RRAPID: Diabetic Ketoacidosis (DKA)

Question 1

Affects which type of diabetics, Type I or II?

Answer 1

Type I

Question 2

Presentation?

Answer 2

SUDDEN ONSET:
Polyuria & Polydipsia (developing over a few days) 
Weight loss & weakness
Vomiting 
Blurred vision 
Abdominal pain
Tachycardia
Hypotensive 
Increased RR (Hyperventilation or breathlessness: the acidosis causes Kussmaul’s respiration (a deep sighing respiration)
Signs of infection

Question 3

Pathophysiology of DKA?

Answer 3

• Occurs as a consequence of absolute/relative insulin deficiency accompanied by increase in counter regulatory hormones e.g. glucagon, cortisol, GH & epinephrine.
• Hormonal imbalance enhances hepatic gluconeogenesis & glycogenolysis  severe hyperglycaemia.
• Enhanced lipolysis increases serum free fatty acids  metabolised  accumulation of ketone bodies  metabolic acidosis
• Predominant ketone = 3-beta-hydroxybutyrate
• Renal threshold for max plasma glucose concentration that active reabsorption can cope with is 10mmol/L.
• When glucose is not reabsorbed into plasma it stays in tubule & draws water in & electrolytes follow  very water and sodium + potassium depleted

Question 4

Common precipitants?

Answer 4

Infection: 30%
First presentation: 25%
Non-compliance with medication: 20%
Alcohol Excess

Question 5

Triad of diagnosis?

Answer 5

Hyperglycaemia (VBG > 11 mmol/L)
Ketonaemia (>3mmol/L) or ketonuria (++ or more)
Acidaemia (pH <7.3 on VBG or HCO3 >15mmol/L)

Question 6

Differentials? (3)

Answer 6

Hyperglycaemia without acidosis or ketones - Not medical emergency

Hyperglycaemia with ketosis but not acidosis – Not medical emergency

Hyperosmolar hyperglycaemic state – medical emergency
- Differentiated by GRADUAL ONSET

Question 7

Response (Airway)?

Answer 7

O2 15/L min via reservoir bag

NBM for at least 6hrs (gastroparesis - delayed gastric emptying is common)

Question 8

Response (Breathing)?

Answer 8

ABG/VBG

CXR (signs of infection)

Question 9

Response (Circulation)?

Answer 9

2 large bore cannula’s IV access: Fluids Mx (see next card)
Bloods: FBC, U&E’s, ketones, glucose, amylase, (pancreatitis may occur), magnesium
Urinanalysis (ketones) & send for M&C
Catheter (if oliguric or high serum creatinine)
Regularly monitor K
ECG

Question 10

Response (Disability)?

Answer 10

Capillary blood glucose

NG tube: if GCS is reduced (to prevent vomiting and aspiration)

Question 11

Fluid Mx of DKA if systolic >90mmHg?

Fluid Mx if systolic < 90mmHg?

Answer 11

1. 0.9% NaCl 1L over 1 hr (for bolus i.e. resus: KCl may be required if more than 1L need to resus)
2. 0.9% sodium chloride 1L with potassium chloride over next 2 hours
3. 0.9% sodium chloride 1L with potassium chloride over next 2 hours
4. 0.9% sodium chloride 1L with potassium chloride over next 4 hours
5. 0.9% sodium chloride 1L with potassium chloride over next 4 hours
6. 0.9% sodium chloride 1L with potassium chloride over next 6 hours

50U of soluble insulin in 50mL of NaCl via a fixed rate of 0.1 units/kg/hr

Give repeated boluses of 500mL 0.9% sodium chloride over 10 - 15 minutes, max 2L). If BP remains low call critical care

Question 12

Mx if Potassium in first 24 hrs if > 5.5 mmol/L?

Answer 12

Nil potassium replacement in mmol/L of infusion solution

Question 13

Mx if Potassium is 3.5-5.5 mmol/L in first 24 hrs?

Answer 13

40 mmol/L potassium replacement in mmol/L of infusion solution (add 20 mmol/L per bag)

Question 14

Mx if Potassium is < 3.5 mmol/L in first 24 hrs?

Answer 14

Senior review as additional potassium needs to be given

Question 15

In what circumstances can you add potassium prior to the second bag?

Answer 15

K+ < 3.5

Question 16

What is recommended when blood glucose < 14mmol/L

Answer 16

Add 10% glucose IV infusion at 125ml/hr in parallel to other fluids, i.e. 5% Dextrose