Diabetic
Ketoacidosis
YASIN M,MD
Diabetic Ketoacidosis
It is an acute metabolic complication of
diabetes mellitus that may present with a
decreased level of consciousness
Cont….
Symptoms
Nausea/vomiting Confusion
Shortness of Abdominal pain
breath Fever
Obtundation/ Altered mental
drowsiness function
Thirst/polyuria Dehydration
Fruity smelling Lethargy
breath Coma
Cont…
Diagnostic Criteria
Blood glucose > 11.0mmol/L or known
diabetes mellitus
Ketonuria ++ or more on Ketostix
Glasgow Coma Scale less than 12,
systolic BP below 90mmHg and pulse
over 100 or below 60bpm each indicate
severe status.
Cont…
Investigations
Check blood glucose
Urine for ketones
Arterial blood gases
Urea, creatinine and electrolyte
Cont…
Non-Pharmacological Treatment
Admit for intensive care
Insert nasogastric tube for gastric
decompression
Use DKA chart to guide treatment and
monitor the patient
Pharmacological Treatment
Fluid and electrolytes replacement
If systolic BP < 90mmHg give:
A: 0.9% sodium chloride solution (500ml) over
10–15 minutes. If SBP remains below 90mmHg
this may be repeated once. Most patients
require between 500 to 1000ml given rapidly.
If systolic BP remains <90mmHg consider
other causes (septic shock, heart failure)
Do NOT use plasma expanders
Cont…
If the systolic BP is > 90mmHg
A: Normal Saline(NS) 1 litre + Potassium chloride
(KCl) 2g when available 2 hourly for 1st 4hours, then
4 hourly OR
A: Ringer’s Solution 1 litre 2hourly for 1st 4hours,
then 4 hourly
When blood glucose falls to 14 mmol/L or below,
start 5% Dextrose 500mls 4hourly
Isotonic dextrose saline may be used in place of
dextrose 5%
If a patient is still dehydrated continue Normal saline
or Ringer’s solution as well.
Cont…
More cautious fluid replacement should be
considered in young people aged 18–25
years, elderly, pregnant, heart or renal failure,
mild DKA, other serious co-morbidities
Cont…
Insulin Therapy
B: Soluble insulin 8 IU (0.1 IU/kg) IM and
8 IU IV at beginning.
Then give 8 IU (0.1 IU/kg) IM soluble
insulin bolus hourly
Check blood glucose 2hourly if using IM
route or 4 hourly if sc route
Cont…
When blood glucose falls to 14 mmol/L or bellow give
soluble insulin 4 IU SC 4 hourly OR IM 2 hourly and
continue until the patient is able to eat again then
change to twice or thrice daily insulin as follows:
Give insulin 0.5–0.75 IU/kg/day (the higher doses for the
more insulin resistant i.e. teens, obese)
Give 50% of total dose with the evening meal in the form
of long-acting insulin and divide remaining dose equally
between pre-breakfast, pre-lunch and pre-evening meal.
OR
Use pre-mixed insulin: give two thirds of the total daily
dose at breakfast, with the remaining third given with the
evening meal.
Non-ketotic hyperosmolar state (NKHS)
It is a serious condition most frequently
seen in older persons with T2DM. In NKHS,
blood sugar level rise and the body tries
to get rid of the excess sugar by passing
into urine.
Diagnostic Criteria
Polyuria Diminished oral
Orthostatic intake of fluids
hypotension Profound
Altered mental dehydration
state lethargy, Hypotension
obtundation, Tachycardia
confusion Weight loss
Seizures, possible
coma
Cont…
Non-ketotic hyperosmolar state
differentiated from DKA by no nausea and
vomiting, no abdominal pain, and no
Kussmaul breathing and commonly
occurred in Diabetic type 2
Precipitating factors:
Poor oral fluid intake
MI, stroke, sepsis,
pneumonia and other serious infections
Medicines: eg. thiazides diuretic,
glucocorticoids, phenytoin
Laboratory investigation
Blood glucose
Serum electrolytes (K+, Na+, Cl–)
Initial serum K+ may be falsely high due
to extracellular shifts.
Renal function (Urea and Creatinine)
Serum osmolarity (usually >330
mosmol/L)
Serum osmolarity = 2(Na++ K+) +
glucose + Urea (Glucose and Urea in
mmol/L)
Normal is < 310 mosmol/L as calculated
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