Diabetic Ketoacidosis Disease

BASICS

DESCRIPTION

A true medical emergency secondary to absolute or relative insulin deficiency characterized by hyperglycemia, ketonemia, metabolic acidosis, and electrolyte depletion

System(s) affected: Endocrine/Metabolic
Genetics: N/A
Incidence/Prevalence in USA: 46 episodes/10,000 diabetic patients; 2 per 100 patient years of type 1 DM
Predominant age: 0-19 years of age
Predominant sex: Male = Female

SIGNS AND SYMPTOMS

Polyuria
Polydipsia
Generalized weakness
Malaise/lethargy
Nocturia
Nausea/vomiting
Abdominal pain and tenderness
Decreased bowel sounds
Decreased perspiration
Hypotension
Hypothermia
Decreased reflexes
Coma
Confusion
Tachycardia
Tachypnea
Fever +/-
Breath fruity, with acetone smell
Dry mucous membranes
Anorexia or increased appetite

CAUSES

Insulin dependent diabetes mellitus (20-30% in newly diagnosed diabetics)
Infarction (myocardial) 5-7%
Infection (30-40%) usually respiratory or urinary
Idiopathic (20-30%)
Medication non-compliance
CVA
Trauma
Surgery
Emotional stress

RISK FACTORS

Any condition that leads to an absolute or relative insulin deficiency
History of corticosteroid therapy

DIAGNOSIS

LABORATORY

Blood sugar elevated (usually 250-800 mg/dL [13.88-44.4 mmol/L] range)
Serum ketosis
Urine ketosis
Glycosuria
Hyponatremia
Hyperamylasemia
Hypertriglyceridemia
Hypercholesterolemia
Increased BUN
HCO3 < 15 (< 15 mmol/L)
Decreased calculated total body K+
Metabolic acidosis on ABGs
Increased serum osmolality
Increased anion gap

Drugs that may alter lab results: N/A
Disorders that may alter lab results:

With concomitant lactic acidosis, acetoacetate production may be inhibited in presence of high levels of beta hydroxybutyrate. The nitroprusside reaction, which measures only acetoacetate, may not be strongly positive.
A very low serum sodium (< 110 mmol/L) suggests an artifact due to severe hypertriglyceridemia
Severe acidosis gives artificially high K+ level
Markedly increased serum ketones may cross react and cause a falsely high serum creatinine

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

ECG (especially if MI suspected). May also assist in evaluation of K+ status. Usually shows sinus tachycardia.
Urine and blood cultures

IMAGING

Chest x-ray to rule out pulmonary infection

DIAGNOSTIC PROCEDURES

N/A

TREATMENT

APPROPRIATE HEALTH CARE

Inpatient intensive care. This is a life threatening emergency.
Goals are to increase rate of glucose utilization by insulin-dependent tissues, to reverse ketonemia and acidosis, and to correct the depletion of water and electrolytes.

GENERAL MEASURES

IV Fluids adults: 1000 mL over first hour, then 500 mL/hr (approximately 7 mL/kg/hr) x 4 hrs or until dehydration improves, then 250 mL/hour (3.5 mL/kg/hr). Switch to D5 in 1/2 NS when serum glucose < 300 mg/dL (16.65 mmol/l). Expect to give 4-8 L/ first 24 hrs. (Some do not recommend initial IV bolus).
Pediatric maintenance requirements: 100 mL/kg for first 10 kg, 50 mL/kg for second 10 kg and 20 mL/kg thereafter. Fluid deficit: (Multiply patient's body weight by percentage dehydration). Replace maintenance and deficit evenly over 48 hours.

SURGICAL MEASURES

N/A

ACTIVITY

Bedrest

DIET

Nothing by mouth initially. Advance to pre-ketotic diet when nausea and vomiting are controlled.

PATIENT EDUCATION

For prevention, careful control of blood glucose (usually HgbA1c 7%)
Monitor glucose carefully during periods of stress, infection, trauma etc.

FOLLOW UP

PREVENTION/AVOIDANCE

Monitor glucose closely during stressful situations
Careful insulin control

POSSIBLE COMPLICATIONS

Cerebral edema
Pulmonary edema
Venous thrombosis
Hypokalemia
Myocardial infarction
Acute gastric dilatation
Late hypoglycemia
Erosive gastritis
Infection
Respiratory distress
Hypophosphatemia
Mucormycosis

EXPECTED COURSE AND PROGNOSIS

DKA accounts for 14% of all hospital admissions for diabetes and for 16% of all diabetic related fatalities
Overall mortality of 5-15%
In children < 10 years old, DKA causes 70% diabetes related fatalities

MISCELLANEOUS

ASSOCIATED CONDITIONS

Look for complications of chronic diabetes (nephropathy, neuropathy, retinopathy, etc.)

AGE-RELATED FACTORS

Pediatric:

Occasionally children or adolescents with DKA exhibit marked mental deterioration, including development of coma 4-6 hrs after therapy has begun. Mortality is high.
- Diagnose by CT scan (cerebral edema)
- Treat with IV bolus of 1 gram mannitol/kg in 20% solution
- If no response, hyperventilation to a pCO2 of 28 mm Hg

Geriatric: Must be careful with renal status or congestive heart failure
Others: N/A

PREGNANCY

Risk of fetal death with DKA during pregnancy is nearly 50%

OTHER NOTES

N/A

ABBREVIATIONS

NS = normal saline
ABG = arterial blood gases
D5 = 5% dextrose

Clinical Investigations

ROLE OF HOMOEOPATHY

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