Why ketones develop in DKA
In diabetic ketoacidosis (DKA), which is more common in patients with type 1 diabetes, no insulin is available to suppress lipolysis, resulting in ketone formation and acidosis.
Antibodies in type 1 DM
Recognized auto-antibodies include glutamic acid decarboxylase (GAD), zinc transporter 8 (ZnT8)
and islet antigen 2 (IA-2)
to confirm the diagnosis of diabetes 3
symptomatic
child by finding a markedly raised random blood glucose
(>11.1 mmol/L by the current WHO definition), glycosuria,
and ketosis. Where there is any doubt, a fasting blood
glucose (>7 mmol/L) or a raised glycosylated haemoglobin (HbA1c) are helpful
factors that increase blood glucose levels 8
Insufficient insulin
Food (especially carbohydrates)
Illness
Menstruation (shortly before onset)
Growth hormone
Corticosteroids
Sex hormones at puberty
Stress
Factors that decrease blood glucose 4
Exercise
Alcohol
Marked anxiety/ excitement
Hot weather
Steps in management of DKA
- assess the severity
- Emergency measures
- fluids
- Insulin
- Monitor Electrolytes
- Normalization
Step 1 assess the severity of DKA
*pH >7.2 or HCO3 10 – 18 mmol/L: Mild DKA
*pH 7.1 to 7.2 or HCO3 5 – 0 mmol/L: Moderate DKA
*pH <7.1 or HCO3 <5 mmol/L: Severe DKA
Step 2 Emergency measures in DKA
-If shocked, give bolus of 20 ml/kg 0.9% NaCl
-Consider intravenous antibiotics, if suspecting sepsis as a trigger of DKA
Step 3 fluids
- even If not in shock, give: Initial bolus
+ - Rehydration fluids:
pH < 7.1 or new onset DM= 9% dehydration;
otherwise pH > 7.2 = 6% dehydration.
Give rehydration fluid over
48 hours
+
deficit fluids &Maintenance
Start with 0.9%
NaCl with 20mmol KCl
per 500ml bag
Step 4 Insulin in DKA
After one hour of rehydration
Start intravenous insulin infusion at 0.1 units/kg per hour
symptoms of diabetic ketoacidosis 5
- smell of acetone on breath
- dehydration
- rapid breathing due to acidosis (Kussmaul
breathing) - hypovolaemic shock
- drowsiness and reduced level of consciousness
Labs for DKA 8
-Serum glucose.
-Serum electrolytes (bicarbonate, Calcium, phosphorus magnesium)
creatinine, urea
-Venous (or arterial) pH and pCO2.
-Hemoglobin A1cΔ.
-Blood ketone
-Urinalysis +/- blood culture
-Cardiac monitor for T-wave changes of
hypokalaemia
- Weight (compare with recent clinic weight to ascertain level of dehydration)
DKA is defined by the presence of all of the following in a patient with diabetes
*Hyperglycemia – Blood glucose ≥200 mg/dL (11 mmol/L).
*Metabolic acidosis – Venous pH <7.30 and/or serum bicarbonate <18 mEq/L.
*Ketosis – Elevated levels of ketones in urine or blood
when to add dextrose to the fluids in DKA px
Add dextrose to the IV fluids when the blood glucose falls below approximately 300 mg/dL (17 mmol/L) to prevent hypoglycemia during treatment
Step 5 Monitor electrolytes hourly 4
*hourly:
Vital signs.
Neurologic status.
Fluid intake (IV and oral) and losses.
Blood glucose hourly.
Step 5 Monitor electrolytes after 1hr
- Electrolytes, VBG every 2 to 4 hours.
- Calcium, phosphorous, and magnesium every 4 to 6 hours.
*More frequent monitoring may be necessary for patients with severe electrolyte derangements or rapid changes in these laboratory values.
When to stop Insulin / Fluids depends on
Insulin depend on pH
Fluids depend on Sugar
Step 6 normalization
When pH, glucose and blood ketones normal:
Give subcutaneous insulin and oral diet.
Stop intravenous insulin infusion 1 hour after giving subcutaneous insulin, as it takes time to be absorbed
