Acute Diabetic Ketoacidosis(DKA)

• Definition:-
DKA can be defined as a blood glucose
level usually >250mg/dl, pH <7.25 & plasma
bicarbonate level of 15mEq/l or less.
Severe DKA is define as a pH of 7.1 or less &
bicarbonate level of 10mEq/l or less.
DKA is a common & potentially life threatening,
acute complication of IDDM. Mortality rate may
be as high as 6-10%.
 Pathophysiology

• The basic causes of DKA are absolute or

relative insulin deficiency & elevated levels
of counter-regulatory or stress hormones
(eg.glucagon,cortisol,GH,catecholamines)
that antagonizes insulin. Due to these
hormonal abnormalities, there is increased
glucose production & decrease glucose
use. This causes hyperglycemia, which
leads to an osmotic diuresis, dehydration,
lipolysis, hyperlipidemia.
 Cont;
• There is acidosis due the production of
ketones (acetoacetate, B-hydroxybutyate)
from fatty acids. Electrolyte abnormalities
are also present due to intra cellular-
extracellular shifts and urinary losses.
 Presentation:
• Usually a patient with DKA presents with H/O
polyuria, polydipsia & weight loss. Acutely pt, is
ketotic & acidotic with fruity breath due to
ketosis. There may be nausea, vomiting &
lethargy.
• Mild DKA pts, may be awake & alert; but in
severe DKA ,pt has drowsiness or coma. There
may be hyperventilation, dehydration or
abdominal pain.
DKA should be suspected in a child who has
vomiting & dehydration but has polyuria.
 Precipitating factors
• DKA should be precipitated in a known
diabetic patient by:
An acute infection
Omission of insulin dose.
 Approach
• 1)History:-known diabetic? Missed dose of
insulin?
Precipitating factors
Source of infection
H/O wt, loss
2) Physical exam:-
i) level of consciousness:-lethargic/weak;
altered mental state (irritability to deep coma);
sign of head trauma
ii) Vital sign:-pulse (tachycardia, feeble pulse);
temp, (increase or decrease); respiration
(kussmaul’s resp; acidotic odour); BP (normal or
hypertension)
iii) Signs of dehydration:-general condition, pulse,
BP, cap.refilling, skin turger, mucous membrane,
urine output, signs of poor perfusion like cold
clammy extremities.
iv) Systemic exam:- find source of infection if any.
v) Abdominal exam:-may present like acute
abdomen.Look for distention/tenderness/BS
 Investigations
i) Blood:- blood glucose(>300mg/dl);urea,
creatinine; Na/K decrease; ketones(+);
pH(<7.3); serum osmolarity (increase).
ii) Urine:-sugar; ketones
iii) ECG
iv) Investigation to find source of infection:-
urine (RE/ME) + c/s; CBC; Blood c/s; CXR
 D/D
• Metabolic acidosis
• Septicaemia
• Pancreatitis
• UTI
• Gastro-enteritis-> dehydration
 AIM OF THERAPY
• i) Expansion of intravascular volume.
• ii) Correction of deficit in fluids.
• iii) Electrolyte & acid-base status.
• iv) Initiation of Insulin therapy to correct
hyperglycaemia
 MANAGEMENT
• i) ABC of resucitation.
• ii) Fluid & electrolyte manage
fluids & electrolytes loss in DKA
components loss maint. req/day.
Water 100ml/kg usual maint.
Na 6mEq/kg 3mEq/kg
K 5mEq/kg 2mEq/kg
Cl 4mEq/kg 2mEq/kg
HCO3 3mEq/kg 0.7mEq/kg
%of dehydration is usually taken as 10%
• Calculation of deficit vol. & maintenance vol.
• Fluids should be given in such a way that it provides 50-
60% calculated deficit in 12 hours & rest 40-50% in next
24 hrs. This is v. imp in preventing central edema.
• Initial bolus is given as 20 ml/kg of isotonic (0.9% NS) in
1 hour.
• 2nd hour-20ml/kg of 0.45%NS + 20mEq/l of KCl
• After bolus- start 1/2NS and KCl 20-40mEq/l (3-12 hrs).
• After 12 hrs maintenance plus deficit vol. for next 24
hours. This is given as 1/5 NS & 40mEq/l of K
If blood glucose is 250-300mg/dl 5% glucose should be
added to prevent hypoglycemia.
• It is v.imp that till blood glucose is
>300mg/dl, no glucose containing fluid
should be given sips, orally should be
started.
• If serum K <3.5mEq/L add 40mEq/L to IV
fluid.
• 3.5-5 then add 30mEq/L
• 5-5.5 then add 20mEq/L
• &>5.5 then no KCl
 Fluid therapy
Time amount/type of fluid
1 hour 20ml/kg of 0.9%NS
2 hour 20ml/kg of 0.45%NS+20mEq/L of
KCl
3-12 hour 1/2NS+30mEq/L of KCl(60% of
total fluid)
Next 24 hrs:-1/5NS+40mEq/L of KCl
+5%dextrose.(40% of total)
• Example
Wt=12kg; Dehydration 10%; Deficient=1200ml;
Maintenance=1100ml in 24 hours therefore 1650
ml in 36 hrs
Total 2850 ml
60% of this in 1st 12 hrs=1710ml
2nd bolus of 20 ml/kg=480ml
rest 1230ml
Rest 40%(1140)in next 24 hours.
 Insulin therapy
• Continuous low dose insulin therapy.
• Bolus 0.1U/kg of regular insulin iv, after 1hr followed by
0.1 U/kg/hr by continuous infusion.
• When bolus glucose is 300mg/dl infusion can be
decrease to 0.05U/kg/hr
• Once acidosis is corrected continuous infusion can be
replaced by sc dose of 0.2-0.4U/kg every 6-8 hourly.
• RBS should be checked before giving each dose.
• If glucose con.increase then increase insulin dose by
50% & vice-versa.
Intermittent insulin therapy for DKA
• Blood glu. tot.insulin iv.dose sc freq.
• >600mg/dl 1U/kg 0.5U/kg 0.5 2-4hrly
• 300-600 0.5 0.25 0.25 2-4 ’’

• Others:
Bicarbonate therapy if pH <7.1 give bicarbonate
1mEq/L over 1 hour iv
SUPPORTIVE:-maintenance of hygiene
,posture,catheterization
• Antibiotics:- no role of prophylactic antibiotics. search
some of infection and manage accordingly.
• COMPLICATIONS:-
• I) central edema:- Rx-slow down infusion rate of fluid and
mannitol 1g/kg bolus over 4-6 hourly.
• II) Hypoglycaemia:-Rx 5-10% of glucose to iv fluids when
blood glucose 250-300mg/dl
• III) Hypokalemia:- prevent by adding KCl after 1st hr once
pts passes urine
• IV) Arrythemia due to decrease or increase of K and
decrease Ca
 Monitoring
• Vital signs
• Blood glucose initially hourly till 300mg/dl
then 2 hrly.
• Urea & electrolyte- every 3-4 hr in 1st 12 hr
then 6 hrly
• Urinary glucose + ketone in each sample
• ECG
• Neurologic status
 Steps in management
1)Conform diag:- Blood glucose, Na, K, pH
urine sugar,ketone & others
ICU care is needed if <2yrs unconscious, pH<7.0, blood
glucose>1000mg/dl
2)Start fluid – 20ml/kg of 0.9% NaCl over 1 hr
3)Reassess – find out ppt factors
4)Fluid therapy +insulin– start 0.1U/kg/h in 2nd hour
5)Measurement of blood glucose + electrolytes and Acid-
Base
6)Continue fluid + insulin therapy. If glucose is about
300mg/dl add glucose to fluid.
7)Once acidosis is corrected insulin can be
given sc
8)If acidosis is not corrected with fluids and
insulin 0.1U/kg/hr infusion—think of sepsis
9)After 4-6 hr of therapy especially in
younger children– suspect cerebral
edema.
10)Contimuous monitoring.