diabetic ketoacidosis
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Diabetic Ketoacidosis
Diabetic Ketoacidosis
(DKA)
(DKA)
DKA - Definition
DKA - Definition
Clinical – Acute state of severe
Clinical – Acute state of severe
uncontrolled diabetes that requires
uncontrolled diabetes that requires
emergency treatment with insulin
emergency treatment with insulin
and intravenous fluids
and intravenous fluids
Biochemical – Triad of hyperglycemia
Biochemical – Triad of hyperglycemia
(blood glucose > 250 mg/dl),
(blood glucose > 250 mg/dl),
ketonemia (serum ketones > 5
ketonemia (serum ketones > 5
mEq/L) and acidemia (blood pH <
mEq/L) and acidemia (blood pH <
7.3)
7.3)
Kitabchi, AE etal., Management of hyperglycemic crisis in patients with diabetes, Diabetes Care, 24:1, Jan. 2001, 132.
Why DKA?
Why DKA?
Medical Illnesses – Alcohol abuse,
Medical Illnesses – Alcohol abuse,
trauma, pulmonary embolism,
trauma, pulmonary embolism,
myocardial infarction
myocardial infarction
Drugs
Drugs
–
Induce insulin resistance
Induce insulin resistance
Corticosteroids
Corticosteroids
–
Decrease insulin secretion
Decrease insulin secretion
B-Blockers
B-Blockers
Diuretics
Diuretics
Dilantin
Dilantin
" Since I have seen three diabetics in the course of a year die,
with remarkably similar symptoms in which there was a peculiar
comatose condition preceded and accompanied by dyspnoea, I
believe that it…has to do with a form of death which…bears the
closest relationship to the disturbances in the metabolism in
diabetes…"
Reference: Kussmaul, Adolf. Zur lehre vom diabetes mellitus. Dtsch Arch Klin Med.
1874; 14:1-4
Adolf Kussmaul (1822-1902)
History And Physical Exam
History And Physical Exam
Physical Exam
Physical Exam
Dehydration – Weak and rapid pulse,
Dehydration – Weak and rapid pulse,
dry tongue and skin, low blood
dry tongue and skin, low blood
pressure (hypotension)
pressure (hypotension)
High Serum Osmolarity - Change in
High Serum Osmolarity - Change in
consciousness
consciousness
Acidosis – Shallow, rapid breathing,
Acidosis – Shallow, rapid breathing,
nausea, vomiting, abdominal pain
nausea, vomiting, abdominal pain
Ketonemia – “Fruity” smell of
Ketonemia – “Fruity” smell of
acetone
acetone
Lab Studies
Lab Studies
Blood glucose – usually higher than
Blood glucose – usually higher than
250 mg/dl
250 mg/dl
ABG – acidosis, low bicarbonate, low
ABG – acidosis, low bicarbonate, low
pH
pH
Serum chloride and phosphorus low
Serum chloride and phosphorus low
WBC increased (even without an
WBC increased (even without an
infection)
infection)
–
Leukocytosis
Leukocytosis
Anion gap present
Anion gap present
(Na + K) – (Cl + HCo3) > 13mEq/L
(Na + K) – (Cl + HCo3) > 13mEq/L
Lab Studies
Lab Studies
Urine and Blood Ketones
Urine and Blood Ketones
–
Can be negative for ketones – most labs
Can be negative for ketones – most labs
test only for acetoacetate (the
test only for acetoacetate (the
nitroprusside reaction). But, in
nitroprusside reaction). But, in
untreated DKA, the most common
untreated DKA, the most common
ketone is beta-hydroxybutyrate
ketone is beta-hydroxybutyrate
–
Thus, as the patient is treated, the urine
Thus, as the patient is treated, the urine
might then become positive for urine
might then become positive for urine
ketones.
ketones.
Lab Studies
Lab Studies
Serum Potassium – Total body
Serum Potassium – Total body
potassium is low in DKA, but often
potassium is low in DKA, but often
the lab results are normal or high
the lab results are normal or high
–
Acidosis: Cells exchange intracellular
Acidosis: Cells exchange intracellular
K for excess extracellular hydrogen
K for excess extracellular hydrogen
ions
ions
–
Dehydration: Due to the low
Dehydration: Due to the low
intravascular fluid status, all lab
intravascular fluid status, all lab
values are initially elevated.
values are initially elevated.
Treatment
Treatment
Correct dehydration
Correct dehydration
Correct hyperglycemia
Correct hyperglycemia
Correct low potassium
Correct low potassium
Correct acid-base balance
Correct acid-base balance
Treat underlying condition (e.g.
Treat underlying condition (e.g.
infection) if present
infection) if present
