Diabetic Ketoacidosis Flashcards

1
Q

What is diabetic ketoacidosis (DKA)?

A

An acute metabolic complication of diabetes that is potentially fatal and requires prompt medical attention for successful treatment. It is characterised by absolute insulin deficiency and is the most common acute hyperglycaemic complication of type 1 diabetes mellitus.

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2
Q

What risk factors are associated with DKA?

A
  • Infection
    • Pneumonia and UTI
  • Discontinuation of insulin (unintentional or deliberate)
  • Inadequate insulin
    • Malfunctioning insulin pen or pump and
      degradation of insulin due to storage at incorrect temperature
  • New onset diabetes
  • Acute illness
    • Myocardial infarction, sepsis and pancreatitis
  • Drug history
    • Corticosteroids, thiazides, sympathomimetics, cocaine, cannabis, and acute intoxication with alcohol
  • Physiological stress
    • Pregnancy
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3
Q

What are the signs of DKA?

A
  • Acetone smell on breath
  • Hyperventilation
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4
Q

What are the symptoms of DKA?

A
  • Known diabetes or features of diabetes e.g. increased thirst, polyuria, recent unexplained weight loss or excessive tiredness
  • Nausea and vomiting
  • Abdominal pain
  • Dehydration
  • Reduced consciousness
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5
Q

What investigations should be ordered for DKA?

A
  • Venous blood gas
  • Blood ketones
  • Blood glucose
  • Urea and electrolytes
  • FBC
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6
Q

What are the parameters for diagnosing DKA?

A
  • Blood ketones are ≥3.0 mmol/L OR there is ketonuria (more than 2+ on standard urine sticks); AND
  • Blood glucose is >11.1 mmol/L OR known diabetes; AND
  • Bicarbonate (HCO3-) is <15.0 mmol/L AND/OR venous pH is <7.3.
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7
Q

Why investigate using venous blood gas? And what may this show?

A
  • Use the pH to determine the severity of DKA:
    • pH ≥7.0 indicates mild or moderate DKA
    • pH <7.0 indicates severe DKA
  • Metabolic acidosis with a raised anion gap
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8
Q

Why use venous blood gas rather than arterial blood gas?

A

Venous blood gas testing may have a lower risk of serious adverse events (e.g., vascular occlusion or infection), is less painful for the patient, and is technically easier to perform than arterial blood gas testing.

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9
Q

Why investigate blood ketones? And what may this show?

A
  • Assessment of ketones should be done at or near the bedside, use urinary ketones if blood is not available
  • Ketonaemia (ketones ≥3.0 mmol/L)
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10
Q

Why investigate blood glucose? And what may this show?

A
  • Assessment of glucose should be done at or near the bedside
  • Hyperglycaemia (blood glucose >11.1 mmol/L)
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11
Q

Why investigate urea and electrolytes? And what may this show?

A
  • Hyponatraemia and hyperkalaemia are common but hypokalaemia is an indicator of severe DKA
  • May show hypomagnesaemia and hypophosphataemia
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12
Q

Why investigate FBC? And what may this show?

A
  • Leukocytosis is common in DKA and correlates with blood ketone levels
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13
Q

What are the 4 aspect which need to be managed in DKA treatment?

A
  1. IV fluid
  2. Potassium
  3. Insulin
  4. Resolution
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14
Q

Briefly describe the IV fluid treatment of DKA

A
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15
Q

Briefly describe the treatment of potassium in DKA

A
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16
Q

Briefly describe insulin therapy in DKA

A
17
Q

Briefly describe the resolution part of DKA treatment

A
18
Q

What complications are associated with DKA?

A
  • Hypokalaemia
  • Hypokalaemia
  • Arterial or venous thromboembolic events
19
Q

What differentials should be considered for DKA?

A
  1. Hyperosmolar hyperglycaemic state (HSS)
  2. Lactic acidosis
  3. Starvation ketosis
  4. Alcoholic ketoacidosis
20
Q

How does DKA and hyperosmolar hyperglycaemic state (HSS) differ?

A
  • Differentiating signs and symptoms: patients are typically older than patients with DKA and are usually patients with type 2 diabetes. Symptoms evolve insidiously over days to weeks. Mental obtundation and coma are more frequent.
  • Differentiating investigations:
    • Serum glucose is >33.3 mmol/L (>600 mg/dL);
    • Serum osmolality is usually >320 mmol/ kg (>320 mOsm/kg);
    • Urine ketones are normal or only mildly positive and serum ketones are negative;
    • ABG: arterial pH is typically >7.30, whereas in DKA it ranges from 7.00 to 7.30
21
Q

How does DKA and lactic acidosis differ?

A
  • Differentiating signs and symptoms: the presentation is identical to that of DKA. In pure lactic acidosis, the serum glucose and ketones should be normal and the serum lactate concentration should be elevated.
  • Differentiating investigations: serum lactate >5 mmol/L.
22
Q

How does DKA and starvation ketosis differ?

A
  • Differentiating signs and symptoms: starvation ketosis results from inadequate carbohydrate availability resulting in physiologically appropriate lipolysis and ketone production to provide fuel substrates for muscle.
  • Differentiating investigations: the blood glucose is usually normal. Although the urine can have large amounts of ketones, the blood rarely does. Arterial pH is normal and the anion gap is at most mildly elevated.
23
Q

How does DKA and alcoholic ketosis differ?

A
  • Differentiating signs and symptoms: classically, these are people with long-standing alcohol use disorder for whom ethanol has been the main caloric source for days to weeks. The ketoacidosis occurs when for some reason alcohol and caloric intake decreases.
  • Differentiating investigations: in isolated alcoholic ketoacidosis, the metabolic acidosis is usually mild to moderate in severity. The anion gap is elevated. Serum and urine ketones are always present. Blood alcohol may be undetectable and the patient may be hypoglycaemic