DKA

Question 1

A 29-year-old woman is brought to resus having been found to be drowsy. Her partner is with her who has told staff that she is an** insulin dependent diabetic**. He has brought her insulin with her. He is unsure of her normal dose or when she takes it. He thinks she has been suffering from the flu for the last few days and has not been eating or drinking as much as she usually does. Today she has been very drowsy and confused.

Observations:
* BP 87/52, HR 114
* T 38.2 C
* SpO2 96% RA
* RR 28

Venous Blood Gas
* pH: 7.18
* pCO2: 4.86
* HCO3: 15.3
* BE: -6.3
* Lactate: 3.4
* Glucose: 18.6

What is the likely diagnosis and what may have precipitated this?

Answer 1

Diabetic Ketoacidosis in an insulin-dependent diabetic precipitated by intercurrent illness (flu) and lack of eating and drinking

Also precipitated by non-compliance with treatment

Question 2

What clinical features might you expect to see with DKA?

Answer 2

• Unexplained weight loss
• Nausea & Vomiting
• Abdominal pain
• Polyuria
• Polydipsia
• Lethargy, drowsiness, coma
• Rapid/deep breathing (Kussmaul)

Question 3

How would you assess this patient?

Answer 3

ABCDE approach

A
* Ensure patent airway, no obstruction
* Assumed if pt alert and communicating

B
* Monitor SpO2 and RR
* High flow O2 if SpO2 < 94%
* Ausculatate for crepitations / consolidation

C
- Monitor HR, BP
- CRT both peripherally and centrally
- 12-lead ECG
- 2x IV access (large bore)
Arterial line may be indicated (easy ABGs & K+) - ITU SpR
- Draw bloods
- IV fluid resuscitation
- Monitor urine output - insert catheter

D
- Temperature, blood sugar

E
- Appropriately expose and examine abdomen and limbs for signs of infection

Question 4

What initial investigations would you do?

Answer 4

Bedside
- Monitor SpO2, HR and BP
- 12-lead ECG monitoring

Bloods
* ABG, blood glucose
* FBC, U&E, LFTs, serum osmolality
* BLood cultures, urine dip, urine MC&S
* CXR (chest infection, fluid)

Question 5

What management would you initiate?

Answer 5

Most trusts will have their protocols, basic principles are:

Fluid replacement
* Avg fluid loss in DKA is 100mL/kg
* Aggressive fluid resuscitation essential
* First litres usually given as STAT
* When BM < 14, IV dextrose given concurrently with 0.9% saline

Insulin replacement
* A fixed rate insulin infussin (FRII) at initial rate of 0.1 unit/kg/hour
* If BM not dropping by 5mmol/h & capillary ketones by 1mmol/L, the infusion is increased by 1 unit/hr

Continue FRII until
* capillary ketones < 0.6, venous pH > 7.3 & venous bicarbonate > 18
* If pt eating and drinking regularly > stop FRII and change to SC insulin regime
* If on long acting insulin, this should be given from the date of admission as usual

Potassium replacement
- Plasma K+ falls rapidly as it shifts into cells under the action of insulin
- Monitor closely - 60 min then 2 hourly
- If K+ < 5.5 mmol/L, add KCL 40mmol/L to the ongoing fluid

Others
* Infection suspected: broad spectrum antibiotics
* Thromboprophylaxis
* NG tube if GCS is reduced

FRII: 50u Actrapid in 50mL 0.9% saline

Question 6

What features of the presentation would indicate early referral to ITU?

Answer 6

Early referral recommended with any of the following features:
* pH < 7.1
* Severe DKA: Ketones > 6 mmol/L or Bicarbonate < 5 mmol/L
* HypoK on admission < 3.5 mmol/L
* GCS < 12
* Systolic BP < 90 mmHg
* Significant co-morbidity
* Pregnant

Question 7

What are some of the complications of DKA?

Answer 7

Secondary to treatment
* Hypokalaemia
* Hypophosphataemia
* Cerebral oedema
* Hypoglycaemia

Secondary to DKA
* Tissue hypoperfusion (from dehydration)
* Hypercoagulable state > thromboembolism

Question 8

How will you manage this patient prior to discharge?

Answer 8

• Discuss precipitants of DKA
  Most common: non-complinance (accidental or intentional)
• Advise to seek early medical advice if she feels that she is becoming unwell in the future (early Rx of underlying infection can stop the progression of DKA)
• Make sure she has been seen by the hospital diabetic team
• Ask GP to arrange early follow up

Question 9

What is Hyperosmolar Hyperglycaemic State (HSS)?

Answer 9

HSS is characterised by:
* Hyperglycaemia (>30 mmol/L)
* Hyperosmolarity (osmolality >320 mOsmol/kg)
* Significant volume depletion (without significant ketoacidosis)

Usually affects patients with T2DM

Question 10

How does the management of HSS differ from DKA?

Answer 10

Initial aggressive fluid resuscitation is similar, but insulin is not given as blood glucose will fall naturally with fluid replenishment
* Typical fluid loss is** 8-15L** for a 70kg adult
* 0.9% NaCl, 1l over 1h, then 2h, then 4h
* Aim 3-4L positive balance by 6h

Osmolality should be reduced by 3-8 mOsmol/kg/h

Insulin usually not needed, as BM will fall with fluid resuscitation. If mixed picture with DKA, Insulin will be necessary

Question 11

You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover.

Answer 11

Situation: I am handing over a 29 year old woman who has presented in diabetic ketoacidosis. Her clinical observations suggest that she may be septic. .

Background: She is an insulin dependent diabetic, and has been unwell for several days with a reduced oral intake. It is not clear when she last took insulin.

Assessment: I have started aggressive fluid management, a fixed rate insulin infusion and broad spectrum antibiotics.

Recommendations: This patient needs a referral to ITU because they are hypotensive and meet the criteria for ITU intervention. Glucose and ketone monitoring will be required once the insulin infusion has started. They will need regular bloods to monitor their potassium which could drop with initiation of treatment.