Diabetic
ketoacidosis (DKA)
D (dextrose) Hyperglycemia (glu>250)
- lytes
K Ketonemia u/a
A metabolic acidosis abg
electrolyte depletion
CAUSES
Insulin
dependent diabetes mellitus (20-30% in newly diagnosed diabetics)
Infarction
(myocardial) 5-7%
Infection
(30-40%) usually respiratory or urinary
Idiopathic
(20-30%)
Medication
non-compliance
CVA
Trauma
Surgery
Emotional
stress
LABORATORY
LYTES Blood sugar elevated (usually 250-800 mg/dL [13.88-44.4 mmol/L] range)
Increased ANION GAP Na-(Cl+HCO3)>14 :
Serum ketosis
Hyponatremia
Increased BUN
HCO3 < 15 (< 15 mmol/L)
Decreased calculated total body K+
U/A Urine ketosis
Glycosuria
WBC / Bacteria - infection
ABG Metabolic acidosis
Hyperamylasemia
Hypertriglyceridemia
Hypercholesterolemia
Increased
serum osmolality
LFTs eval abd pain
Disorders
that may alter lab results:
With
concomitant lactic acidosis, acetoacetate production
may be inhibited in presence of high levels of beta hydroxybutyrate.
The nitroprusside reaction, which measures only acetoacetate, may not be strongly positive.
A very
low serum sodium (< 110 mmol/L) suggests an
artifact due to severe hypertriglyceridemia
Severe
acidosis gives artificially high K+ level
Markedly
increased serum ketones may cross react and cause a
falsely high serum creatinine
CBC - leukocytosis
SPECIAL
TESTS
ECG
(especially if MI suspected). May also assist in evaluation
of K+ status. Usually shows sinus tachycardia.
Urine and
blood cultures
IMAGING
Chest
x-ray to rule out pulmonary infection
Blood Cx – r/o infection
Urine Cx – infection
Abd
x-ray – evaluate abdominal pain
TREATMENT
Type I
Diabetics
admit :
ICU
IVF -
isotonic 0.9 NaCl
1-2 L bolus
then 500mL
/hr until glu<250
then D5NS
SE cerebral edema, ARDS
Insulin IV
Regulin
0.1U/kg loading dose
If glu
does not fall 10% in 1hr repeat loading dose, again if needed, then double dose
0.1U/kg/hr IV continuous
until
glu normal
ketones gone
drop glu too fast :
then
cerebral edema
continuous
to avoid ketogenesis
K+
start once
urine output started
check for hyperkalemia
EKG
10meq/hr, if K<4.0=20/hr
NaHCO3
if pH
<7.0 only
Monitor q4h
ABG - pH
glu
Ketones
lytes - anion gap
Dialysis
hyperkalemia
Once all
under control start NPH (18-24h half life SQ) while under regulin
(4h)
Gradually
wean to sliding scale
APPROPIATE
HEALTH CARE
Inpatient intensive care. This is a life threatening emergency.
Goals are
to increase rate of glucose utilization by insulin-dependent tissues, to
reverse ketonemia and acidosis, and to correct the
depletion of water and electrolytes.
GENERAL
MEASURES
IV Fluids
adults: 1000 mL over first hour, then 500 mL/hr (approximately 7 mL/kg/hr)
x 4 hrs or until dehydration improves, then 250 mL/hour
(3.5 mL/kg/hr). Switch to D5 in 1/2 NS when serum
glucose < 300 mg/dL (16.65 mmol/l).
Expect to give 4-8 L/ first 24 hrs. (Some do not recommend initial IV bolus).
Pediatric
maintenance requirements: 100 mL/kg for first 10 kg,
50 mL/kg for second 10 kg and 20 mL/kg
thereafter. Fluid deficit: (Multiply patient's body weight by percentage
dehydration). Replace maintenance and deficit evenly over 48 hours.
ACTIVITY Bedrest
DIET Nothing by mouth initially. Advance to pre-ketotic diet when nausea and vomiting are controlled.
PATIENT
EDUCATION
For
prevention, careful control of blood glucose (usually HgbA1c 7%)
Monitor
glucose carefully during periods of stress, infection, trauma etc.
MEDICATIONS
DRUG(S) OF
CHOICE
Insulin -
initiate infusion at 0.1U/kg/hr
Potassium
phosphate orPotassium chloride
Sodium
bicarbonate, rarely
Contraindications:
No
demonstrable clinical benefit from bicarbonate with a pH > 7.0.
Hold K+ if
> 5.5 (> 5.5 mmol/L)
Precautions:
Double
insulin if no response in serum glucose over first 2 hours
Must
continue insulin until serum bicarbonate and anion gap normalize
Add
dextrose to IV fluid when blood sugar< 300 mg/dL
(16.65 mmol/L)
If using
bicarbonate, add 50 mg NaHCO3 to 1L 1/2 NS and give over 2 hours
Delay K+
administration in patients with inadequate urine output or evidence of diabetic
nephropathy
If blood
sugar does not fall by approximately 75 mg % q2h, increase insulin rate
Taper IV
insulin and start NPH/Reg insulin after acidosis
clears and patient is eating
Significant
possible interactions: For each 0.1 unit of pH, serum K+ will change by
approximately 0.6 mEq (0.6 mmol/L)
K in the opposite direction
FOLLOWUP
PATIENT
MONITORING
Monitor
mental status, vital signs, urine output q 30-60 minutes until improved, then
q2-4 h x 24 hrs
Blood
sugar q 1 hr until < 300 mg/dL (16.65 mmol/L), then q2-6h
Potassium,
bicarbonate, sodium, anion gap; q 2 hrs
Phosphate,
calcium, magnesium; q4-6h
PREVENTION/AVOIDANCE
Monitor
glucose closely during stressful situations
Careful
insulin control
EXPECTED
COURSE/PROGNOSIS
DKA
accounts for 14% of all hospital admissions for diabetes and for 16% of all
diabetic related fatalities
Overall
mortality of 5-15%
In
children < 10 years old, DKA causes 70% diabetes related fatalities
Complications
lactic
acidosis
cerebral
edema
arterial
thrombosis