DIABETIC KETOACIDOS IS A MAJOR MADICAL EMERGENCY AND REMAINS A SERIOUS CAUSE OF MORBIDITY PRINCIPALLY IN PEOPLE WITH TYPE 1 DM.

IT IS DEFINED AS “A MEDICAL EMERGENCY IN WHICH

HYPERGLYCEMIA IS ASSOSIATED WITH A METABOLIC ACIDOSIS DUE TO

GREATLY RAISED ( > 5 MMOL ) KETONE LEVELS”

INFECTIONS SURGERY MI NON COMPLAINCE OR WRONG INSULIN

DOSE

CARDINAL BICHEMICAL FEATURES OF DKA ARE

1. HYPERGLYCEMIA

2. HYPERKETONEMIA

3. METABOLIC ACIDOSIS

GLUCOSE

HYPERGLYCEMIAGLYCOSURIA

OSMOTIC DIURESIS

FLUID & ELECTROLYTE DEFICIENCY

RENAL HYPOPERFUSION

DECREASED EXCRETION OF KETONES

INCREASED H IONS

KETONES

ACIDOSIS

VOMITING

FLUID & ELECTROLYTE DEFICIENCY

RENAL HYPOPERFUSION

DECREASED EXCRETION OF KETONES

INCREASED H IONS

INSULIN DEFICIENCY

INCREASED LIPOLYSIS

INCREASE FREE FATTY ACID TAKE UP BY LIVER

SUBSTRATE FOR KETONE FORMATION (ACETOACITIC ACID,ACETONE AND BETA

HYDROXYBUTYRIC ACID )

PASS INTO BLOOD

ACIDOSIS

WATER 6 LITRE SODIUM 500 MMOL CHLORIDE 400 MMOL POTASSIUM 350 MMOL

SYMPTOMS IN FULMINATING CASES STRICKING

FEATURES ARE THOSE OF SALT AND WATER DEPLETION

POLYURIA THURST WT LOSS WEAKNESS NAUSEA VOMITING LEG CRAMPS BLURRED VISION ABDOMINAL PAIN

LOSS OF SKIN TURGER FURRED TONGUE CRACKED LIPS TACHYCARDIA SMELL OF ACETONE AIR HUNGER HYPOTHERMIA CONFUSION , DROWSINESS AND

COMA

DIABETIC KETOACIDOSIS IS CONFIRMED BY

1. HYPERGLYCEMIA

2. METABOLIC ACIDOSIS

3. KETONURIA,HYPERKETONEMIA

1. BLOOD GLUCOSE & ELECTROLYTES

2. URINARY KETONESURINE IS STRONGLU +VE FOR KETONE

BODIES

3. ABG’S

4. BLOOD CP

CXRTO LOOK FOR ANY INFECTIONECGK+ LEVELSUREA & CREATININERENAL FUNCTIONPLASMA OSMOLARITY2[Na+]+[UREA]+[GLUCOSE] MMOL/L

Diagnostic criteria* Blood glucose: >250 mg per dL (13.9 mmol per L) pH: <7.3 Serum bicarbonate: <15 mEq per L Urinary ketone: >=3+ Serum ketone: positive at 1:2

dilutions Serum osmolality: variable Typical deficits Water: 6 L, or 100 mL per kg body weight Sodium: 7 to 10 mEq per kg body weight Potassium: 3 to 5 mEq per kg body weight Phosphate: ~1.0 mmol per kg body weight

PRINCIPAL COMPONENTS OF TREATMENT ARE

1. FLUID REPLACEMENT2. ADMINISTRATION OF SHORT ACTING

(REGULAR) INSULIN3. K+ RERPLACEMENT4. ADMINISTRATION OF ANTIBIOTICS

Protocol for management

Asses your ABC’s Asses the consious levels, GCS NG tube Urinary cathetarization Address the circulatory issues, CVP line &

plasma expanders if BP not maintained Antibiotics if obvious source of infection Labs, Monitoring, ECGs

AVERAGE FLIUD LOSS IS 6 LITRES

3 LITERS FROM EXTRRACELLULAR COMPARTMENT

3 LITERS FROM INTRA CELLULAR COMPARTMENT

FIRST WE REPLACE EXTRA CELLULAR FLUID BY 0.9% NaCl

1L 30MIN

1L 1HOUR

1L 2HOURS

USE DEXTROSE SALINE OR 5% D/W WHEM BLOOD GLUCOSE IS < 15 mmol/L

THOSE >65 YRS OLD OR WITH CCF NEEDS LESS SALINE MORE CAUTIOUSLY

START WITH I/V INSULIN INFUSION @ 5U/HRS

ALTERNATIVELY 10 – 20 U I/M FOLLOWED BY 5 U/HR I/M

BLOOD GLUCOSE CONCENTRATION SHOULD FALL BY 3 –6 mmol/L

IF BLOOD GLUCOSE LEVELS DONOT FALL IN FIRST 2 HR THE DOSE OF INSULIN SHOULD BE DOUBLED

WHEN LEVEL FALL TO 10 – 15 mmol/L DOSE OF INSULIN SHOULD BE DECREASED TO 1 – 4 mmol/L

S/C ROUTE SHOULD BE AVOIDED BECAUSE S/C BLOOD FLOW IS REDUCED IN SHOCKED PT

VERY RAPID BLOOD GLUCOSE FALL SHOULD BE AVOIDED BECAUSE IT CAN LEAD TO CEREBRAL OEDEMA

AS THE PLASMA K IS OFTEN HIGHER AT PRESENTATION TREATMENT WITH I/V KCL SHOULD BE STARTED CAUTIOSLY

S K+ (mmol/L) AMOUNT OF KCL

< 3 mmol/L 40 mmol/L

<4 mmol/L 30 mmol/L

<5 mmol/L 20 mmol/L

IN PTS WHO ARE SEVERILY ACIDOTIC

pH < 7.0 [H+] > 100mmol/L

INFUSION OF NaHCO3 ( 300ml 1.26 % OVER 30 MIN )SHOULD BE CONSIDERED WITH SIMULTANEOUS ADMINISTRATION OF K

INFECTION SHOULD BE CAREFULLY SOUGHT AND VIGOROSLY TREATED

CATHETERIZATION IF NO URINE OUTPUT FOR > 3 HRS

N/G TUBE TO KEEP STOMACH EMPTY IN UNCONCIOUS

CVP LINE IF CVS COMPROMISED PLASMA EXPANDER IF BP DOES NOT

RISE WITH IV SALINE S/C HEPARIN 5000U/8 HR UNTIL

MOBILE IN COMOTOSE , ELDERLY ,OBESE

BLOOD GLUCOSE & ELECTROLYTES HOURLY FOR 8 HRS

VITAL MONITORING HOURLY URINE O/P KETONES ECG ABG’S

I/V DEXTROSE AND SALINE SHOULD BE CONTINUED UNTIL PT FEEL ABLE TO EAT AND KEEP FOOD DOWN

A SIMILAR AMOUNT OF INSULIN IS GIVEN AS THERE INJECTION OF REGULAR INSULIN

S/C INSULIN AT MEAL TIMES AND A DOSE OF INTERMEDIATE ACTING INSULIN AT NIGHT

HYPOTENTION CEREBRAL OEDEMA ARDS THROMBOEMBOLISM DIC ACUTE CIRCULATORY FAILURE

O hour

Start iv insulin 5 u /hr alt give 10-15u i.m. followed by 5 u im thereafter

O.9 % NS 1 lt over 30 mins Send urgent electrolytes Urine and serum for ketone levels

30 mins

Cont. insulin 5 u/hr iv or im O.9 % NS half lt in 30mins If K levels >5.5 mmol/l no need for KCl, if 3.5-

5.5 mmol/l give 20 mmol kcl If K <3.5 mmol/l then give 40 mmol/l of

infused levels If pH <7.O , give 3OO ml sod bicarbonate

over 3O mins

Hour 1

Cont. insulin 5 u/hr iv or im O.5 lt NS in 1 hr Recheck K levels Recheck vitals every 15 mins

Hour 2

Cont. insulin 5 u/hr iv or im O.5 lt NS in 2 hrs Cont. observing vitals & biochemistry

When RBS <15 mmol/l

Reduce rate of insulin to 1-4 U/hr Change to 5 % dextrose inf 0.5 lt/2

hrs Continue K replacement Recheck every aspect hourly till pt. stable

then 2 hrly

PLASMA GLUCOSEIS USUALLY HIGH BUT NOT ALWAYS

HIGH WCC MAY BE SEEN IN ABSENCE OF

INFECTION INFECTION IN ABSENCE OF FEVER CREATININE SOME ESSAYS FOR CREATININE

CROSS REACT WITH KETONE BODIES

HYPONATREMIA

DUE TO OSMOLAR COMPENSATION FOR HYPERGLYCEMIA

SERUM AMYLASE

RAISED UPTO 10 TIMES

WHAT IS THE FIRST STEP IN THE

MANAGEMENT OF PT WITH DKA

1. GET AN IV ACCESS AND GIVE INSULIN ACCORDING TO SLIDING SCALE

2. GET AN IV ACCESS AND GIVE IL OF 0.9% NaCl IN 30 MIN

3. GET AN IV ACCESS AND GIVE 50 ML OF 50% DW

AMOUNT OF KCL GIVEN IN DKA PT WITH SERUM K+ LEVEL OF <3 mmol/L

1. 20 mmol/L

2. 30 mmol/L

3. 40 mmol/L

A 15 YEARS OLD BOY PRESENTED IN EMERGENCY DEPARTMENT WITH COMPLAINTS OF HIGH GRADE FEVER,PRODUCTIVE COUGH WITH YELLOWISH SPUTUM FOR LAST 5 DAYS.HE HAS PERSISTENT VOMITINF AND ABDOMINAL PAIN FOR 2 DAYS AND DROWSINESS FOR ONE DAY.

WHAT IS YOUR CLINICAL IMPRESSION? WHAT CLINICAL SIGNS DO YOU SUSPECT IN

THIS CASE?

BP 80/60mmHg PULSE 110/min, regular. TEMP 97 F R/R 26/min GCS 7/15 PUPILS HAS SLUGGISH REPONSE TO LIGHT,NORMAL

SIZED. PLANTARS BILATERAL NON-SPECIFIC THERE IS BRONCHIAL BREATHING IN RIGHT BASAL LUNG THERE ARE SIGNS OF DEHYDRATION,REST OF

EXAMINATION IS NORMAL.

WHAT IS LIKELY DIAGNOSIS? HOW WILL YOU INVESTIGATE THIS CASE?

BSR SERUM KETONES URINARY KETONE SERUM ELECTROLYTES ABGS CP CXR

HOW WILL YOU MANAGE THIS PATIENT?