DIABETC KETO

ACIDOSIS
 INTRODUCTION

• Diabetic ketoacidosis is the most common and severe manifestation of type I

diabetes.
• It occurs as a result of insulin deficiency with concomitant increased production of
the stress hormones, glucagon, cortisol, and growth hormone.
• It is a state of hyperglycemic dehydration and ketotic acedemia.
• DKA most commonly occurs in children and adolescents who are non compliant
to insulin therapy.
PATHOPHYSILOGY
CRITERIA FOR DKA
 Blood sugar ->250mg/dL

 Ketonemia with ketones greater than 1:2 dilution

 Serum Ph <7.3
 Serum bicarbonate <15mmo/L

 Moderate DKA serum Ph <7.2, serum bicarbonate <10mmol/L

 Severe DKA serum pH<7.1, serum bicarbonate <5mmol/L
CLINCAL FEATURES
• Abdominal pain
• Nausea & vomiting
• Polyuria/ polydipsia
• Shortness of breath
• Tachycardia
• Dry mucous membrane/reduced skin turgor/hypotension
• Tachypnoea/Kussmaul respirations/respiratory distress
• Abdominal tenderness
• Lethargy/cerebral oedema/coma
DIAGNOSTIC EVALUATION
 Serum K may be elevated or normal initially but declines with therapy
 Serum Na is low and elevated
 Creatinine are reflective of dehydration

 Leucocytosis, hypertriglyceridemia are found

 Ketones elevated
 Beta hydroxybutyrate is three fold higher than acetoctate
MANAGEMENT

• The goal is to slow correction of dehydration and acidosis, preventing

development of cerebral edema.
Initial assessment
 History:
 New onset diabetes- evaluate onset and duration of symptoms
 Known diabetic –evaluate:
 Precipitating factors-insulin dose, illness, stress, dietary indiscretions

 History of diabetes( date of diagnosis, hospital admission & insulin dose)

 Duration of symptoms

 Recent home glucose levels,

 Most recent insulin dose and timing
 Physical examination
 Vital signs, hydration status, infections

 CNS status-Glasgow coma scale

 Signs of acidosis
 Laboratory

 Blood glucose, urine glucose and ketones

• Complete metabolic panel. HbA1C,lipid profile, insulin autoantibodies

• Blood gas &serum electrolytes every 4 hours

• Calcium, magnesium and phosphate every 12 hours
• Appropriate cultures & X-rays.

Acute management
 Fluids & Electrolytes( goal to correct dehydration over 24-48hours)

• Initial bolus should determined based on blood pressure and capillary refill

• Hypovolemic shock-continue fluid for another hour

• Isotonic fluids( normal saline) to be continued till blood sugar 300mg/dL
• Calculate fluid based on 10% dehydration

• Total fluids must not exceed 4000ml/m2/day, unless patient is in hypovolemic shock

• IV fluids are without glucose until blood glucose is 250-300mg/dL, add 5% dextrose
when blood glucose is 250-300mg/Dl, and 10% glucose when blood glucose is <
180mg/dL
• Potassium (20-40mEq/L, ½ KCL and ½ KPO4) is added in fluids after urine flow is
established serum K is <5.5mEq/L
 Use of bicarbonate

• To be considered if pH does not improve and serum bicarbonate is less than 5-10

mEq/L
 Insulin therapy

• Start insulin drip at 0.1units/kg/hour, if a patient is known diabetic and has

received insulin subcutaneously start lower insulin dose 0.05u/kg/hr
• When blood glucose <300mg/dL, change IV fluids to 5% dextrose with 0.45
saline.
• If blood glucose drops <180mg/dL change IV fluids to 10% dextrose

• If blood glucose drops to 150mg/dL reduce isulin drip in o.o2units /kg/hr

• If patient is acidotic and ketotic never decrease insulin infusion below
0.05u/kg/hr
• Monitor blood glucose every 30 minutes when changing insulin drip
• Insulin must be continued until pH >7.36 or serum bicarbonate >20meq/L
 Monitoring

• Fluid balance- IO Chart hourly

• Vital signs-every hour
• Neurological signs-alertness. Glasgow coma scale, pupils every 2 hours
• Serum Ph, bicarbonate, ketones every 2 hourly initially

• If acidosis is severe and bicarbonate is given then every hourly should check
• Bedside blood sugar hourly, serum electrolytes every 2 hourly
THANK YOU