DIABETIC KETOACIDOSIS

Moderator-DR.RIZWAN AKHTAR
 DIABETIC KETOACIDOSIS
TYPE I DM IS MOST COMMON FORM OF
DIABETES IN CHILDREN AND DKA IS MOST
SERIOUS COMPLICATION,ACCOUNTING FOR
MEJORITY OF DEATH IN DIABETES THAT
NECESSITATES EARLY DIAGNOSIS AND
MANAGEMENT OF DIABATIC KETOACIDOSIS
PATHOPHYSIOLOGY
 ALONG WITH SIGN/SYMPTOMS OF
DIABETES

DUE TO DEHYDRATION DUE TO CEREBRAL EDEMA

 IMPAIRED SKIN TURGURE HEADACHE

 SUNKEN/DRY EYES IRRITABILITY
 DRY MUCOSA ALTERED SENSORIUM
 TACHYCARDIA LETHARGY
 PROLONG CRT LOSS OF CONSCIOUSNESS
 LOW VOLUME PULSE
 HYPOTENSION
 DUE TO
HYPERGLYCEMIA/KETOACIDOSIS/HYPERKALEMIA

FAST BREATHING
FRUITY SMELL
DIARRHEA
VOMITING
ABDOMINAL PAIN
 CLINCHING THE DIAGNOSIS
LETHARGY
●

PRESENTATION TACHYPNEA
●

RBS
GO FOR
●

CHEST AUSCULTATION
●

HYPERGLYCEMIA ( RBS >300mg/dl)

IF
●

●
CHEST EXAMINATION WNL
DM IN FAMILY, PROPER INSULIN INTAKE
TAKE H/O
●

●
POLYDIPSIA,POLYPHAGIA,POLYURIA

ABG/VBG
●

IF POSITIVE GO FOR DIPSTICK TEST FOR KETONURIA/KETONEMIA

●

PH <7.3 /HCO3 <15meq/l

●

DIAGNOSIS CONFIRM IF KETONURIA >+2

●
 Mild Modera Sever
DKA te DKA DKA

●
PH 7.3_7.2 ●
PH 7.2_7.1 ●
PH <7.1
●
HCO3 15_10 meq/l ●
HCO3 10_5 meq/l ●
HCO3 <5 meq/l
 Management…..
 MILD DKA DOES NOT REQUIRES HOSPITALISATION
 MAIN TARGET OF MANAGEMENT IS DEHYDRATION RATHER THAN
HYPERGLYCEMIA AND ACIDOSIS
 CORRECTION OF DEHYDRATION ITSELF STABLISES GLUCOSE LEVEL
AND ACIDOSIS UPTO SIGNIFICANT EXTANT
 CORRECTION OF HYPERGLYCEMIA WITH REGULAR INSULIN
INITIATED AFTER 1_2 hrs OF FLUID REPLACEMENT BEGINS
 ALWAYS SLOW CORRECTION IS DONE TO REDUCE CHANCE OF
CEREBRAL EDEMA
 FLUID OF CHOICE IS NS/RL BUT WE HAVE TO CHANGE IT TO
N/2DNS AFTER 4_6 hrs TO AVOID HYPOGLYCEMIA AND
HYPERNATRAMIA SINCE INSULIN HAS TO BE CONTINUED TILL
ACIDOSIS CORRECTED
 WE HAVE TO BE CAUTIOUS AFTER 22-23 hrs AS ACIDOSIS IS ABOUT
TO GET CORRECTED SO HIGH CHANCE OF HYPOKALEMIA
 PHARMACOLOGICAL CORRECTION OF ACIDOSIS IS ONLY
REQUIRED WHEN THERE IS PROFOUND ACIDOSIS (PH <6.9)
A.CORRECTION OF DEHYDRATION
 TO START WITH,WE SHOULD LOOK FOR NEED OF ABC
MANAGEMENT
 IF GCS <8 THEN INTUBATE THE PATIENT AND IF IN SHOCK THEN
GO FOR 10_20 ml/kg NS/RL ONCE OR TWICE WITH/WITHOUT
IONOTROPS
 IF NO SHOCK THEN GIVE NS/RL 10_20ml/kg/hr OVER 1-2 hrs
 ASSESSMENT OF DEHYDRATION(DEFICIT) BY CONSIDERING
FOLLOWING RULE…

 TOTAL FLUID(NS/RL) IS CALCULATED BY ADDING DEFICIT AND

MAINTENANCE FLUID AND SUBSTRACTING BOLUS FLUID AND
GIVEN OVER REST 46_47 HRS
 AFTER 4_6 hrs WHEN RBS TEND TO 300mg/dl , CHANGE THE
FLUID TO N/2DNS
 AFTER 22_23 hrs WE CAN SHIFT TO ORAL FLUID FOR REST OF
HRS IN EXACTLY CALCULATED MANNER
 B.CORRECTION OF HYPERGLYCEMIA
 GOAL OF INSULIN THERAPY IS CORRECTION OF ACIDOSIS RATHER
HYPERGLYCEMIA SO INSULIN THERAPY IS CONTINUED TILL ACIDOSIS IS
CORRECTED IRRESPECTIVE OF CORRECTION OF HYPERGLYCEMIC STATE
 IF ACIDOSIS PERSISTS WHEN GLUCOSE LEVEL TENDS TO BE
NORMAL,FIRST WE INCREASE GLUCOSE CONCENTRATION FROM 5% TO
12% FOLLOWED BY REDUCING INSULIN INFUSION RATE TO
0.03U/KG/HR TO AVOID HYPOGLYCEMIA.SIMILARLY WE CAN INCREASE
INSULIN RATE TO 0.3U/KG/HR IN CASE OF INSULIN RESISTANCE OR IF
ACIDOSIS IS NOT CORRECTED
 INSULIN THERAPY STARTED 1_2 hrs AFTER FLUID REPLACEMENT
INITIATED
 REGULAR INSULIN IS PREPARATION OF CHOICE
 RATE IS 0.05_0.1 U/KG/HR
 AFTER 22_23 HRS WE CAN SHIFT TO SC/IM INSULIN @0.3U/KG STATE
FOLLOWED BY 0.1 U/KG EVERY HRS
 PREPARATION OF CHOICE FOR SC/IM IS ULTRA SHORT ACTING OR
SHORT ACTING INSULIN,EVEN REGULAR INSULIN CAN BE USED
 C.ACIDOSIS

BICARBONATE ADMINISTRATION IS
CONSIDERED ONLY WHEN THERE IS PROFOUND
ACIDOSIS WITH LIFE
THREATNINGHYPERKALEMIA(>6.5meq/l)
IT IS GIVEN AS 1_2 meq/kg OVER 60min DILUTED
IN 0.45% NS
 D.HYPOKALEMIA
POTASSIUM SHOULD BE ADDED TO FLUID AT
THE RATE OF 40 meq/l
IT USUSALLY START WITH INSULIN THERAPY
 E.CEREBRAL EDEMA
 CAUSES 90% MORTALITY
 COMMON IN NEW CASE OF DM,SMALL AGE(<5yrs),LATE
PRESENTATION WITH SEVERE ACIDOSIS
 IT IS ALSO RELATED TO RAPID CORRECTION OF
DERANGEMENTS
 MUIR’S CRITERIA IS USED FOR DIAGNOSIS
 CEREBRAL EDEMA USUALLY OCCURS 6_12 HRS OF TREATEMENT
 HEAD IS ELEVATED WITH SECURED AIRWAY
 DURING VENTILATION ,AGGRESSIVE
HYPERVENTILATION(PCO2<22mmhg) IS AVOIDED
 FLUID IS REDUCED TO 1/3rd
 IV 3%NS IS GIVEN AS 5_10 ml/kg OVER 30 minutes
 IV 20% MANNITOL GIVEN AS 0.5 TO 1 g/kg OVER 20 MINUTES
MONITORING…….
IT IS IMPORTANT TO MONITOR FOLLOWING
PARAMETERS TO ASSESS TREATMENT PROGRESS
AND DEVELOPMENT OF COMPLICATIONS
HR,RR,BP,ABG,RBS,HYDRATION STATUS,FLUID
INPUT/OUTPUT, GCS SCALE,CRANIAL NERVE
EXAMINATION
OTHER COMPLICATIONS INCLUDES DVT,RENAL
FAILURE,INTESTINAL
NECROSIS,RHABDOMYOLYSIS,PULMONARY
EDEMA,ARRHYTHMIA
THANK

YOU