DKA

Question 1

When is diabetic ketoacidosis seen?

Answer 1

*Hallmark of type 1 diabetes
*Seen in:
>previously undiagnosed diabetes
>Interruption of insulin therapy
>Stress of intercurrent illness

Question 2

What is the pathophysiology of DKA?

Answer 2

• Insulin deficiency (type 1 diabetic)
• Rising BLOOD glucose, as no insulin to drive glucose into cells, levels lead to osmotic diuresis = loss of fluids electrolytes and dehydration
• Leads to renal hypoperfusion = impaired excretion of ketones and hydrogen ions
• Cells starved of glucose stimulates lipolysis, leads to free fatty acids, converted to ketones
• Accumulation of ketone produces metabolic acidosis
• Acidosis causes vomiting which leads to further loss of fluids
• Respiratory compensation for acidosis leads to hyperventilation

Question 3

What is the presentation of DKA? (Signs and symptoms)

Answer 3

Symptoms

• Nausea
• Vomiting
• Abdo pain occassionally
• Confusion (severe)

Signs:

• Hyperventilation
• Dehydration signs: dry skin, mucous membranes etc
• Pear drop breath
• Pyrexia/hypothermia

Question 4

What are red flag results/observations of severe DKA?

Answer 4

• pulse >100bpm or <60bpm
• systolic BP <90mmHg
• GCS <12 or abnormal AVPU
• Blood ketones over 6mmol/L
• Bicarbonate <12mmol
• ABG <7.1
• Hypokalaemia on admission of <3.5mmol/L

Question 5

How is DKA diagnosed?

Answer 5

*ABG!!
>Blood glucose levels
>Ph <7.35 acidosis
*Ketones
*Urinalysis (glucose and ketones)

Question 6

What are the normal result for blood ketones?

Answer 6

<0.6mmol/L

Question 7

What is the management of DKA as an FY1?

Answer 7

1. A-E assessment & GCS score
2. Diagnosis: ABG + Urinalysis

3a. Fluids 0.9% Sodium chloride IV
>Bolus over 10-15mins if <90mmHg systolic

3b. Replace K+ in fluids

4a. IV insulin
>soluble short acting diluted in NaCl 0.9% 1 unit/mL @ rate 0.1unit/kg/hr

4b. SC long acting insulin continued

5. Glucose
   >Blood glucose <14mmol/l give 10% dextrose with Sodium chloride infusion

Question 8

How much are blood ketones and glucose meant to fall by?

Answer 8

0.5mmol/l/hr + glucose falls by 0.3mmol/l/hr

Question 9

How long is insulin infusion continued for?

Answer 9

Until blood-ketone below 0.3mmol/l & blood pH >7/3 and patient able to eat and drink