Diabetic ketoacidosis

Course of events
Intercurrent infection

Lose their appetite

Drastically stop or reduce insulin intake

Pathogenesis
Insulin deficiency Enhanced lipolysis (lipoprotein lipase) Increased free fatty acids delivery to the liver. Increased fatty acyl-CoA entry into hepatic mitochondria (acetone)

And Glucagon excess

Altered hepatic metabolism Increased activity of carnitine palmitoyl transferase. Free fatty acid conversion to ketoacids: 1)acetoacetic acid 2)beta-hydroxybutyric acid

Cardinal biochemical features

Hyperglycaemia Hyperketonaemia Metabolic acidosis

Clinical features
Symptoms Polyuria,thirst Nausea ,vomiting Abdominal pain

Symptoms
Leg cramps Blurred vision Weakness

Signs
Dehydration Hypotension (postural or supine) Cold extremities/peripheral cyanosis Tachycardia

Signs
Air hunger (kussmaul breathing) Smell of acetone Hypothermia Confusion

Investigation
Blood glucose Urea and electrolytes Arterial blood gases Urinanalysis ketones ECG Infection screen (FBC and Blood culture)

Management
Medical emergency. Regular clinical and biochemical review. Particularly the first 24 hours of treatment.

Monitoring
Laboratory Glucose Urea, Electrolyte Creatinine Bicarbonate Blood gases baseline 1 hr () 2hr 3hr 6hr 12hr 24hr

Prevention
Carefully track blood sugar levels . Be informed and watchful for early signs of dehydration and infection Know what to do should blood glucose levels rise too high - i.e. eating less, exercising, or taking medication Stay in control of type 2 diabetes

Principles of mx
Administration of short acting insulin Fluid replacement Potassium replacement Administration of antibiotics if infection is present.

Insulin
50 units soluble insulin in 50 ml 0.9% saline i.v. via infusion pump. 6 units /hr initially 3 units/hr when blood glucose < 15 mmol/l 2 units/hr if blood glucose declines< 10 mmol/l. Check blood glucose hourly,if no reduction in first hour, increase the dose.

 The blood glucose level should fall by 3-6 mmol/l per hour. A more rapid fall should be avoided. When the blood glucose has fallen 10-15 mmol/l the dose should be reduced to 1-4 units hourly. Sliding scales of insulin should not be used.

Fluid replacement
Extracellular fluid deficit should be replenished by intravenous isotonic saline(0.9% Na Cl) Early and rapid rehydration for insulin to reach the poorly perfused tissues. The intracellular deficit must be replaced by 5% or 10% dextrose and not by more saline.

Fluid replacement
O.9% NaCl i.v. - 1 litre over 30 min - 1 litre over 1 hr - 1 litre over 2 hrs - 1 litre over next 2-4 hrs. When blood glucose < 15 mmol/l,give dextrose 5% ,1 litre 8 hourly. Typical requirement is 6 litres over first 24 hrs. Avoid fluid overload in elderly patients. Monitor urine output.

Potassium
Start when < 3 mmo/l. At presentation,potassium is usually high,start infusion cautiously! If > 3.5 mmol/l,give 40 mmol in 1 litre of fluid. Avoid infusion rate of > 20 mmol/hr.

 If potassium,3.5-5.0mmol/l ,give 20 mmol/l added potassium. If more than 5.0 mmol/l ,or patient is anuric,give no potassium. Carefully monitor the level and cardiac rhythm monitoring.

Bicarbonate
In patients who are severely acidotic ({H+}> 100 nmol/l,pH < 7.0),infusion of sodium bicarbonate should be considered. With simultaneous potassium infusion. Complete correction should not be attempted.

Antibiotics
Vigorously treat infection to control ketosis.

Complications
Cerebral oedema Acute respiratory distress syndrome. Thromboembolism Acute circulatory failure.

HHS
Plasma osmolality =2 [Na+] + 2 [K+]+ [glucose]+[urea] (all in mmol/l) Normal value= 280 -300 mmol/kg The patient should be given 0.45% saline until osmolality approaches normal. Then 0.9% saline substituted.