By Melese A (mi)

Kalkidan A(mi)
Outline
Introduction
Pathophysiology
Precipitating factors
Work up
Management
Complications
Patient education
Our practice
References

8/14/22 DKA MANAGEMENT 2

 Objectives
At the end of this session every body should know
What DKA is
The pathophysiology of DKA and the precipitating factors
How to work up a patient with DKA
The management of DKA

8/14/22 DKA MANAGEMENT 3

 INTRODUCTION
Defn: DKA is one of acute complications of DM which is characterized
by the triad of hyperglycemia, anion gap metabolic acidosis, and
ketonemia.

The serum glucose concentration is usu. < 500 mg/dL (27.8 mmol/L)
and less than< 800 mg/dL (44.4 mmol/L)

may exceed 900 mg/dL (50 mmol/L) in patients with DKA who are
comatose

8/14/22 DKA MANAGEMENT 4

 Pathophysiology
DKA results from relative or absolute insulin deficiency combined
with counter regulatory hormone excess

The decreased ratio of insulin to glucagon promotes

fat gluconeogenesis,
glycogenolysis, and
 ketone body formation in the liver,
increases in substrate delivery from fat and muscle

8/14/22 DKA MANAGEMENT 5

Cont’d
Glucagon excess ↓ the activity of pyruvate kinase,insulin
deficiency ↑ the activity of phosphoenolpyruvate
carboxykinase→pyruvate toward glucose synthesis and away
from glycolysis.

Insulin deficiency also ↓ levels of the GLUT4 glucose transporter

which impairs glucose uptake into skeletal muscle and fat

8/14/22 DKA MANAGEMENT 6

Cont’d
Reduced insulin levels&↑catecholamines and growth hormone,
increase lipolysis and the release of free fatty acids.

 these free fatty acids are

normally converted to triglycerides or VLDL in the liver.
In DKA b\c of hyperglucagonemia → ketone body formation

8/14/22 DKA MANAGEMENT 7

 Precipitating factors
 Inadequate insulin administration
Infection (pneumonia, UTI, Gastroenteritis, sepsis)
Infarction (cerebral, coronary, mesentric, peripheral)
Drugs: glucocorticoids, higher dose thiazide diuretics, dobutamine and
terbutaline,cocaine
Pregnancy
Stress(trauma and surgery)
Burns,acute pancreatitis,PTE

8/14/22 DKA MANAGEMENT 8

Clinical features
HISTORY
polydipsia, polyuria
anorexia,nausea, vomiting
Abdominal pain
SOB
Generalized weakness and fatiguability

8/14/22 DKA MANAGEMENT 9

Cont’d
Altered consciousness...........coma(5-10%)
Symptoms of possible intercurent infections such as fever,
dysuria, coughing, acute chest pain, palpitation etc.
History of rapid weight loss
History of DM(unless first presentation)

8/14/22 DKA MANAGEMENT 10

Cont’d
Physical examination
sign of dehydration
Tachycardia
Sunken eye ball
Reduced tissue turgor
Dry tongue and skin
Hypotension
Increase cap.refill time

8/14/22 DKA MANAGEMENT 11

Cont’d

8/14/22 DKA MANAGEMENT 12

 ADA diagnostic criteria for DKA
&HHS
DIAGNOSTIIC Mild DKA Moderate DKA Severe DKA HHS
CRITERIA
Serum <250 <250 <250 <600
glucose(mg/dl)
Arterial Ph 7.25-7.3 7-7.24 <7 <7.3
Serum 15-18 10-15 <10 <18
bicarbonate
Serum variable variable variable .<330
osmolality
Anion gap <1o <12 <12 variable
Mental status Alert Alert/drowsy Stupor/coma Stupor/coma

Table 1.ADA dagnostic criteria for DKA &HHS

8/14/22 DKA MANAGEMENT 13

Laboratory findings of
DKA
DKA is characterized by
hyperglycemia
ketosis
metabolic acidosis

8/14/22 DKA MANAGEMENT 14

Work up
U/A- glucose&ketone
Blood glucose level
Serum ketones- beta hydroxybutyrate and acetoacetate
ABG
Serum electrolytes –K,Na,HCO3,Cl,Mg…
CBC
RFT
Plasma osmolality

8/14/22 DKA MANAGEMENT 15

Cont’d
Based on indication
Urine culture
Blood culture
CXR
MRI
ECG

8/14/22 DKA MANAGEMENT 16

 DKA HHS
Glucose,mmol/L (mg/dL) 13.9–33.3 (250–600) 33.3–66.6 (600–1200)

Sodium, meq/L 125–135 135–145

Potassium Normal to Normal

Magnesium Normal Normal

Chloride Normal Normal

Phosphate decrease Normal

Creatinine Slightly increase Moderately increase

Osmolality (mOsm/mL) 300–320 330–380

Plasma ketones ++++ +/–

Serum bicarbonate,meq/L <15 meq/L Normal to slightly decrease

Arterial pH 6.8–7.3 <7.3

Arterial PCO2,mmHg 20–30 Normal

  8/14/22 DKA MANAGEMENT 17
DDx of DKA
Starvation ketoses
Alcoholic ketoacidosis(AKA)
HHS
MI
Appendicitis
Acute pneumonia
Drug toxicity eg. salicylate
Dehydration due to gastroenteritis
Shock
sepsis

8/14/22 DKA MANAGEMENT 18

Management
Principles of management
Supportive therapy (ABC of life, NG tube and
catheterization.)
Fluid replacement
Correction of hyperglycemia
Correction of electrolytes and acid base disturbance
Treatment of precipitating cause

8/14/22 DKA MANAGEMENT 20

1.Fluid replacement
Fluid deficit 3-5L
2-3L of 0.9% N/S over the 1st 1-3 hr(15-20ml/kg/hr)
If hemodynamic stability and adequate urine output is present
switch to 0.45% saline at a rate of 250 to 500 ml/hr.
Change to 5% glucose and 0.45 saline when the plasma glucose
reaches 200 mg/dl at a rate of 150-250ml/hr.

8/14/22 DKA MANAGEMENT 21

2.Correction of
hyperglycemia
Administer short acting insulin IV(0.1u/kg) bolus then continue
with 0.1u/kg/hr continuous infusion
If no response after 2-4hr increase the infusion 2-3 fold
If the initial serum potassium level is <3.3meq/l hold insulin until
adequate urine out put(50ml/hr) and
the potassium level is corrected.
Hyperglycemia usually improves at a rate of (75–100 mg/dL)
per hour as a result of insulin-mediated glucose
disposal, reduced hepatic glucose release, and rehydration.

8/14/22 DKA MANAGEMENT 22

Correction cont’d
Continue insulin & electrolyte administration until
Patient is stable
Glucose goal is 8.3-13.9meq/l(150-250mg/dl) and
Acidosis resolves
Insulin infusion may be reduced to 0.05-0.1U/kg/hr
Administer long acting insulin a soon as patient is eating allow for
over lap in infusion & SC insulin injection.

8/14/22 DKA MANAGEMENT 23

3.Correction of electrolytes and acid
base disturbance

8/14/22 DKA MANAGEMENT 24

Potassium
K+ deficit 3-5 meq/kg (350 meq 70kg)
Need K with initial IV fluid & insulin Rx unless:
Anuric
K < 5.5 meq/L or hyperkalemia ECG changes
Ketoacid Initial [K] Replacement
osis H+ H+
K+ K+ < 5.5 mEq/L nil (initially)
5.2-5.5 10 mEq/h
mEq/L
Insulin
4-5.2 mEq/L 20 mEq/h
3-4 mEq/L 30 mEq/h
< 3 mEq/L 40 mEq/h
8/14/22 DKA MANAGEMENT 25
Other electrolytes
Bicarbonate
May exacerbate hypokalemia
Only give if pH < 6.9 AND evidence of cardiovascular
instability (arrythmia, CHF, hypotension)
50mmol/l NaHCO3 in 200ml of sterile water with 10mEq/l of
KCl given over 2h or until pH < 7.0
Phosphate
Routine IV not recommended
Rx symptomatic hypophosphatemia (rhabdo, unexplained
CHF or respiratory failure, severe confusion) or <0.32meq/l
10cc K Phos soln (3.0mEq Pi and 4.4 mEq K/cc) in 1L NS IV
over 8-12h

8/14/22 DKA MANAGEMENT 26

4. Treatment of precipitating
cause

Asses patient what precipitate the episode

Non compliance
Infection
Trauma
Infarction
Cocaine

8/14/22 DKA MANAGEMENT 27

Monitoring
Monitor BP,PR,RR,Mental status,fluid intake and out put every 1-4
hour.
Measure capillary glucose every 1-2 hour
Measure electrolyte( especially ,bicarbonate, phosphate) and
anion gap every 4 hr for the first 24hr

8/14/22 DKA MANAGEMENT 28

Complications
Common complications Occasional complications
Hyperglycemia Venous thrombosis
Hypokalemia ARDS
Cerebral edema Upper GI bleeding

8/14/22 DKA MANAGEMENT 29

Prognosis
With proper Mgt mortality rate of DKA is low (<1%)

May be Related to precipitating factor such as infection and MI

8/14/22 DKA MANAGEMENT 30

Patient Education
During illness or when oral intake is compromised, patients
should
Frequently measure the capillary blood glucose;
 Measure urinary ketones when the serum glucose < 16.5
mmol/L (300 mg/dL);
 Drink fluids to maintain hydration;
 Continue or increase insulin; and
 Seek medical attention if dehydration, persistent vomiting, or
uncontrolled hyperglycemia develop.

8/14/22 DKA MANAGEMENT 31

Our practice
Give 2-3 liters of N/S over 1-3 hr guided by the rehydration status of
the patient and the other 2 liters over 24 hour.

20 units of insulin(10 IM &10 IV)followed by 5iu IM every hour.

When the patient is completely out of ketosis we transfer the

patient on sliding scale. Regular inulin is given 4hourly according
to the following

8/14/22 DKA MANAGEMENT 32

 Cont’d
If RBG <350mg/dl...............16units
If RBG <250-350mg/dl......12units
If RBG <180-250mg/dl.......8units
If RBG <120-180mg/dl.........4units
If RBG <120mg/dl.................0 units of regular insulin is given.

8/14/22 DKA MANAGEMENT 33

Cont’d
We can also use the modified sliding scale
That’s by calculating by 0.5iu/kg/24hr(NPH),2/3 in the morning
and 1/3 in the evening
We do Q6hrs RBS and give 5iu regular insulin if the RBS is
<250mg/dl

8/14/22 DKA MANAGEMENT 34

cont’d
We add 1 ampule of KCL in each bag of N/S after adequate
urine out put.

Follow ; PR, RR, T, BP, Mental status ,urine output, RBS every
1hr, Urine ketone every 2hr.

8/14/22 DKA MANAGEMENT 35

References
Harrison's™PRINCIPLES OF INTERNAL MEDICINE 18th
Edition
UpToDate® 20.3

8/14/22 DKA MANAGEMENT 36

8/14/22 DKA MANAGEMENT 37
 Comments/
Suggestion

8/14/22 DKA MANAGEMENT 38