DIABETIC KETOACIDOSIS (DKA)

DEFINITION:

• Diabetic keto-acidosis (DKA) is a state of inadequate insulin levels resulting in high blood sugar and accumulation of organic acids and ketones in the blood. It is also common in DKA to have severe dehydration and significant alterations of the body’s blood chemistry.
  
  WHO’S THE PATIENT: usually a type I diabetic
• Could be a yet undiagnosed diabetic
• or a known diabetic non-compliant on drugs
• or a known diabetic who skipped his insulin because of history of diarrhea and vomiting
  
  SIGNS AND SYMPTOMS:
  
  Systems affected : CNS, respiratory, gastrointestinal and excretory
  
• CNS:
  1. lethargy
  2. anorexia
  3. coma
  
• RESPIRATORY:
  1. Ketotic breath
  2. Air Hunger / Kussmall breathing
  
• GASTROINTESTINAL:
  1. Vomiting (in 2/3rds of patients)
  2. abdominal pain, severe enough to be called pseudoappendicitis of DKA
  3. polydipsia
  
• EXCRETORY:
  1. dehydration
  2. polyuria
  
  DIAGNOSTIC INVESTIGATIONS:
  
  Hyperglycemia, ketonemia and hypercapnea are the significant findings. So we do the following laboratory investigations:
  
• blood and urinary glucose, urinary ketones
• urea, creatinine and electrolytes
• HCO3
• ABG
• osmolality
• serum lipid profile
• CBC
• serum amylase
• culture and sensitivity (if signs of infection)
  
  DIFFERENTIAL DIAGNOSIS:
  
• Insulin reaction – exclude by administering 50ml of 50% glucose, condition will improve if it is an exogenous insulin reaction, if not then too no harm is done by the administered glucose.
• salicylate poisoning – there will be history of aspirin (or some other salicylate) overdose.
• lactic acidosis
• hyperglycemia
• hyper osmolar state
• non – ketotic coma
• advanced renal failure
  
  TREATMENT:
  1. Infuse normal saline through the same vein that’s used for taking blood sample, as this is an emergency. Replace 4-8 L in first 24 hours of onset. When glucose levels are 200mg, start orange juice and/or 5% saline to the normal saline.
  2. Administer insulin, both subcutaneously and IV, giving 200 units in first 3 hours. You may give up to 10,000 units in first 24 hours.
  if the patient has low potassium levels, demonstrated by a flattened or inverted T wave and prolonged QT interval, start potassium infusion in the 2nd or 3rd hour. Do not exceed 20 mEq/hr, giving up to 80 mEq in the first 24 hours.
  3. Gastric lavage may be done, to prevent any aspiration.
  
  If the DKA is severe, then monitoring of glucose, carbondioxide and acetone levels should be done every 2 hours, otherwise every 4 hours.
  
  THE STABLE PATIENT:
  The patient is said to be stabilized when his blood glucose is <200mg/100ml,>