DKA

Question 1

What is diabetic ketoacidosis (DKA)?

Answer 1

DKA is a complication of type 1 diabetes mellitus or can be the first presentation, accounting for around 6% of cases.

Question 2

Can type 2 diabetes mellitus lead to DKA?

Answer 2

Rarely, under extreme stress, patients with type 2 diabetes mellitus may also develop DKA.

Question 3

What has happened to the mortality rates of DKA in the past 20 years?

Answer 3

Mortality rates have decreased from 8% to under 1%.

Question 4

What causes DKA?

Answer 4

DKA is caused by uncontrolled lipolysis, resulting in an excess of free fatty acids converted to ketone bodies.

Question 5

What are the most common precipitating factors of DKA?

Answer 5

The most common factors are infection, missed insulin doses, and myocardial infarction.

Question 6

What are the key features of DKA?

Answer 6

Key features include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and acetone-smelling breath.

Question 7

What are the diagnostic criteria for DKA according to the American Diabetes Association (2009)?

Answer 7

Glucose > 13.8 mmol/l, pH < 7.30, serum bicarbonate < 18 mmol/l, anion gap > 10, and ketonaemia.

Question 8

What are the diagnostic criteria for DKA according to the Joint British Diabetes Societies (2013)?

Answer 8

Glucose > 11 mmol/l or known diabetes mellitus, pH < 7.3, bicarbonate < 15 mmol/l, and ketones > 3 mmol/l or urine ketones ++ on dipstick.

Question 9

What are the main principles of management for DKA?

Answer 9

The main principles include fluid replacement, insulin administration, and correction of electrolyte disturbance.

Question 10

How much fluid do most patients with DKA require?

Answer 10

Most patients are depleted by around 5-8 litres.

Question 11

What is the initial fluid used for DKA management?

Answer 11

Isotonic saline is used initially, even if the patient is severely acidotic.

Question 12

What is the recommended insulin infusion rate for DKA?

Answer 12

An intravenous infusion should be started at 0.1 unit/kg/hour.

Question 13

What should be done once blood glucose is < 14 mmol/l?

Answer 13

An infusion of 10% dextrose should be started at 125 mls/hr in addition to the 0.9% sodium chloride regime.

Question 14

What is the JBDS example of fluid replacement regime for a patient with a systolic BP on admission 90mmHg and over?

Answer 14

0.9% sodium chloride 1L over 1st hour, followed by 1L with potassium chloride over the next 2 hours, and so on for a total of 5 more litres over specified hours.

Question 15

What are the JBDS potassium guidelines for the first 24 hours?

Answer 15

Potassium level over 5.5: Nil; 3.5-5.5: 40; Below 3.5: Senior review needed.

Question 16

How is DKA resolution defined?

Answer 16

DKA resolution is defined as pH > 7.3, blood ketones < 0.6 mmol/L, and bicarbonate > 15.0 mmol/L.

Question 17

What should be done if DKA criteria are met and the patient is eating and drinking?

Answer 17

Switch to subcutaneous insulin and review by the diabetes specialist nurse prior to discharge.

Question 18

What are some complications of DKA?

Answer 18

Complications may include gastric stasis, thromboembolism, arrhythmias, cerebral oedema, acute respiratory distress syndrome, and acute kidney injury.

Question 19

Who is particularly vulnerable to cerebral oedema following fluid resuscitation in DKA?

Answer 19

Children and young adults are particularly vulnerable.