S17C20 - DKA

Question 1

DKA - Counterregulatory hormones

Answer 1

• glucagon
• catecholamines
• cortisone
• growth hormone

-increase gluconeogenesis, glycogenolysis, breakdown of fats into FFA and glycerol, proteolysis (gluconeogenesis worsens the hyperglycemia)

Question 2

DKA - FFA

Answer 2

• in liver converted to ketone bodies: beta-hydroxybutyrate and acetoacetic acid = metabolic acidosis
• as adipose tissue is broken down prostaglandins are released causing a vasodilation despite volume depletion

Question 3

DKA - metabolic acidosis

Answer 3

• from breakdown of free fatty acids to ketones
• hyperglycemia causes an osmotic diuresis leading to worsening hyperglycemia and ketonemia

-note: metabolic alkalosis can also occur from vomiting, diuresis and concomitant diuretic use therefore may have a normal appearing bicarb therefore pay attn to anion gap

Question 4

DKA - potassium

Answer 4

RAAS is activated by volume depletion, this increases renal potassium losses

• osmotic diuresis also causes loss of K
• chloride retained in exchanged for ketoanions in kidneys so ketones can be excreted – leads to hyperchloremic acidosis
• total body potassium depleted
• measured serum potassium normal b/c of ECF shift secondary to acidemia and incrased intravascular osmolarity d/t hyperglycemia

Question 5

DKA - causes

Answer 5

• non-compliance
• machinery malfunction
• infxn
• pregnancy
• hyperthyroidism
• substance use (cocaine)
• meds
• CVA
• GIB
• MI
• PE
• pancreatitis
• trauma
• surgery

Question 6

DKA - Sx

Answer 6

• polydipsia, polyuria
• tachypnea ( in response to acidosis)
• vasodilation from prostaglandins
• n/v, abdo pain (n/v from acidemia, ketones)
• aLOC (esp if osm >320)
• kussmail breathing (increased rate and depth)
• fruity breath from acetone

Question 7

DKA - Dx

Answer 7

• blood sugar >14
• anion gap >10
• bicarb

Question 8

DKA - Ddx

Answer 8

• alcoholic ketoacidosis
• starvation ketoacidosis
• renal failure
• lactic acidosis
• ingestions (Salicylates, ethylene glycol, methanol)

Question 9

DKA - Tx

Answer 9

• labs: glucose, urine, ECG, CBC, lytes, Cr, cultures, u/a, VBG
• goals: glucose 18, pH >7.3
• fluids
• wait until K >3.3 before giving insulin
• will often need 100-200mEq of KCl in first 24h
• give inuslin at 0.1 units/kg/h once K >3.3, loading dose not necessary
• if no response to insulin (

Question 10

DKA - phosphate

Answer 10

• goes from ICF to ECG during DKA
• serum levels normal or increased in DKA but overall loss of body phosphate
• hypophosphatemia is worst at 24-48h after starting insulin
• hypophos: hypoxia, rhabdo, hemolysis, resp failure, cardiac dysfunction

Question 11

Should bicarb be used in DKA?

Answer 11

• generally no: worsens hypkalemia, worsens intracellular acidosis, causes sodium overload, delays recovery from ketosis, elevates lactate levels, may precipitate cerebral edema
• however in severe cases with cardiovascular instability it may be considered (pH

Question 12

DKA: complications

Answer 12

• hypoglycemia
• hypokalemia
• hypophosphatemia
• ARDS
• cerebral edema

Question 13

DKA - cerebral edema

Answer 13

• any change in neurological fxn is an indication for IV mannitol (1-2g/kg)
• or give hypertonic saline 3% (3mL/kg) over 30mins (can go up to 5-10ml/kg)

Question 14

DKA in pregnancy

Answer 14

-fetal mortality of 30%