Diabetic Ketoacidosis
OVERVIEW
Diabetic Ketoacidosis (DKA) potentially life-threatening complication of diabetes mellitus resulting from the consequences of insulin deficiency
Diagnostic criteria
- pH < 7.3
- ketosis (ketonemia or ketonuria)
- HCO3 <15 mmol/L due to high anion gap metabolic acidosis (HAGMA)
- hyperglycemia (may be mild; euglycemic DKA can occur)
PATHOGENESIS
- increased glucagon, cortisol, catecholamines, GH
- decreased insulin
-> hyperglycaemia
-> hyperosmolality + glycosuria
-> electrolyte loss
-> ketone production from metabolism of TG
-> acidosis
HISTORY
- dry, abdominal pain, polyuria, weight loss, coma
- risk factors: non-compliance, illness, newly diagnosed
- ROS to rule find out possible precipitant (infection, MI, pneumonia, GI illness)
- normal insulin regime
- diabetic control
- previous DKA / admissions
- previous ICU admissions
EXAMINATION
- volume assessment
- signs of cause e.g. (infection)
- GCS
- work of breathing
INVESTIGATIONS
- ABG
- electrolytes
- osmolality
- urinalysis: ketones
- pregnancy test
- standard investigations to rule out cause: FBC, ECG, CXR
MANAGEMENT
Goals
(1) establish precipitant and treat
(2) assess severity of metabolic derangement
(3) cautious fluid resuscitation with replacement of body H2O
(4) provision of insulin
(5) replacement of electrolytes
Resuscitate
- intubation for airway protection if required
- O2 as required
- IV access
- fluid boluses (20mL/kg boluses of NS/HMN)
- urinary catheter
Acid-base and Electrolyte abnormalities
- will have a severe metabolic acidosis with probable incomplete respiratory compensation
- K+ may be normal but patient will have a whole body K+ deficiency -> needs to be replaced once < 5mmol/L -> use KH2PO4
- Na+ may be deranged
- acidaemia rarely requires HCO3- therapy and will respond to other treatments
Specific therapy
- start insulin infusion (avoid bolus) 0.1u/kg/hr
- aim to lower glucose by 1-2mmol/L/hr
- balanced salt solution fluid resuscitation
- once glucose < 15mmol/L -> provide dextrose (5%) 100mL/hr
- monitor urinary ketones or BE clearance
- correct osmolality by 3mosmol/kg/hr
Underlying cause
- treat infection
- review compliance
- ischaemia (ACS, CVA, PVD, mesenteric ischaemia)
- pregnancy
COMPLICATIONS
- hypoglycaemia
- hyponatraemia
- hyperchloraemic acidosis
- cerebral oedema
- arrhythmias
- venous thrombosis
- infection
- hyperchloraemia
References and Links
LITFL
Journal articles
- Beck LH. Should the actual or the corrected serum sodium be used to calculate the anion gap in diabetic ketoacidosis? Cleve Clin J Med. 2001 Aug;68(8):673-4. PMID: 11510523.
- Chua HR, Schneider A, Bellomo R. Bicarbonate in diabetic ketoacidosis – a systematic review. Ann Intensive Care. 2011 Jul 6;1(1):23. dPMC3224469.
- Chua HR, Venkatesh B, Stachowski E, Schneider AG, Perkins K, Ladanyi S, Kruger P, Bellomo R. Plasma-Lyte 148 vs 0.9% saline for fluid resuscitation in diabetic ketoacidosis. J Crit Care. 2012 Apr;27(2):138-45. PMID: 22440386.
- Kelly AM. The case for venous rather than arterial blood gases in diabetic ketoacidosis. Emerg Med Australas. 2006 Feb;18(1):64-7. PMID: 16454777.
- Rosenbloom AL. The management of diabetic ketoacidosis in children. Diabetes Ther. 2010 Dec;1(2):103-20. PMC3138479.
- Savage MW. Management of diabetic ketoacidosis. Clin Med. 2011 Apr;11(2):154-6. PMID: 21526698.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
very excellent review, Chris.
thank you
tom fiero, ed doc in merced, california