DIABETIC KETOACIDOSIS:

clinical features and management

• Dr SANJAY KALRA, D.M. [AIIMS]

 OUR VISION
To be a globally-acknowledged centre of excellence
for clinical care, education & training, and research
in diabetology and endocrinology.
 Clinical features
• Common cause of death in type 1 diabetics
• Can occur in type 2 as well
• Hyperketonemia/significant ketosis
• Metabolic acidosis
• Hyperglycemia
• Ppt factors: infection, inadequate
insulinization, stress, MI, new cases
BHARTI HOSPITAL EXPERIENCE 10
April to 16 May 2004
• 20 patients; 7 aged less than 18 yrs
• 10 with BG ‘Hi’; 14 with large UK; 7 with clinical
acidosis; 4 with altered sensorium [ 1 not
responding to pain]; 2/2 with BK ‘Hi’
• OPD management for 3 [successful in 2 with 30 U
insulin each, unsuccessful in 1]
• ADA recommends admission for moderate
ketosis
Green: male
Blue: female

Age/gender distribution
6

0
<10 y 11-20 y 21-30 y 31-40 y >40 y
 Precipitating factors
[Bharti Hospital, 10 Apr to 16 May, 2004]
5
4.5
4
3.5
3
ppt factor
2.5
2
1.5
1
0.5
0
omit inad ins alc TB preg new AGE uncer
 Symptoms
• Polyuria, nocturia, thirst
• Rapid weight loss
• Muscular weakness
• Visual disturbance
• Air hunger
• Abdominal pain, nausea, vomiting
• Leg cramps
• Altered sensorium
 Signs
• Acetone breath
• Air hunger
• Impaired consciousness
– Hyperglycemia, osmolarity
– Cerebral edema if sensorium worsens during treatment
• Hypotension: due to peripheral vasodilatation due to acidosis
• Hypothermia
• Succussion splash
• May mimic surgical emergency
Presentation [Bharti Hospital]
20
18
16
14
12
10
8
6
4
2
0
sens BP resp abdo cramps asth asym olig
 D/D
• Hyperosmolar non-ketotic coma
• Hypoglycemia
• Lactic acidosis
• Associated CNS pathology
• Other metabolic encephalopathies
• Acute pancreatitis
 Cardinal principles
• Replace insulin
• Replace fluids
• Correct electrolytes
• Treat the cause
• Supportive treatment
• Prevent complications
 Insulin
• Begin IV infusion of NS
and regular insulin
• Monitor BG hourly
• Shift to 5D + insulin when
BG = 200 – 250 mg%
• Try 0.1 – 0.2 U insulin/ kg
body wt/ hour initially;
reduce gradually
• Check BG after every
2nd to 3rd bottle of IV
fluid
• Give first few vacs
‘fast’ until patient
regains consciousness/
BG comes down from
‘Hi’/BK come down
from ‘Hi’
 Insulin
• Give continuous IV regular insulin to produce
steady high physio or supraphysio insulin that
adequately corrects biochemical derangements
• High doses are required to counter catabolic
hormones/cytokines in infective/stressful states
• Insulin aims to
– Inhibit lipolysis; inhibit ketogenesis
– Inhibit hepatic gluconeogenesis
– Enhance disposal of glucose and ketone bodies by
peripheral tissues
Who saved
me: the
insulin or the
nurse ?
SC insulin
• Begin as soon as
patient is fit to eat
• Inject at least 30 min
before stopping IV
insulin
• Always begin with
regular or short-acting
analogue
 Electrolyte balance
• Focus on K • Average req = 20
• Total body K is low mmol of K per 1000
even if plasma report ml of NS
is high • Do not give K in first
• Insulin and rising pH hour unless K < 3.5
both stimulate entry of • Reduce if anuria/renal
extracellular K into failure
cells • ECG monitoring can
• Aim for K > 3.5 mEq/l help
 Fluids
• 1000 ml/hour x first 2-3
hrs, thereafter adjust acc
to need, hydration status
• NS, N/2 saline, 5D
• Consider NaHCO3 if
pH < 7.0
• Avoid N/2S as it is
hypotonic, and promotes
rapid movement of water
into cells; may ppt Remember to
cerebral edema adjust for
polyuria
 Bicarbonate
• Beneficial ONLY if
patient is severely acidotic
or nearing
cardiorespiratory collapse
• HCO3 + H = carbonic acid
= H2O + CO2 in ECF
• CO2 readily enters cells,
where reverse reaction
occurs, i.e., H is produced
intracellularly, leading to
intracellular acidosis
• Hypokalemia
• Paradoxical acidosis of
CSF
• Adverse effects on oxyHb
dissociation curve: tissue
hypoxia
• Overshoot alkalosis
• Acceleration of
ketogenesis by raising pH
• Cerebral edema
• Local necrosis
 Management
• Always count • Average requirement
insulin, fluid, KCl is 100 U insulin in 4 l
requirement to fluid over 24 hours
make your patient • Keep BG 150 – 200
is conscious/ mg%
ketone-free • Requirement varies
• Correlate with ppt acc to ppt factor,
factor, other duration of ketosis
variates
 Management
• Avoid recurrent • Keep separate IV line
ketosis: stopping IV for IV antibiotic
infusion for few infusions
minutes can revert • Give SC NPH insulin
patient to ketotic state b.d.; give first dose as
• Maintain IV infusion soon as patient is
(5D + insulin) until at reasonably hydrated
least 2 urine samples
are ketone-negative
 Management
• Check BG hourly • Keep a glass bottle of
initially, then 2 – 4 NS + 2 units insulin;
hourly give 100 ml after
• If patient is on 5D completing 5D
infusion, stop the drip infusion; check BG
15 – 30 mins prior to after that
test; take blood from
contralateral arm
 Our experience
• Insulin req: 14 to 410 U [mean 115.53 U]
• minimum: 14, 32, 38 U
• maximum: 260, 410 U
• all others: 48 to 146 U
• Per kg body wt: 0.71 to 14.6 U [mean 3.6 U/kg]
• minimum: 0.53, 0.71
• maximum: 5.91, 8.5, 14.6
• all others: 1.2 to 3.8
 Our experience
• Fluid req: 1500 ml to 17 000 ml
• minimum 1500 ml in 4 patients
• maximum 9500, 17000 ml
• Per kg body wt: 25 to 607 ml/kg [mean 128]
• minimum 25, 25, 30
• maximum 607 ml/kg till ketone-free
•
 Complications
• Cerebral edema • ARDS
– Incr intracellular osmolarity
in CNS neurone [glucose, • Thromboembolism
ketones, idiogenic osmoles] • DIC
– Sudden fall in ECF
osmolarity [insulin • Rhinocerebral
hypotonic fluids] mucormycosis
– Increased gradient
– Increased entry of water
into CNS
– CEREBRAL EDEMA
Prevention/treatment of c. edema
• Slow rate of IV
infusion
• Avoid hypotonic fluids
• Slow insulin
replacement
• IV mannitol dose
0.2 to 1 g/kg
 Reading lab tests
• First capillary BG may be low because of
dehydration; next value can be higher
inspite of insulin
• Initial TLC/DLC, bl urea may be high due
to hemoconcentration; OT/PT, se amylase
high
• Initial Na is low, K may be high
• If in doubt, repeat the next day
Thank you for your attention

Thank you for

saving me
from DKA