DKA Flashcards
What is diabetic ketoacidosis?
When there is severe lack of insulin in the body
This means the body can’t use sugar for energy, and starts to use fat instead.
When this happens, chemicals called ketones are released. If left unchecked, ketones can build up and make the blood become acidic
What are the symptoms of DKA?
- Abdominal pain
- Vomiting/nausea
- Dehydration
- Weakness
- Altered mental state (e.g. confusion, black outs)
- Kussmaul respirations (deep, rapid breathing)
- Tachycardia
- Hypotension
- Hypothermia (peripherally vasodilated)
- Sweet smelling breath (fruity)
What can cause DKA?
- Infection (due to increased counter-regulatory hormones resulting in increased insulin resistance)
- Non-compliance with medication
- Surgery or injury
- Drugs that affect carbohydrate metabolism (e.g. corticosteroids, thiazide diuretics, antipsychotics, sympathomimetics)
- SGLT2 inhibitors
How is DKA diagnosed?
DKA is possible even if glucose levels are normal
Differential diagnosis with other types of acidosis:
- Lactic acidosis (will have raised lactate)
- Starvation and alcoholic ketosis (will be hypoglycaemic or mildly raised glucose)
What is the treatment for DKA?
- Fluid replacement
- Aim to restore circulatory volume
- Start crystalloid, sodium chloride 0.9%, prior to starting the fixed rate insulin
- Amount dependent on systolic blood pressure
- Potassium is then added to the second litre of IV fluid if potassium is <5.5 mmol/L - Fluid rate insulin
- FRII is a solution of 50 units of human soluble insulin in 50mL 0.9% sodium chloride
- FRIII should be continued until ketones are less than 0.6 mmol/L and venous pH is over 7.3
- Continue long acting basal insulin (detemir, glargine, degludec) - Glucose
- When blood glucose is <14mmol/L, IV glucose 10% infusion should be introduced alongside sodium chloride 0.9% to prevent hypoglycaemia
- This should not be discontinued until the patient is eating and drinking normally
Routine phosphate or bicarbonate replacement not usually indicatedd
- Bicarbonate will correct as DKA resolves and due to fluid replacement
What monitoring is required during DKA treatment?
Ketones
- Ketones should be monitored hourly and should fall by 0.5mmol/L/hr, if this is not the case, insulin infusion should be increased by 1.0 unit/hr
Blood glucose
- Monitor hourly
- The infusion rate should be increased by 1.0unit/hr if blood glucose is not falling by at least 3.0mmol/L/hr
Potassium
- Individuals with DKA often present with hyperkalaemia (potassium >5.5 mmol/L), which falls dramatically when insulin infusion is initiated
- Monitor venous blood gases for pH, bicarbonate and potassium every hour for 2 hours, every 2 hours thereafter for up to 6 hours, and then 12-hourly after that
Venous blood gases
- Bicarbonate
- Phosphate
How is sliding scale stopped?
Transfer to subcutaneous insulin once patient is eating and drinking
AND ketones < 0.6mmol/L AND pH > 7.3
Do not discontinue intravenous
insulin infusion until 30 minutes after subcutaneous short acting insulin has been given
What are key counselling points to help prevent/recognise DKA?
If you become unwell ensure you:
- Stay hydrated (100-150ml p/hour)
- Maintain food intake
- Never stop insulin; you may have to adjust the dose
- Increase the frequency of blood glucose monitoring to 2 to 4-hourly, if you normally
check your blood sugar levels.
- If you are unwell and do not have access to blood glucose monitoring,
look for symptoms of high blood glucose and seek medical advice if you
have these
Medication (if you unable to eat and drink as normal):
- Stop taking the SGLT-2 inhibitors (‘flozins’), metformin, sulfonylureas (gliclazide, glipizid), GLP-1 analogues (e.g. exenatide, dulaglutide) until you feel well again and are eating and drinking normally
- Stop other medication such as metformin, ACE inhibitors/ARBs, diuretics, NSAIDs
