Diabetic Ketoacidosis

From Anvita Health Wiki

Contents 1 Etiology 2 Pathology 3 Clinical-manifestations 4 Laboratory 5 Diagnostic-procedures 6 Radiology 7 Complications 8 Differential-diagnosis 9 Management 10 More General Terms 11 Additional Terms 12 References

Etiology

• new onset type 1 diabetes
• inappropriate use of insulin by a type-1 diabetic
• type 1 diabetic with a systemic infection
• type 1 diabetic with an acute myocardial infarction or other vascular event
• type 1 diabetic with trauma
• use of steroids or adrenergic agonists by type 1 diabetic
• type 1 diabetic with hyperthyroidism or pheochromocytoma
• pancreatitis

Pathology

• deficiency of insulin
• increase in glucagon
• increase in catecholamines
• increase in cortisol

Clinical-manifestations

• nausea/vomiting
• anorexia
• abdominal pain
• fatigue
• weight loss
• shortness of breath
• muscle cramps
• tachycardia
• tachypnea
• orthostatic hypotension
• polyuria
• polydipsia
• hypothermia

Laboratory

• serum chemistries

• serum glucose (> 250 mg/dL)
• urea nitrogen generally mildy increased
• serum creatinine
• electrolytes

• hyponatremia: expected decrease in Na+ due to glucose (glucose - 100) x 0.016
• hyperkalemia (decreased total body K+)
• serum bicarbonate < 15 meq/L

• serum amylase & serum lipase if suspected pancreatitis

• arterial blood gas, pH < 7.30
• serum ketones positive
• serum osmolality
• complete blood count with differential

• non specific leukocytosis often present

• cultures when indicated: blood, urine, throat, sputum, cerebrospinal fluid
• hemoccult stool for suspected GI blood loss

Diagnostic-procedures

• electrocardiogram

• monitor significant hyperkalemia or hypokalemia
• rule out acute myocardial infarction & arrhythmias

Radiology

• chest radiograph

Complications

• infection

• pyelonephritis
• pneumonia

• shock

• hypovolemia
• aggravation of hypovolemia by acidosis
• cardiogenic shock from myocardial infarction

• thrombosis

• increased factor VIII in DKA
• decreased antithrombin III in DKA
• hyperosmolar state
• low cardiac output with acidosis
• coronary artery disease

• cerebral edema

• generally observed in children
• more rapid fall in plasma glucose than in intracerebral glucose

• pancreatitis
• disseminated intravascular coagulation ( DIC)

Differential-diagnosis

• diabetic ketoacidosis*

• glucose > 250 mg/dL
• pH < 7.35 or HCO3- < 15 meq/L
• positive serum or urine ketones

• alcoholic ketoacidosis*
• starvation ketoacidosis*
• inherited disorders of branched-chain amino acids (uncommon)
• lactic acidosis
• renal failure with GFR < 20 mL/min
• salicylate intoxication
• methanol ingestion
• ethylene glycol ingestion
• paraldehyde ingestion
• formaldehyde ingestion
• toluene ingestion *Criteria for diabetic, alcoholic & starvation ketoacidosis overlap. A higher glucose favors DKA. A very low glucose favors starvation ketoacidosis.

Management

• goals

• reverse metabolic acidosis
• replace fluid & electrolytes

• fluid replacement

• normal saline (1st line)

• 15 mL/kg/ hr for 1 hour
• 7.5 mL/kg/ hr for 2-4 hr
• 3.75 mL/kg/ hr for 24-36 hr until fluid loss is corrected
• 15-20 mL/kg/ hr for 1st few hours [3]

• if serum Na+ > 145 meq/L, use 1/2 normal saline

• insulin

• serum K+ > 3.3 meq/L
• 0.15 units/kg regular insulin IV bolus (or 10 units)
• insulin drip

• 0.1 units/kg/ hr of regular insulin adjusted to maintain serum glucose 100-100 mg/dL
• ([[[Glucose_In_Serum | serum glucose]] ( mg/dL)] - 60) x 0.03 units/ hr

• the 60 may be adjusted to the lowest level of acceptable serum glucose
• the 0.03 may be adjusted for sensitivity of the patient to insulin

• change to subcutaneous insulin (70/30) when ketoacidosis has resolved & the patient is eating
• stop insulin drip one hour after 1st dose of SQ insulin
• reducing insulin infusion too early, before clearance of ketones, will cause relapse of DKA [2]

• glucose replacement:

• IV fluid is switched to D5 normal saline when glucose < 250 mg/dL

• K+ replacement

• if serum K+ < 3 meq/L, add 0.5 meQ/kg/ hr in IV fluid
• if serum K+ 3-4 meq/L, add 0.4 meQ/kg/ hr in IV fluid
• if serum K+ 4-5 meq/L, add 0.3 meQ/kg/ hr in IV fluid
• K+ replacement if serum K+ < 5.5 meq/L [2]
• serum K+ should be checked every 2-3 hours

• phosphate replacement

• does not improve recovery or mortality [1]
• may prevent rhabdomyolysis from hypophosphatemia [2]

• bicarbonate replacement

• does not improve recovery or mortality
• do not use unless pH < 7.0 [2]

• magnesium sulfate 2 g IV for magnesium deficiency
• subcutaneous heparin for patients at risk for DVT
• identify precipitating factors
• diet

• nothing by mouth until ketoacidosis & nausea/vomiting resolve
• ADA diet

• Diabetes education

More General Terms

• metabolic acidosis

Additional Terms

• diabetes mellitus
• hyperglycemic-hyperosmolar syndrome; hyperglycemic-hyperosmolar nonketotic coma (HHNC)
• hypokalemia
• hypophosphatemia

References

1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 632-634
2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, American College of Physicians, Philadelphia 1998, 2006
3. UpToDate Online 15.3 [1]
4. National Guideline Clearinghouse
   - Diabetic ketoacidosis. (Intracorp) ngc-guideline: [2]

diabetic ketoacidosis (DKA)