Diabetes Health Center

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DKA
SUMMARY

DKA is a complex disordered metabolic state characterized by hyperglycemia, ketoacidosis, and ketonuria.

Signs and symptoms
The # most common early symptoms of DKA are the insidious increase in polydipsia and polyuria. The following are other signs and symptoms of DKA:
Malaise,# generalized weakness, and fatigability
Nausea # and vomiting; may be associated with diffuse abdominal pain, decreased appetite, and anorexia
Rapid # weight loss in patients newly diagnosed with type 1 diabetes
History of failure to comply with insulin therapy or# missed insulin injections due to vomiting or psychological reasons or history of mechanical failure of insulin infusion pump
Decreased # perspiration
Altered consciousness (eg,# mild disorientation, confusion); frank coma is uncommon but may occur when the condition is neglected or with severe dehydration/acidosis

On examination, general findings of DKA may include the following:

Ill appearance
Dry skin
Labored respiration
Dry mucous membranes
Decreased skin turgor
Decreased reflexes
Characteristic acetone (ketotic) breath odor
Tachycardia
Hypotension
Tachypnea
Hypothermia

TESTING
Initial and repeat laboratory studies for patients with DKA include the following:
Serum glucose levels
Serum electrolyte levels (eg, potassium, sodium, chloride, magnesium, calcium, phosphorus)
Bicarbonate levels
Amylase and lipase levels
Urine dipstick
Ketone levels
CBC count
BUN and creatinine levels
urine


Management

Goals

Treatment of ketoacidosis should aim for the following:
Fluid resuscitation (A .
(it { is important to pay close attention to the correction of fluid and electrolyte loss during the first hour of
{ treatment, and this should always be followed by gradual correction of hyperglycemia & acidosis ----
the ( correction of fluid loss makes the clinical picture clearer and may be sufficient to correct acidosis ).
{ The{ presence of even mild signs of dehydration indicates that at least 3 L of fluid has already been lost.

B) Reversal of the acidosis and ketosis

C) Reduction in the plasma glucose concentration to normal

D) Replenishment of electrolyte and volume losses
AND
Identification the underlying cause

The 2011 JBDS guideline recommends the intravenous infusion of insulin at a weight-based fixed rate until ketosis has subsided. Should blood glucose fall below 14 mmol/L (250 mg/dL), 10% glucose should be added to allow for the continuation of fixed-rate insulin infusion.


The initial insulin dose is a continuous IV insulin infusion using an infusion pump, if available, at a rate of 0.1 U/kg/h. A mix of 24 units of regular insulin in 60 mL of isotonic sodium chloride solution usually is infused at a rate of 15 mL/h (6 U/h) until the blood glucose level drops to less than 180 mg/dL; the rate of infusion then decreases to 5-7.5 mL/h (2-3 U/h) until the ketoacidotic state abates.

https://emedicine.medscape.com/article/ ... eatment#d9

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Larger volumes of an insulin and isotonic sodium chloride solution mixture can be used, providing that the infusion dose of insulin is similar. Larger volumes may be easier in the absence of an IV infusion pump (eg, 60 U of insulin
(in 500 mL of isotonic sodium chloride solution at a rate of 50 mL/h

The optimal rate of glucose decline is 100 mg/dL/h. Do not allow the blood glucose level to fall below 200 mg/dL during the first 4-5 hours of treatment. Hypoglycemia may develop rapidly with correction of ketoacidosis due to improved insulin sensitivity.
Allowing blood glucose to drop to hypoglycemic levels is a common mistake that usually results in a rebound ketosis derived by counter-regulatory hormones. Rebound ketosis necessitates a longer duration of treatment. The other hazard is that rapid correction of hyperglycemia and hyperosmolarity may shift water rapidly to the hyperosmolar intracellular space and may induce cerebral edema.

If the potassium level is greater than 6 mEq/L, do not administer potassium supplement. If the potassium level is 4.5-6 mEq/L, administer 10 mEq/h of potassium chloride. If the potassium level is 3-4.5 mEq/L, administer 20 mEq/h of potassium chloride.


Potassium replacement should be started with initial fluid replacement if potassium levels are normal or low. Add 20-40 mEq/L of potassium chloride to each liter of fluid once the potassium level is less than 5.5 mEq/L.
Potassium can be given as follows : two thirds as KCl, one third as KPO4


Sodium bicarbonate only is infused if decompensated acidosis starts to threaten the patient's life, especially when associated with either sepsis or lactic acidosis. If sodium bicarbonate is indicated, 100-150 mL of 1.4% concentration is infused initially. This may be repeated every half hour if necessary. Rapid and early correction of acidosis with sodium bicarbonate may worsen hypokalemia and cause paradoxical cellular acidosis.

Bicarbonate typically is not replaced as acidosis will improve with the above treatments alone. Administration of bicarbonate has been correlated with cerebral edema in children.

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