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DIABETIC KETOACIDOSIS

Diabetic Ketoacidosis - Definition

HCO3 < 15 mEq/L


Blood glucose >
pH < 7.3 • (LWPES & ESPE,
200 mg/dl 2004)

Ketonemia (1:2
Anion Gap > 12
dilution)
Diabetic Ketoacidosis - Classification

HCO3
Severity pH
(mEq/L)
Mild <7.3 <15
Moderate <7.2 <10
Severe <7.1 <5

(LWPES & ESPE, 2004)


Etiology
Results from Accidental or Inappropriate
inadequate intentional intervention
omission when stressed
insulin

newly
diagnosed

infection
Symptoms of ketoacidosis
Polyuria, polydypsia, weight loss

CNS depression – impaired sensorium to coma

Severe dehydration, Smell of ketones

Acidotic breathing (, Kussmaul respiration

Abdominal pain, Vomiting

Drowsiness and coma

more susceptible to recurrent infection,

Candidiasis may develop

hyperglycemia
Pitfall in Diagnosis – History & PE
• Vomiting, weight loss, severe dehydration,
Kussmaul breathing  WD/ Gastroenteritis

CLUE?

•Polyuria
•Acetone smell
Elements of Therapy

Fluids
• Treat dehydration/shock
• Decrease hyperglycemia
- Use isotonic fluid

- Fluid restriction for 48 hrs

Insulin
• Decrease hyperglycemia
• Decrease ketosis
Elements of Therapy

Electrolyte
• Replace electrolyte loss
• Cardiac problems
Monitoring
• Clinical improvement
• Clinical deterioration - cerebral edema
• - hypoglycemia
Controversies and Risks of Therapy

 Fluids - composition, bolus


Cerebral
amount and total fluids/day
Edema
 Use of Bicarbonate
 Phosphate replacement
Insulin in DKA

0.1 unit/kg/hr continuous drip (regular)


• Flush tubing with 50 ml
• 250 units regular in 250 cc NS (1.0 units/ml) 
= 0.1 u/kg/hr = 0.1 ml/kg/hr
Low-dose insulin regimen:
• short-acting insulin
• Intravenously
• Decreases BG by 50-75 mg/dl per hour
Bicarbonate

only in severe DKA (pH < 7.0)


• recommended dose 1–2 mmol/kg
• ½ of the dose over 30 minutes and ½ over 1-2 hours
• Correct until pH > 7.1

Hazards to bicarbonate treatment:


• precipitation of hypokalaemia
• paradoxically exacerbating of CNS acidosis
• cerebral oedema
Summary
Timely initiation of insulin is critical

Insulin analogs most closely match normal physiology

There is a wide variety of insulin regimens and insulin delivery


methods

It is important to match the insulin regimen to patient lifestyle and


characteristics

When blood glucose goals are not met, titrate insulin in a timely
manner

Refer to a Certified Diabetes Educator