DIABETIC KETOACIDOSIS

 Acute complication of type 1 diabetes

 Diagnostic criteria:

 Hyperglycemia (Capillary blood glucose >11 mmol/L)

 Hyperketonemia (Capillary ketones >3 mmol/L or urine

ketones >2+)

 Metabolic Acidosis (Venous pH <7.3 and/or bicarbonate

<15 mmol/L)
Symptoms to ask:
 Polyuria
 Loss of weight
 Nausea and vomiting
 Lethargy
 Blurring of vision
 Crampy abdominal pain
Sign to elicit:
 Inspect for Dehydration ( loss of skin turgor, cracked
lips)
 Breathing sound (Kussmaul breathing / air hunger)
 Fruity odor (acetone breath)
 Hypotension
 Tachycardia
 Confusion, drowsiness
Step 1
 Commence 0.9% saline drip using large bore
cannula.
Step 2
 Commence a fixed rate intravenous insulin
infusion (IVII) (0.1 unit/kg/hr based on
estimate of weight).
 50 units short-acting human insulin made up
to 50 mL with0.9% saline solution.
Step 4. Investigations

 Capillary and venous blood glucose

 Arterial blood gases
 Blood or urinary ketones
 BUSE
 FBC
 Blood cultures
 MSU
 ECG (if indicated)
 CXR (if indicated)
Step 6. Look for precipitating causes and treat
accordingly

 Start broad-spectrum antibiotics if infection suspected

 Precipitating factors that should be actively sought

out: infection, missed therapy, acute coronary
syndrome, CVA, surgery
 Aims of treatment:
 Rate of fall of ketones of at least 0.5mmol/L/hr, or

 Bicarbonate rise 3 mmol/L/hr

 Blood glucose fall 3 mmol/L/hr

 Maintain serum potassium in normal range

 Avoid hypoglycaemia
Step 9. Assess response to treatment

 Review the insulin infusion rate if:

 Blood ketones does not fall by at least 0.5 mmol/L/hr
 Venous bicarbonate does not rise by at least 3mmol/L/hr
 Plasma glucose does not fall by at least 3 mmol/L/hr

 If equipment is working but response to treatment

inadequate, increase insulin infusion rate by 1
unit/hr increments hourly until targets achieved.
Aims:
 Ensure clinical and biochemical parameters
improving
 Continue IV fluid replacement
 Avoid hypoglycaemia
 Assess for complications of treatment e.g.
fluid overload, cerebral oedema
 Treat precipitating factors as necessary
 Once blood glucose falls below 14 mmol/L:
 Switch to 5% dextrose at 125 mL/hr and reduce insulin

infusion rate to 0.05 units/kg/hour; or

 Switch to 10% dextrose at 125 mL/hr with no change in

insulin infusion rate.

 Reassess cardiovascular status at 12 hours;
further fluid may be required
 Check for fluid overload
Step 12. Reassess patient, monitor vital signs,
review biochemical and metabolic parameters
 At 12 hours check venous pH, bicarbonate,
potassium, capillary ketones and glucose
 Resolution is defined as ketones <0.3 mmol/L,
venous pH >7.3
 If not resolved review Step 9 and Step 10.
 Estimate Total Daily Dose (TDD) of Insulin (patient’s
weight (in kg) X 0.5) (0.75 units)
 Example: A 80 kg person would require approximately
80kg x 0.5 units = 40 units in 24 hours
 Give 50% of total dose at bedtime in the form of long
acting insulin and divide remaining dose equally
between pre-breakfast,pre-lunch and pre-evening meal.
 E.g. Short-acting insulin 7u tid & 20 units bedtime
 HONKS aka HHS
Hyperosmolar Non-ketotic State aka
Hyperosmolar Hyperglycemic state
Definition

• is a metabolic complication of diabetes mellitus (DM) characterized

by
i. severe hyperglycemia,
ii. extreme dehydration,
iii. hyperosmolar plasma, and
iv. altered consciousness
Diagnostic criteria

• Hypovolaemia
• Marked hyperglycemia
• Osmolality>320 mosmol/kg
Precipitating factor

a) Infections and sepsis

b) Thrombotic stroke
c) Intracranial haemorrhage
d) Silent myocardial infarction
e) Pulmonary embolism
History taking

• Symptoms
i. Nausea, vomiting, abdominal pain?
ii. Polydipsia, polyuria?
iii. Headache, muscle cramp?
• Complication
i. Confusion, Coma, Thromboembolic complication
• Risk factors
i. Uncontrolled DM
ii. Severe illness/ infection
Physical Examination

• Low Glasgow coma scale

• Confusion
• Hypotension
• Tachycardia
• Dehydration
• Low urine output
 Management

Goals
• Normalise the osmolality
• Replace fluid and electrolyte losses
• Normalise blood glucose
• Prevention of complications