Endocrine System >
Diabetic Ketoacidosis (DKA)

“Life-threatening medical emergency due to the build-up of ketones in the body”

Risk Factors
  • Modifiable:
    • Alcohol
    • Dehydration
    • Insulin omissions
  • Non-Modifiable:
    • Acute illness/infection e.g. UTI, pancreatitis, MI
    • Surgery
    • Type I Diabetes
Aetiology
  • Infection (30-40%)
  • New-onset diabetes
  • Insulin errors
Clinical Presentation
  • Drowsiness, lethargy
  • Anorexia
  • Weight loss (due to increased lipolysis)
  • Vomiting
  • Dehydration
  • Abdominal pain
  • Polyuria, polydipsia
  • Ketotic breath
  • Kussmaul hyperventilation – respiratory compensation for metabolic acidosis by the increasing the rate of deep breathing to excrete CO2
  • Coma
Pathophysiology
  • In DKA there are high blood glucose levels but insufficient insulin to promote glucose uptake and metabolism to create energy
  • The stress of acute illness or trauma also increases secretion of catabolic hormones: glucagon, catecholamines, cortisol, growth hormone
  • As a result, the body undergoes uncontrolled catabolism and ketogenesis as alternative metabolic pathways to create energy in starvation states
  • This results in the accumulation of ketone bodies e.g. acetone (fruity acetone breath) which can cause severe metabolic acidosis → vomiting, abdo pain, Kussmaul breathing
  • Hyperglycaemia → osmotic diuresis, polydipsia and polyuria → dehydration
Investigations
  • Bloods:
    • Capillary and lab glucose, blood ketones, venous pH, U&Es, HCO3-, osmolality, blood cultures, FBC
  • Imaging:
    • Chest X-Ray
  • Special:
    • Midstream urine sample
    • ECG
    • Urine DipStick

Chest X-Ray, Midstream urine sample, and blood cultures to check for presence of infection

Diagnosis
  • Requires all three:
    • Acidaemia: pH < 7.3 or HCO3- < 15.0mmol/L
    • Hyperglycaemia: BG > 11.0mmol/L or known diabetic
    • Ketonaemia (> 3.0mmol/L) or ketonuria (more than 2+ on dipstick)
Management
  • Replace volume then correct metabolic defects.
  • Fluids:
    • Use 0.9% saline
    • Fluid deficit typically
    • Avoid bicarbonate as can exacerbate cerebral oedema
  • Prevention: Counselling on sick day rules
    • More frequent BG monitoring
    • Adequate hydration and carbohydrate intake (with drinks/liquids if unable to eat)
    • Urine ketone monitoring

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