DKA

Question 1

Define DKA

Answer 1

1. Ketonemia > 3 mmol/L or significant ketonuria ( > 2+ on standard urine sticks)
2. Blood glucose > 11.0 mmol\L or known DM patient
3. Serum venous bicarbonate < 15 mmol\ L and/or pH < 7.3

Question 2

Pathophysiology of DKA

Answer 2

INSULIN DEFICIENCY

1. increased gluconeogenesis - leads to hyperglycemia , glycosuria and cause osmotic diuresis.
2. Decreased glucose uptake by cells
3. Lipolysis is increased - increased free fatty acids in the blood, acetyl coA high, forms ketone bodies (beta hydroxy butyrate & acetone) — leads to acidosis

Question 3

Causes of DKA

Answer 3

1. Insulin deficiency
   - undiagnosed DM
   - diagnosed non compliant patient
   - diagnosed but low dose
2. Infectious- UTI
3. Iatrogenic - surgery
4. Intoxication- alcohol, abuse
5. Infarction- MI,CVA
6. Inflammatory

Question 4

Clinical features of DKA

Answer 4

Symptoms
1. Polyuria,polydypsia, weakness, nausea, vomiting
2. Coffee ground hematemesis
3. Abdominal pain

Physical findings
1. Dry mucous membrane
2. Tachycardia
3. Hypotension
4. Altered mental status
5. Sweet smell in the breath
6. Kussmauls breathing

Question 5

Investigations in DKA

Answer 5

Capillary blood glucose

VBG to determine pH, HCO3-, K+
Urine dipstick to ketone & urinalysis
EXG to Ix silent MI

Question 6

How to assess severity in DKA

Answer 6

1. Bicarbonate level below 5 mmol/L
2. Venous/arterial pH below 7
3. Blood ketones over 6
4. Hypokalemia on admission (under 3.5mmol/L)
5. GCS less than 12
6. O2 saturation below 92% on room air
7. SBP below 90mmHg
8. Pulse over 100 or below 60
9. Anion gap above 16

Précis & elderly —- HDU

Question 7

Causes of mortality in DKA

Answer 7

Severe Hypokalemia
ARDS
Co-morbid conditions that precipitated DKA (pneumonia, acute MI, sepsis)

Question 8

Management of DKA steps

Answer 8

1. Assess severity
2. Fluid replacement
3. Insulin therapy
4. Potassium replacement
5. Correct the acidosis
6. Assess the resolution of ketoacidosis
7. Identify precipitating factors

Question 9

Fluid replacement in DKA

Answer 9

• Replaced as crystalloids
• 0.9 NS 500ml over 10-15 mins

Check SBP

If SBP is less than 90mmHg - then repeat
No improvement? Consider other causes of hypotension
Still SBP < 90mmHg —- senior review
ICU & critical care

Water 100 ml/kg
Na+ 7-10 mmol/kg
K+ 3-5 mmol/kg

Initial SBP> 90 mmHg
01L of NS over 60mins

Replace fluids in 1,2,2,4,4,6 step
- 0.9% NaCl 1L, 1000ml over 01hrs
- 0.9% NaCl with KCl 1000ml over the next 02 hrs
- 0.9% NaCl with KCl 1000ml over the next 02 hrs
- 0.9% NaCl with KCl 1000ml over the next 04 hrs
- 0.9% NaCl with KCl 1000ml over the next 04 hrs
- 0.9% NaCl with KCl 1000ml over the next 06 hrs

Question 10

Insulin therapy in DKA

Answer 10

Fixed rate IV insulin infusion 0.1u/kg
- Monitor CBG hourly
- if the targets are not achieved- increase rate of infusion

• if the patient is in exogenous basal insulin//Lantus - administer as normal
• if glucose drops to less than 14mmol/L , add 10% dextrose infusion
  And
  Reduce the rate of IV insulin infusion to 0.05u/kg/hr

Question 11

Continue insulin infusion until ?

Answer 11

Ketone < 0.6
Venous pH > 7.3
Venous bicarbonate > 18 mmol/ L

Question 12

Potassium replacement

Answer 12

Over 5.5 - no need
3.5-5.5 : 40mmol/Lb
<3.5: senior review

Question 13

Complications of DKA

Answer 13

1. Hypoglycemia
2. Hypokalemia
3. Cerebral edema
4. ARDS