DKA Flashcards
1
Q
How does DKA occur?
A
- Excessive glucose with a lack of insulin
- Therefore the glucose cannot enter the body cells to be metabolised, leading to a starvation like state
- Lipolysis increases free serum fatty acids which converts to ketones
- Ketone production is the only way to make energy, particularly in the presence of cortisol/glucagon/GH
- The combination of severe hyperglycaemia and ketoacidosis is deadly
2
Q
What are some triggers for DKA?
A
- Infection eg UTI, surgery
- MI
- Pancreatitis
- Chemotherapy
- Antipsychotics
- Wrong insulin dose / non-compliance
3
Q
What patients get DKA?
A
- Type 1 diabetics
- VERY OCCASIONALLY, type 2
4
Q
What are the symptoms of DKA?
A
- Gradual drowsiness
- Vomiting
- Dehydration
5
Q
Who should you measure blood glucose in when they present?
A
ALL PATIENTS WITH UNEXPLAINED:
- Abdominal pain
- Vomiting
- Polyuria, polydipsia
- Lethargy
- Anorexia
- Ketotic breath
- Dehydration
- Coma
- Deep breathing (Kussmaul hyperventilation)
6
Q
What is the triad required for a DKA diagnosis?
A
- Acidaemia (pH<7.3 or HCO3-<15mmol/L)
- Hyperglycaemia (blood glucose >11mmol/L or known DM)
- Ketonaemia (>3mmol/L or over 2+ on dipstick)
7
Q
What investigations would you undertake?
A
- ECG
- CXR
- Urine dipstick and MSU
Bloods - - Capillary and lab glucose
- Ketones
- pH (only aBG if low GCS/hypoxia)
- U+E’s
- HCO3-
- Osmolality
- FBC
- Blood cultures
8
Q
What signs would you look for in DKA?
A
- Abdominal tenderness
- Dehydration
- Hypotension
- Kussmaul breathing
- Ketotic breath
- Reduced GCS
9
Q
What signs suggest severe DKA?
A
- Blood ketones >6mmol/L
- Venous bicarbonate < 5mmol/L
- pH <7
- K+ < 3.5mmol/L on admission
- GCS <12
- O2 sats <92%
- Systolic BP <90mmHg
- Pulse >100bpm or <60bpm
- Anion gap above 16
10
Q
What is euglycaemic DKA?
A
- DKA with normal or near normal blood glucose
- May occur in the presence of exhausted glycogen stores in the liver (vomiting, alcohol, malnourished)
- SGLT-2 inhibitors can cause them
11
Q
What are the three targets of treating DKA?
A
- Fluid resuscitation
- Insulin therapy
- Electrolyte monitoring
12
Q
What is the insulin regimen in DKA?
A
- Give 10 units of soluble insulin either i/m or s/c if likely to be delay of 15 minutes in starting IV insulin
- Add 50 units soluble insulin (actrapid) to 50ml 0.9% saline. Fixed rate infusion at 0.1units/kg/hour
- Continue patients usual long acting insulin at usual doses and times, start if new T1DM
13
Q
What is the fluid regimen in DKA?
A
- If systolic BP<90, give fluid bolus.
- Give 1 litre saline over 1hr.
- Two litres saline, each over 2 hours
- Two litres saline, each over 4 hours
- One litre saline, over 6 hours
14
Q
Why do patients need potassium?
How do you give this in DKA?
A
IV insulin decreases plasma potassium levels Don't add potassium to 1st bag If K+ >5.5 = Nil If K+ 3.5-5.5 = 20mmol per 500ml fluid If K+ <3.5 = Discuss with consultant ITU
15
Q
How do you avoid hypoglycaemia in treatment of DKA?
A
- When glucose <14mmol/L, start 10% glucose at 125ml/hr to run alongside saline
- Slow down saline infusion to match fluid output
