Diabetic Ketoacidosis(DKA)

Question 1

in what circumstances does DKA usually occur

Answer 1

absolute or relative insulin deficiency, accompanied by an increase in the counter-regulatory hormones(eg glucagon, adrenal, cortisol, GH)

Question 2

in what types of diabetes can DKA occur, and what type does it most often occur in

Answer 2

type 1 or type 2, but mostly occurs in type 1

Question 3

describe the pathophysiology of DKA

Answer 3

when insulin deficiency, glucose can’t enter the cells so instead of glucose other metabolites are used, one of which is lipids which metabolised forms FFAs and build up leads to ketogenesis/acidosis

Question 4

what measurements are used in the biochemical diagnosis of DKA (3)

Answer 4

ketonaemia >3mmol/l, or ketonuria >2 on urine stick
BG >11mmol/l, or known diabetic
Bicarbonate <15mmol/l, or venous pH<7.3

Question 5

what are some of the causes of death in people with DKA

Answer 5

hypokalaemia, aspiration pneumonia, ARDS
cerebral oedema in children
(only 2-5% mortality for DKA)

Question 6

what are the precipitants of DKA due to insulin deficiency

Answer 6

newly diagnosed patients, or non-adherence/poor self-management is commonest cause

Question 7

what are the precipitants of DKA due to increased insulin demand

Answer 7

infections(eg pneumonia), inflammation(eg pancreatitis), intoxication(eg alcohol), infarction(eg acute MI), iatrogenic(eg steroids)

Question 8

what are the typical osmotic related signs and symptoms of DKA

Answer 8

thirst, polyuria, dehydration

Question 9

what are the typical ketone body related signs and symptoms of DKA

Answer 9

flushed, vomiting, abdo pain/tenderness, breathless, palpitations/chest pain
(note not all patients can smell ketones on breath)

Question 10

what are some typical associated conditions with DKA

Answer 10

underlying sepsis, gastroenteritis

Question 11

describe the monitoring of potassium in DKA

Answer 11

often above 5.5mmol/l at start, but soon as insulin given can drop and cause hypokalaemia if not monitored and replenished

Question 12

describe the levels of sodium, creatinine and amylase in DKA

Answer 12

sodium = often low or low normal
creatinine = often raised
amylase = often raised

Question 13

what are the management principles for DKA

Answer 13

replace losses, address risks, IV fluid resuscitation, monitoring

Question 14

what losses need to be replaced in DKA treatment

Answer 14

fluid(initially with 0.9% sodium, then switch to dextrose when glucose drops to 15)
insulin, potassium, phosphate

Question 15

what risks need to be addressed when treating DKA

Answer 15

is naso-gastric tube needed?, monitor K+, prescribe prophylactic LMWH, source sepsis(CXR, blood culture etc.)

Question 16

describe the IV Fluid resuscitation treatment for DKA

Answer 16

1000ml NaCl 0.9% in first hour
2000ml NaCl by 2 hours
3000ml NaCl by 4 hours

Question 17

describe the biochemistry monitoring during DKA treatment

Answer 17

blood for U&Es and bicarbonate level at start, hour 2 and hour 4
IV K+ replacement

Question 18

what insulin should be given in DKA treatment

Answer 18

‘usual’ subcutaneous insulin given daily along with IV insulin

Question 19

describe the urine ketone monitoring of DKA patients

Answer 19

urine ketone testing - measure acetoacetate, indicates last 2-4hr ketone levels
(note ketonuria continues after clinical improvement due to mobilisation of ketones from fat tissue)

Question 20

describe the blood ketone monitoring of DKA patients

Answer 20

blood ketone testing - optium metre, measure beta-hydroxybutyrate, metre range 0-8mmol/l, normal <0.6mmol/l

Question 21

what is beta-hydroxybutyrate

Answer 21

one of the main ketones that is measured in DKA

Question 22

what can be done to prevent recurrence of DKA

Answer 22

if new patient/poor management give education about diabetes management and ‘sick day’ rules, can give ketone monitors, arrange follow up consultations and inform local GP