DKA **** Flashcards
What is it?
What is usually the cause?
Acute
Severe manifestation of insulin deficiency
Type 1 diabetes
Pathophysiology starting at very low insulin levels …
Hyperglycaemia and high ketones
Low pH and bicarbonate due to high ketones
Dehydration from polyuria and vomiting leading to renal impairment.
Causes
Can occur in patients known to have DM
Poor diabetic control
Illness - infection, surgery, MI
Insulin pump failure
Severity classification - CHECK NICE GUIDELINES
Using pH
<7.3 - mild
<7.2 - moderate
<7.1 - severe
Symptoms:
In an attempt to remove protons.... Where is the pain? Thirst and urine Energy levels What about consciousness
N&V - due to gastroparesis and attempt to remove H+ Abdo pain Polydipsia +uria Lethargy Low consciousness - drowsy, coma
Signs
BP HR Water levels Breathing Breath One more thing ....
Low BP High HR Dehydration Kussmauls (deep) breathing to compensate for acidosis Ketone smell on breath Signs of cause (e.g. infection)
Diagnosis criteria - 3
(1) Hyperglycaemia - Capillary glucose >11mmol/L or known diabetes
(2) Ketones in urine and blood - capillary/serum ketones >3 or urine 2+
(3) Acidosis - Venous pH <7.3 or bicarbonate <15
Other investigations
High urea and creatinine
Altered electrolytes usually lost in urine except potassium which goes up
Increased anion gap, osmolality, WCC if infection and amylase
Management
Dehydration - how long should it be corrected over?
Potassium - at what level should potassium be given?
- what if potassium is under <3.5 mol/L?
What about correcting hyperglycaemia? When should it be started?
Normal saline through large bore cannula - calculate appropriate fluids for weight and given dehydration over 48 hours
Potassium IV if <5.5 mmol/L
Stop until insulin potassium normalised
Insulin IV - 0.1 unit/kg/hr - 1 hr after fluids correction
Management
When to consider HDU transfer?
What should be monitored?
If severe Ketones >6 Potassium <3.5 - very low GCS<12 Acid base abnormalities Vital - low SATS, SBP <90, tacky/brady cardia
Continuous o2 SATS and ECG (potassium)
BM, ketones and venous blood gas every hr
U&E initially, then 2 hourly, then 4 hourly
Management
When should resolution be seen?
What ketones and venous pH levels would you see?
What happens to insulin treatment when the patient starts eating and drinking?
What should be ensured to happen within 24 hrs of the DKA?
24 hrs
Ketones <0.3
Venous pH <7.3
Subcutaneous insulin - give short acting insulin with meals
They meet with diabetes team within 24 hrs
Complications from the DKA itself?
Complications that are iatrogenic?
VTE and PE
Cerebral oedema mainly in children - headache, altered mental status, pupillary/oculomotor abnormalities
Hypokalaemia
Hypoglycaemia
Degree of dehydration signs:
Mild
Moderate
Severe
Hard to detect - usually have some weight loss
Dry mucous membranes and reduced skin turgor
Sunken eyes
Reduced cap refill time
