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Diabetic Ketoacidosis (DKA)

Pathophysiology

Ketoacidosis occurs as the body enters a state of starvation, so it gets its energy from fat stores via ketogenesis. Ketone bodies are weak acids, which can lead to significant acidosis and severe illness in increasing quantities. Kidneys then keep Bicarbonate in to try and buffer the ketones, but over time the ketones become too much → Acidosis.


Dehydration occurs due to the glycosuria, which draws water out into the urine in a process called Osmotic Diuresis → Polyuria and Polydipsia. This is why patients should be started on insulin immediately, as they can develop severe Hypokalaemia as lots of K+ is pushed into cells, therefore leading to fatal Arrhythmias.


The most aspect of management in these patients is Fluid resuscitation.

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Presentation

  • Usually triggered by e.g. infection, non-compliance to meds, emotional/physical stress, dehydration

  • Dehydration

  • Polyuria, Polydipsia

  • N+V

  • Altered consciousness

  • O/E – Kussmaul breathing, Fruity breath (Acetoacetone), Hypotension


N.B. Kussmaul breathing is a deep, laboured breathing pattern in an attempt to compensate for a metabolic acidosis. This releases a lot of CO2, therefore increasing the pH.


Diagnosis

  • Diabetes – > 11mmol/L

  • Ketosis - > 3mmol/L

  • Acidosis - < 7.3


Management

  1. Fluid Resuscitation!, which is acheived with an initial bolus of 10ml/kg 0.9% NaCl over 60 mins. KCl should be added in every 500 ml with the K levels monitored closely. This shouldn't be done too quickly as it increases the risk of cerebral oedema.

  2. Fixed-rate Insulin infusion at 0.05-0.1units/kg/hour 1-2 hours after starting IVF


Other things to do include:

  • Monitor glucose, ketones, ph, gcs

  • Avoid hypoglycaemia with dextrose if glucose falls < 4mmol/L

  • Monitor for signs of cerebral oedema e.g. unequal pupils, lower GCS etc.



Complications

Main complication here is Cerebral Oedema. Dehydration and Hyperglycaemia cause water to move out of brain cells, causing them to shrink. Rapid correction of this dehydration and hyperglycaemia causes lots of water to move into cells too quickly. This causes oedema and can lead to brain cell death. It's managed with IV Mannitol, Hypertonic Saline, or Slowing IVF.


Other complications include Hypoglycaemia and Hypokalaemia (arrhythmias).



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