AIIMS Raipur

1. Diabetic Ketoacidosis
Presenter: Dr Vinod Kumar
Moderator: Dr Sarita Ramchandani

2. Overview
Introduction
Pathogenesis
Clinical features
Diagnosis
Laboratory findings
Management and prevention
Differential diagnosis
Summary
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Dr
Vinod
Kumar

3. Diagnosis ?
• A 13-year-old girl with a past medical history of
anxiety is brought to the emergency room for nausea,
vomiting, & abdominal pain. She also reports of ↑ed
urinary frequency.
• On physical exam, she is lethargic & markedly
dehydrated with dry mucous membranes & sunken
eyes. Her abdominal exam is normal.
• Laboratory results - ↑ed serum glucose 400 mg/dL &
K+ 4.9mEq/L. Urinalysis- +ve for ketones.
• IV fluids given, admitted to the ICU for close
monitoring & administration of an insulin drip.
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Vinod
Kumar

4. Introduction
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DKA is a serious acute complications of
Diabetes Mellitus.
Significant risk of death and/or morbidity
especially with delayed treatment.
The prognosis of DKA is worse in the extremes
of age, with a mortality rates of 5-10%.
With the new advances of therapy, DKA
mortality ↓ed to < 2%.
Before discovery & use of Insulin (1922) the
mortality was 100%.
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Vinod
Kumar

5. Introduction
• HHS and DKA are not mutually exclusive but
rather 2 conditions that both result from some
degree of insulin deficiency.
• They can and often do occur simultaneously. In
fact, 1/3rd of patients admitted for
hyperglyceamia exhibit characteristics of both
HHS & DKA.
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6. Definition
• DKA is defined as the presence of all 3 of the
following:
(i) Hyperglycemia (glucose >250 mg/dL)
(ii) Ketosis
(iii) Acidemia (pH <7.3).
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7. Pathophysiology
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8. Role of Insulin
• Required for transport of glucose into:
• Muscle
• Adipose
• Liver
• Inhibits lipolysis
• Effects of absence of insulin:
Glucose accumulates in the blood.
Uses amino acids for gluconeogenesis
Converts fatty acids into ketone bodies : Acetone, Acetoacetate, β-
hydroxybutyrate.
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9. Precipitating events
Infection(Pneumonia / UTI / Gastroenteritis / Sepsis)
Inadequate insulin administration
Infarction(cerebral, coronary, mesenteric, peripheral)
Drugs (cocaine)
Pregnancy.
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10. Presentation
Symptoms
• Nausea/vomiting
• Thirst/polyuria
• Abdominal pain
• Shortness of breath
Physical findings
• Tachycardia
• Dehydration/hypotension
• Tachypnea /Kussmaul
respirations/respiratory distress
• Fruity odour in breath.
• Abdominal tenderness(may resemble
acute pancreatitis/surgical abdomen)
• Lethargy/obtundation/cerebral
edema/possibly coma.
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11. Diagnosis (Initial evaluation)
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• Identify precipitating event leading to elevated glucose
(pregnancy, infection, omission of insulin, MI, CNS event)
Identify
• Assess hemodynamic status
• Assess volume status & degree of dehydration
• Assess presence of ketonemia & acid-base disturbance
Assess
• Examine for presence of infection
Examine
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12. Diagnosis ( Lab Investigations)
Complete blood count
Serum ketones/ Urine ketones + sugar
Calculate serum osmolality & anion gap
Urinalysis & urine culture
Consider blood culture
Consider chest X-ray
Acid-base assessment
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13. Treatment of DKA
Initial hospital
management :
• Replace fluid and
electrolytes
• IV Insulin therapy
• Watch for complications
• Treat causes
Once resolved:
• Continue insulin therapy
• Prevent recurrence
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14. FLUID REPLACEMENT
Administer NS as indicated to maintain hemodynamic status, then
follow general guidelines:
NS for first 4 hrs.
Consider 0.45% NS thereafter.
Change to D5 & 0.45% NS when blood glucose ≤250 mg/dL.
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15. FLUID
REPLACEMENT
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Hours Volume
1st hour 1 L
2nd hour 1 L
3rd hour 500ml – 1 L
4th hour 500ml – 1 L
5th hour 500ml – 1 L
Total 1st 5 hours 3.5- 5L
6-12 hours 250– 500 mL/hr
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16. INSULIN MANAGEMENT
Regular insulin 10 U IV stat (for adults) / 0.15 U/kg IV stat.
Start regular insulin infusion 0.1 U/kg/h / 5 U/h.
↑e insulin by 1 U /h every 1–2 hr if <10% ↓e in glucose/no improvement in
acid-base status.
↓e insulin by 1–2 U/h (0.05–0.1U/kg/h) when glucose ≤250 mg/dL &/or
progressive improvement in clinical status with ↓e in glucose of >75 mg/dl/h.
Don’t ↓e insulin infusion to <1U/h.
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17. INSULIN MANAGEMENT
Maintain glucose b/w 140 & 180 mg/dL.
If BSL ↓es to <80 mg/dl, stop insulin infusion for no >1 hr & restart infusion.
If BSL consistently <100 mg/dl, change IV fluids to D10 to maintain BSL b/w 140 & 180
mg/dL.
Once patient is able to eat, consider change to S/C insulin:
Overlap short-acting insulin S/C & continue IV infusion for 1–2 hr.
For pts. with previous insulin dose: return to prior dose of insulin.
For pts. with newly diagnosed diabetes: full-dose S/C insulin based on 0.6 U/kg/day.
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18. Start S/C insulin:
Anion gap normal
Serum HCO3- ↑es to >15mEq/L
Patient able to eat
Mental status improves
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19. Na+ REPLACEMENT
Calculate effective Sr. Na+ = Sr. Na+ + 1.6 (BG -100)/100
0.9% NaCl is infused @ 15–20ml/kg/wt/h or greater during 1st
hour (∼1– 1.5L in avg. adult). Subsequent choice for fluid
replacement depends on the state of hydration, serum
electrolyte levels, & urinary output.
0.45% NaCl infused @ 4–14ml/kg/h is appropriate if the
corrected Sr. Na+ is N/↑ed; 0.9% NaCl at a similar rate is
appropriate if corrected Sr. Na+ is low.
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20. K+ REPLACEMENT
• Don’t administer K+ if Sr. K+ >5.5 mEq/L or patient is anuric.
• Use KCl but alternate with KPO4 if there is severe phosphate depletion & patient is
unable to take phosphate by mouth.
• Add IV K+ to each litre of fluid administered unless contraindicated.
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Sr. K+ (mEq/L) Additional K required
<3.5 - 4.0 40mEq/L
3.5–4.5 20mEq/L
4.5–5.5 10mEq/L
>5.5 Stop K+ infusion
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21. PHOSPHATE
Hypophasphatemia may develop during ↑ed
glucose usage
If Sr. level <1mg/dl then phosphate
supplementation considered + monitor for
hypocalcemia & hypomagnesemia
No benefit demonstrated in RCT .
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22. BICARBONATE
Clinical trials don’t support the routine use of HCO3- replacement
HCO3- replacement & rapid reversal of acidosis can impair cardiac function,
reduce tissue oxygenation and promote hypokalemia & hypocalcemia.
In presence of severe acidosis pH<6.9, in hemodynamic instability with pH<7.1
and hyperkalemia with ECG findings, HCO3- therapy considered .
In presence of severe acidosis (arterial pH <6.9), ADA advises HCO3- [50
mmol/L (meq/L) of Na2HCO3- in 200 mL of sterile water with 10 meq/L KCl/h for
2 h until the pH>7.0].
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23. MONITORING
Flow sheet mantained tabulating mental status, vital signs,insulin
dose,fluid and electrolyte administered and urine output
Capillary glucose 1-2hrly,electrolytes especially K+, HCO3- &
phosphate) and anion gap every 4 hrly for first 24 hrs
Monitor BP, pulse, respiration, fluid intake & output every 1-4 h
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24. Blood Glucose monitoring
• Check initial blood glucose (BG) q1h. Goal - to ↓e 50-75mg/dL/h
• Once stable ( 3 consecutive values ↓ed in target range), change BG
monitoring to q2h.
• Resume q1h monitoring for each change in insulin infusion rate
• Add dextrose 5% to IV fluids when BG <250mg/dL
• For Goal BG is 150-200 mg/dL until anion gap treated
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25. ONCE DKA RESOLVED
• Most patients require 0.5-0.6U/kg/day
• Highly insulin resistant patients: 0.8-
1U/kg/day
• Give subcutaneous insulin at least 2
hrs prior to weaning insulin infusion.
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26. COMPLICATIONS OF DKA
Shock (If not improving with fluids, then consider MI)
Vascular thrombosis
• Severe dehydration
• Cerebral vessels - occurs hrs to days after DKA
Pulmonary Edema (Result of aggressive fluid resuscitation)
Cerebral Edema
• First 24 hrs
• Mental status changes
• May require intubation with hyperventilation
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27. CLINICAL ERRORS
• Giving insulin without sufficient fluids
• Using hypertonic glucose solutions
Fluid shift & shock
• Premature K+ administration before insulin has begun to act
Hyperkalemia
• Recurrent ketoacidosis
• Premature discontinuation of insulin & fluid when ketones still present
• Failure to administer K+ once levels falling
Hypokalemia
Hypoglycemia (Insufficient glucose administration)
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28. Differential diagnosis
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29. Compare & Contrast
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VALUE DKA HHS
Plasma glucose (mg/dl) > 250 > 600
Arterial pH < 7.30 > 7.30
Serum bicarbonate
(mEq/L)
<15 >15
Serum Osmolarity
(mOsm/L)
Variable >320
Urine and serum ketones Positive Trace
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30. Compare & Constrast
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VALUE DKA HHS
Anion gap >12 <12
Mental status Alert, drowsy to stupor and
coma
Stupor/coma
Sodium (mEq/L) 125-135 135-145
Pottassium (mEq/L) Normal to High Normal
Creatinine (mg/dl) Slight Increase Moderate increase
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Dr
Vinod
Kumar

31. Summary
• A 13yr old girl with a past h/o of anxiety is brought to the emergency
room for nausea, vomiting, and abdominal pain. She also reports ↑ed
urinary frequency. On physical exam, she is lethargic and markedly
dehydrated with dry mucous membranes and sunken eyes. Her
abdominal exam is normal. Laboratory results show ↑ed serum
glucose of 400 mg/dL and Potassium is 4.9mEq/L. A urinalysis is
positive for ketones. She is given fluids and admitted to the ICU for
close monitoring and administration of an insulin drip.
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Vinod
Kumar

32. Thank you!
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