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.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.