Diabetic Ketoacidosis

Diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones.The condition develops when your body can't produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.

Causes

DKA results from insulin insufficiency with a relative or absolute increase in glucagon and may be caused by insufficient or interrupted insulin therapy, infections (pneumonia, urinary tract infection, gastroenteritis, sepsis), infarction (cerebral, coronary, mesenteric peripheral ), emotional stress, excessive alcohol intake, surgery, pregnancy and trauma, and certain drugs such as steroids, cocaine etc.

Clinical features

Polydipsia, polyuria, anorexia, nausea or vomiting, abdominal pain, rapid breathing (kussmaul respiration), fruity breath odor of acetone, fever, tachycardia, hypotension, signs of dehydration ( dry skin and mucous membranes and poor skin turgor ) and mental status change ranging from altered conscious level to coma.

Investigations

Urgent RBS ( RBS > 250 mg / dL ), Serum ketones, Urine for Ketones, Serum electrolytes, Serum bicarbonates ( > 10 mmol / L ) and ABGs. Also advise ECG, CXR, urine, sputum and blood cultures.

Diagnosis confirmation

Elevated blood sugar ( RBS > 250 ), positive serum / urinary ketones, metabolic acidosis - low serum bicarbonate ( < 15 ) and low blood PH ( < 7.3 ).

Management: (ADA 2009, AAFP 2013 Guidelines)

Admit the patient to ICU for frequent monitoring and pass large bore I / V line

Fluid therapy

• Inf - 1-1.5 L of 0.9 % saline over first hour ( 15-20 ml / kg per hour ). Subsequently, 0.45 % saline at 250-500 ml / hour ( 4 14ml / kg / hr ).
• In our setup for adults usually 1st L of 0.9 % N / S is given in 1 hr ( 30 minutes if BP is low ) . 2nd liter of 0.9 % N / S is given in two hour. 3rd L of 0.9 % N / S is given in four hours . 4th of 0.9 % N / S is given in 8 hours and 5th L of 0.9 % N / S is given in 16 hours.
• Switch to 5 % dextrose and 0,45 % saline at 150-250 ml / hour when plasma glucose reaches 250 mg / dL.
• Monitor labs, urine output, hemodynamics, state of hydration and physical exam to determine adequacy of hydration.
• Avoid fluid overload in renal and cardiac patients ( Give controlled IV fluids at the rate of 80-100ml./hr )

Insulin therapy

• Inj - Insulin Regular IV ( 0.14 units / kg ) stat , then Inj - Insulin Regular IV 0.1 units / kg per hour by continuous IV infusion ; increase the dose if not achieving 50-75 mg / dl / hr decrease in the blood sugar. Decrease the rate to 0.02-0.05 U / kg / hr. if blood sugar is 200 mg / dL.
• If initial serum potassium is < 3.5 meq / L, do not administer insulin until the potassium is corrected to > 3.5 meq / L

Assess the patient

What precipitated the episode ( noncompliance , infection , trauma , infarction , cocaine ) ? Initiate appropriate workup for precipitating event ( cultures, chest x - ray, ECG ), The agent or event that precipitated DKA should be aggressively treated. Give IV antibiotics in case of infection. If the patient is vomiting or has altered mental status, a nasogastric tube should be inserted to prevent aspiration of the gastric contents.

Measure

Measure random blood glucose 1 hourly, measure electrolytes (especially K +, bicarbonate, phosphate and magnesium) and anion gap 2 hourly for first 24 hrs.

Monitor

Monitor blood pressure, pulse, respiration, mental status, fluid intake and output every 1-4 hours.

Electrolytes repletion

• If the potassium > 6mEq / L, don’t give potassium . If the Potassium level is 4.5-6 mEq / L , give 10mEq / hr of KCI . If the potassium level is 3-4.5 , give 20 mEq / hr of KCl . Goal is to keep potassium levels at 4-5 mEq / L . Potassium can be given as follow : two thirds as KCl and one third as KPO4.
• If pH < 6.9 , give 100ml of 1.4 % sodium bicarbonate ( 2 amp ) in 400 ml sterile water ( isotonic solution ) with 20 mEq KCI at a rate of 200 mL / h for 2 hours until venous pH is > 7.0 ; if necessary , repeat every 2 hours until pH 7.0 ( AAFP 2013 - recommends > 6.9 )
• In DKA , replace phosphate if any of the following : Cardiac dysfunction , anemia , respiratory depression , or phosphate levels < 1.0 mEq / dl , or symptoms of hypophosphatemia ( there are no studies on phosphate repletion in HHS )
• Replete Mg if it falls < 1.2 mg / dL or if develops symptoms of hypomagnesaemia ( No recommendations for Mg )

Continue above until patient is stable

Once glucose goal level is achieved ( 150-250 mg / dL ) and acidosis is resolved . Insulin infusion may be decreased to 0.05-0.1 units / kg per hour. When the patient become stable, calculate the dosage of insulin according to the units of short acting insulin given in the last 8 hours.

Administer intermediate or long - acting insulin

Acting insulin as soon as patient is eating. Allow for overlap in insulin infusion and SC insulin injection

Transition to Subcutaneous Insulin Regimen

Once the DKA is controlled and the patient is awake and able to eat, subcutaneous insulin therapy can be initiated.