 1 unit/milb@ 6 units/h or as prescribed
If <16mmol reduce to 3-4 Units/hour
10-15mmol reduce time 2-3 units
What do you do for hypokalaemia/ hyponatraemia?
Cardiac monitor
IV potassium chloride prescribes in accordance to blood chemistry
Initially 10-30mmol/L administered with I.V fluids via a syringe driver
Sodium chloride infusion
What other investigations could you do?
Blood cultures ECG Chest x ray Urine and sputum for culture Swab any potential infection Pregnancy test
What do you do for prevention?
Sick day rules:
Never stop insulin and check for ketones
Measure bms four times a day
If bm < 11mmol continue normal insulin
If bm 11-17mmol add extra 4 unit with meals
If bm>add extra 6 units with meals, drink milk, fruit juice and 5 pints of sugar free fluid a day
If nausea and vomiting and bm >17 call dr
What is hypoglycaemia?
Common side effect of treatment with insulin or sulphonylureas
Does not occur with metformin or diet alone
Yearly 25-30% of all insulin treated patients have one or more episodes of severe hypoglycaemia
What are the predisposing factors of hypoglycaemia?
Inadequate food intake Excess dosage Exercise Weight loss Alcohol
What are the stages of hypoglycaemia?
Asymptomatic - awake or asleep
Mild symptomatic patient able to treat themselves
Severe symptomatic - help needed to treat hypoglycaemic attack
Coma
What are the symptoms of hypoglycaemia?
Sweating Palpitations Tremor Hunger Confusion Clumsiness Behavioural changes Temper tantrums in children
What is the treatment for hypoglycaemia?
Mild
Treat immediately with oral glucose
If patient unable to swallow
IV 50% dextrose 30-50mls
IM GLUCAGON (1mg)
Patients should recover immediately
