DKA

Question 1

What is DKA?

Answer 1

• = Hyperglycaemia + metabolic acidosis + ketonaemia
• Biochemical criteria:
  
  1. Venous pH < 7.3 or bicarbonate <15 mmol/l
  2. Presence of blood or urinary ketones

Question 2

What can cause DKA?

Answer 2

• Previously undiagnosed diabetes
• Precipitated by:
  ○ Illness
  ○ Poor insulin compliance

Question 3

In the hospital, when should you assess for DKA?

Answer 3

• BGL ≥ 11.1mmol/l

Question 4

What should be assessed when ?DKA

Answer 4

Degree of dehydration

• None/Mild ( < 4%): no clinical signs
• Moderate (4-7%): easily detectable dehydration eg. reduced skin turgor, poor capillary return
• Severe(>7%): poor perfusion, rapid pulse, reduced blood pressure i.e. shock

Level of consciousness (GCS)

Sx:

- Polydipsia
- Polyuria
- Abdo pain
- Vomiting
- Confusion
- Drowsiness -> coma

Signs:

- Altered respiration: Kussmaul's -> inc CO2 expired
- Dehydration signs
- Acetone breath

Question 5

What investigations should be done for ?DKA

Answer 5

• Urinalysis
• Venous blood sample - try put IV in as it’ll be needed if diagnosed:
  • FBE
  • UEC
  • Blood glucose
  • Blood ketones on capillary sample (positive > 0.6mmol/l)
  • Venous blood gas
• For newly diagnosed patients, consider insulin antibodies, GAD antibodies, coeliac screen, TFTs
• Consider blood/urine cultures if suspected infection

Question 6

Give some general Mx points for managing DKA (more info in notes).

Answer 6

1. Primary survey - resusc if required
2. NBM (may suck on ice chips if dry/cracked lips)
3. Fluid rehydrationgently
4. Correct K+imbalance
5. Insulin - 50 units
6. Monitor for cerebral oedema
7. Regular monitoring and observation
   • Hour observations
   • Hourly glucose and blood ketones while on insulin infusion
   • Re-check K+within one hour of commencing insulin
   • VBG and electrolytes 2-4 hourly

Question 7

Risks with DKA Mx

Answer 7

A. K correction risk
B. Cerebral oedema from fluid correction
C. Over insulin -> hypoglycaemia

Question 8

Why might you need a second IV access?

Answer 8

• these patients need frequent sampling and have many things given to them
• also can’t afford for other access to stuff up

Question 9

Why should the patient by NBM?

Answer 9

• If the patient is eating, it will lead to a fluctuating glucose level, which will make insulin treatment difficult
• If the patient is drinking due to thirst, it may have a dilutional effect and worsen hyponatraemia