DKA

Question 1

DKA Three Characteristics?

Answer 1

• Hyperglycaemia over 11 or known diabetes
• Acidosis <7.3, bicarb <15
• Ketonaemia 3 and over

(Hyperglycaemia not always present, low blood ketone does not exclude)

Question 2

DKA Precipitating Conditions?

Answer 2

Infection, discontinuation of insulin, inadequate insulin, CV disease, drug treatments (steroids, thiazides or SGLT2i), physiological distress

Question 3

DKA Presentation

Answer 3

Diagnosis not always apparent consider DKA in any unwell diabetic

• DKA develops within 24hours
• Polyuria, polydipsia, vomiting, dehydration, altered mental state if severe
• Weight loss, weakness, lethargy, acetone smell

Question 4

Kussmaul Respiration?

Answer 4

Deep hyperventilation (DKA)

Question 5

DKA Examination

Answer 5

• Signs of gross dehydration
• Respiratory compensation (Kussmaul or tachypnoea)
• Pear drop breath
• Check for: pneumonic consolidation, CF, pericardial rub, murmurs, intra-abdominal precipitant, mental state, near screening exam, skin surface

Question 6

DKA Differentials?

Answer 6

Ketoacidosis due to starvation or alcoholism, hyperosmolar hyperglycaemic state (usually in older patients), lactic acidosis, other causes of metabolic acidosis, sepsis, acute abdomen, acute pancreatitis

Question 7

DKA Ix

Answer 7

• Blood glucose and plasma glucose
• Urine dipstick testing, microscopy and culture
• Assay of blood ketones (sensitive but not always available)
• FBCs (WCC can be elevated in DKA without sepsis)
• U/Es
• ABG- metabolic acidosis low pH low HCO3
• Cardiac enzymes if suspected
• ECG
• CXR
• CT/MRI head if neurological signs
• Plasma osmolality + anion gap

Question 8

DKA Plasma Osmolality

Answer 8

Plasma osmolality = 2 ([Na mmol/L] + [K mmol/L]) + [Urea mmol/L] + [glucose mmol/L].
-Should be higher than 290 in DKA, if higher than 320 and no ketnoaemia/ketonuria then HONK may be diagnosis

Question 9

DKA Anion Gap

Answer 9

• Anion gap = ([Na mmol/L] - ([Cl mmol/L] + [HCO3 mmol/L]).

- Anion gap is elevated at >13 mmol/L in DKA.

Question 10

DKA Initial Management

Answer 10

• Sa02 monitor, continuous ECG and HR/BP monitor
• Large bore IV access
• Urinary catheterisation to monitor urine output and allow urinalysis
• LMWH and thrombotic deterrent stockings
• If unconscious, drowsy or vomiting, consider passing NG tube

Question 11

DKA Management

Answer 11

• Fluids followed by insulin
• DKA deficits are 100ml/kg, sodium, chloride and potassium deficiencies
• Fixed rate insulin infusion calculated on 0.1 units/kg of body weight/hour
• If capillary glucose has not fallen by 4 in first hour, check lines are patent then double dose of insulin for next hour
• When plasma glucose below 12, replace normal saline with 5% dextrose to prevent over-rapid correction of blood glucose, continue saline
• Continue glucose until patient is eating and drinking normally

Question 12

DKA Metabolic Treatment Targets

Answer 12

• Reduction in blood ketones by 0.5 mmol/L/hour
• Increase bicarbonate 3.0mmol/L/hour
• Reduce capillary blood glucose 3.0mmol/L/hour
• Maintain K 4.0-5.5mmol/L/hour

Question 13

DKA Complications

Answer 13

Cerebral oedema, pulmonary oedema, iatrogenic hypoglycaemia, iatrogenic hypokalaemia, dysrhythmias, myocardial suppression, VTE

Question 14

DKA Prognostic Indicators

Answer 14

Age, coma, hypothermia, persistent oliguria

Cerebral oedema and hypokalaemia are main causes for mortality