Diagnosis

Diabetic ketoacidosis

Etiology

Casuses [tgn]

• Catabolic stress: Acute illness (pulmonary embolism, and myocardial infarction), trauma, surgery, infection (pneumonia, UTI), alcohol abuse

• Drugs affecting carbohydrate metabolisms: corticosteroids, thiazides, sympathomimetic agents, pentamidine, SGLT2 inhibitors (promote glucagon secretion, decrease urinary excretion of ketone bodies --> euglycemic DKA)

• Missed insulin treatments

• Newly diagnosed, previously unknown diabetes

Pathophysiology

1. Absolute or relative insulin deficiency

2. Increase in counter-regulatory hormones: glucagon, cortisol, growth hormone, epinephrine

3. This is possible due to hepatic gluconeogenesis, glycogenolysis, and lipolysis

4. Result: severe hyperglycemia and increased serum free fatty acids

5. Hepatic metabolism of free fatty acids --> accumulation of acidic metabolites (ketones, ketoacids) faster than the capacity to extract them --> overflow into urine (ketonuria)

6. A greater accumulation of organic acids --> drop in pH and bicarbonate serum levels

7. Respiratory compensation: rapid shallow breathing (Kussmaul respirations)

8. Clinical finindgs:

   • Ketones -> breath odour, vomiting

   • Hyperglycemia -> osmotic diuresis -> decrease of GFR -> renal failure

   • Acidosis -> electrolyte disturbances

   • Hyperosmolarity -> decreased consciousness

Complications [tgn]

• Seizure

• Arrhythmia

• Hypokalemia

• Cerebral edema

• Rhabdomyolysis

• Respiratory failure: pneumonia, ARDS, or pulmonary edema

Epidemiology

Incidence per 100.000 [v6v][sru][ceg]

Approach

• Blood test: glucose, electrolyte, creatinine, amylase, ketone levels, troponine T

• Urine dipstick

• Blood gas

• Blood culture

• ECG

• Chest x-ray

• CT caput

• MR caput

• Telemetry

Treatment

Aims of treatment: [soi]

• Ketones fall at least 0.5 mmol/L/hr

• Bicarbonate rise 3 mmol/L/hr and

• Blood glucose fall 3 mmol/L/hr

• Maintain serum potassium in normal range

• Avoid hypoglycaemia

Algorithm: [tgn]

1. Fluid infusjon: 0.9% sodium chloride: 15-20 ml/kg in the first 1 hour

2. I.V. fast-acting Insulin infusion (0.1unit/kg/hr):

   • 50 IU fast-acting insulin (Actrapid or Humulin) + 50ml 0.9% sodium chloride solution

3. Potassium: hyperkalemia despite a deficit of potassium:

   • K<3.3 mmol/L: potassium replacement

4. Magnesium: Correct hypomagnesemia to improve hypokalemia

5. Assess patient:

   • Respiratory rate

   • Temperature

   • Blood pressure

   • Pulse

   • Oxygen saturation

   • GlasgowComaScale

6. Further investigations:

   • Capillary and laboratory glucose

   • Venous BG

   • U&E and FBC

   • Blood cultures

   • ECG

   • Chest x-ray

   • MSU

7. Monitor:

   • Hourly capillary blood glucose

   • Hourly capillary ketone measurement

   • Venous bicarbonate and potassium at 60 minutes, 2hours and 2 hourly thereafter

   • 4-hourly plasma electrolytes

   • Continuous cardiac monitoring if required

   • Continuous pulse oximetry if required

Differential diagnoses

Acute pancreatitis, Acute renal failure, Acute respiratory distress syndrome, Alcoholic ketoacidosis, Appendicitis, Asthma, Eating disorder, Gastroenteritis, Hyperglycemic hyperosmolar nonketotic state, Hyperosmolar Coma, Hypokalemia, Hypophosphatemia, Hypothermia, Intoxication, Lactic acidosis, Metabolic acidosis, Myocardial infarction, Pneumonia, Salicylate intoxication, Sepsis, Shock, Syndrome of inappropriate antidiuretic hormone secretion, Urinary tract infection