DIABETIC KETOACIDOSIS

SECONDARY TO POOR COMPLIANCE TO

MEDICATION
WITH UNDERLYING PULMONARY TB
(CONSOLIDATION AT RIGHT LOWER ZONE)
Kussmauls
breathing

Nausea

Loss of
appetite

DDX?

Lethargy

Dehydrate
d

Abdominal
pain

Vomiting

Mild
disorientati
on

Hx of
missing
insulin
shot

Differential diagnosis

Points to support

Points against

Hyperosmolar
hyperglycaemic state
(HHS)

-Common in type II DM
-Didnt give insulin shot
-drowsiness
-Nausea
-Lethargy
-Dehydrated
-Disoriented

-Kussmauls breathing
-abdominal pain
-HHS usually develops
over a course of days to
weeks, unlike(DKA)
No drowsiness
No seizure
No coma

Hypoglycemia

-LOC
-Hx of diabetes mellitus
-Headache
-Confused and disoriented
-Weakness and tiredness
-Inappropriate behaviour
- Did not take food for few
days
-Alcohol intake
-LOW
-Nausea, vomiting

-Patient skip his insulin

shot
-Kussmauls breathing
-Loss of appetite

Differential
diagnosis

Points to support

Points against

Alcoholic ketoacidosis -Nausea

-Vomiting
-Dizziness
-Consume alcohol
-Abdominal pain
-LOC

-Kussmauls breathing
-No tremor
-Reduce in taking alcohol, not everyday
-no muscle pain
-no diarrhea
-no seizure
-SOB
-hematemesis, melena

Acute pancreatitis

-Abdominal pain
-Vomiting
-Fatigue
-Nausea
-Used to drink 2-3 cans of alcohol
per day

-No fever
-No abdominal tenderness
-Pain located at the umbilical area

Acute appendicitis

-Abdominal pain
-Nausea
-Vomiting

-No fever
-No rebound tenderness
-Abdominal pain did not radiate

Diagnose criteria for

DKA?

DX CRITERIA FOR DKA

> 3 CRITERIA :
Hyperglycaemia
Blood glucose: >14mmol/L

Acidaemia
pH: <7.3 (7.35-7.45)
Bicarbonate: <15mmol/L (22-26mmol/L)
Anion gap: >10

Ketonaemia or ketonuria

DIABETIC
DIABETICKETOACIDOSIS
KETOACIDOSIS
Acute and life-threatening complication of diabetes
mellitus(DM) typically occur in DM TYPE 1(insulin dependent) &
sometimes type 2(non insulin dependent)
Is a result of cellular starvation brought on by relative insulin
deficiency and counter regulatory or catabolic hormone excess
resulting into:
Hyperglycaemia
Osmotic diuresis
Pre-renal azotemia
Ketone formation
Wide anion gap metabolic acidosis

Aetiology?

AETIOLOGY

S&S?

Poor
complian
ce to
insulin
injection
Major
trauma @
surgery

Infection

Type
1&2
DM
Medicatio
ns

pregnanc
y

Intercurre
nt illness

tachycard
ia

Hypotensi
on

Kussmaul
respiratio
n

Nausea &
vomiting

Investigation?
Abdomina
l pain

S&S
of
DKA

Confusion
, drowsy

Sweet
smelly
breath
(acetone)

fatigue

Polydypsi
a

Polyuria

Fruity breath odour

INCREASE LIPOLYSIS
INCREASE LIPOLYSIS
Acetoacetic acid
Acetoacetic acid

Increase ffa to liver

Increase ffa to liver
convert into ketone bodies
convert
into ketone bodies
(ketogenesis)
(ketogenesis)
ketonaemia
ketonaemia

B- hydroxybutyrate
B- hydroxybutyrate

ketonuria
ketonuria

Increase lactate
Increase lactate

polyuria

acetone
acetone

Nausea
+
vomitin
g
+
abd.pai
n

Met.acidosis
Met.acidosis
(ketoacidosis)
(ketoacidosis)
Respi. compensatory
Respi. compensatory

Rapid or shallow breathing

(Kussmauls breathing)

INVESTIGATION
1. The diagnosis of Diabetic
Ketoacidosis
2. Identification of underlying
causes
3. Monitor the effects of therapeutic
regime

Hyperglycae
mia
Blood
glucose >14
mmol/L

Diagnos
tic
Criteria
Ketonaemia
or ketonuria

Acidaemia
pH <7.3
bicarbonate
<15mmol/L

Diagnostic
Investigation
Random
glucose (DXT)

: 53.1 mmol/L

hyperglycaemi
a

Urine UFEME (28/10/2013)

PH (4.5 8)

Ketone

4+

Glucose

4+

pH

7.10

Protein

2+

pCO2

16.10

Leucocyte

Negative

pO2

117.00

Nitrite

Negative

Base

8.0

HCO3

23.1

Arterial blood gas

(28/10/2013)

Metabolic
acidosis

Blood count

Values

Normal
ranges

WBC

21.99

4-11 x 109/L

RBC

5.11

2-10 x 106/L

Hb

13.1

13-18 g/dl

Haematocrit

42.0

36-45%

Platelet

566

110-450 x 109/L

% neutrophils

92.8

40 75

3.7

20 45

% lymphocytes

Renal profile (28/10/2013)

Electrolyte

Values

Normal ranges

Na+

128

(135 145
mmol/l)

K+

4.0

(3.5 4.5
mmol/l)

Urea

11.9

(2.5 8.0
mmol/l)

Liver profile

Values

Normal ranges

Total protein

91

(64 - 83 g/l)

Albumin

31

(35 50 g/l)

(3.4 20.5 g/l)

ALP

165

(40 150 U/L)

ALT

(0 55 U/L)

Total bilirubin

ECG (28/20/2013)

Sinus rhythm, no ischemic changes, no

changes suggestive of hypokalemia
and hyperkalemia

How to manage patient DKA?

Initial Management
ABC
Monitor- ECG, Vital sign
Set 2 large bore IV line
Urinary catheter to monitor urine input
and output

Definite
Management
Fluid
therapy

Insulin
infusion

Electrolyte
managem
ent

Treatment
of
underlying
cause

Electrolyte
management
Total body potassium
is invariably low, and plasma K+

falls as K+ enters cells with treatment.

Begin potassium replacement at 2nd hour of fluid
therapy.
Replacement based on serum K+ measurement
Caution: should only be added to the replacement fluids
as soon as there is absence of renal failure. (URINE
OUTPUT >30 ml/hr )

Serum K+ (mmol/L)

Amount of KCl to added

per litre IV fluid

<3.0

40 mmol

3-4

30 mmol

4-5

20 mmol

Insulin infusion
Route-Intravenous
Type-short acting (regular insulin, Actrapid HM, or
Humulin R)
Bolus dose of 0.15 units/kg body weight
Low dose continuous infusion of 0.1 units/kg body
weight/hour
Achieve drop rate of about 3-4 mmol/l per hour
Caution:
Inform endocrinologist on-call if insulin rate is
>6u/hr.
Withold insulin infusion if serum potassium
<2.5mmol/L with ECG changes of hypokalaemia.
Correct potassium under continuous cardiac
monitoring. restart insulin therapy once serum
potassium 3.0mmol/L or normalization of ECG

Fluid therapy
IV 0.9% NaCl
Starting point depend on severity of
dehydration
Patient not severely dehydrates start
Step 2 or Step 3
After each step =>review
Adequacy of fluid replacement
Evidence of fluid overload
Rate
Action
Fluid
Step 1

1 pint over 30 min for

1 hour

=> review

1 litre

Step 2

1 pint over 1 hour for 2 => review

hour

1 litre

Step 3

1 pint over 2 hour for 4 => review

1 litre

At review

Haemodynamicall
y unstabledehydrated,
hypotensive, no
urine output

If improving

Fluid overload

Repeat the same

step

follow from step

1- step 4 and
continue step 4
as maintenance

withhold fluid
therapy
and manage the
fluid overload
accordingly

Once stable,
restart fluid
therapy at slower
rate

Fluid therapy
If glucose level falls below 14 mmol/l use
IV dextrose 5%. (to prevent hypoglycemia)
Fluid replacement should correct
estimated 4-6 liters within 1st 24 hours.
Serum osmolality should not decrease by 3
mOsm/kg/h to avoid cerebral edema.
Urine output must be monitored hourly
Electrolytes and creatinine should be
monitored every 2-4 hours.

Treat the underlying

causes

Cardiac
event

Infection

THANK YOU