Definition of dka
DKA is, by definition, a state in which high levels of ketones make the blood acid.
• • Any suspicion of DKA requires immediate transfer to hospital.
• Caused by absolute or relative insulin lack.
• A major diabetic emergency—preventable, predictable, treatable.
• Mortality 1–4 %—the most common cause of death in diabetic patients < 50 yrs of age.
• One in 200 diabetic inpatients developed new DKA in English hospitals after admission in 2012–13 (NaDIA). If the patient dies, prosecution
may follow; see M : http://www.bbc.co.uk/news/uk-england-stoke-staffordshire-26279657
DKA may recur if III is stopped after successful treatment without SC insulin being restarted.
DKA in children and young people should be managed by paediatric diabetologists. Doses of fluid and insulin are given for guidance but treatment must be tailored to the individual patient. Seek senior advice and DST advice in all patients.
Symptoms of dka
• Vomiting (most common symptom).
• Tiredness, malaise, weakness.
• Thirst, polyuria.
• Weight loss.
• Deep and rapid respiration—‘air hunger’.
• Anorexia, abdominal pain, diarrhoea, or constipation.
• Symptoms of diabetic complications.
• Symptoms of precipitating condition.
• May be few symptoms.
Signs of Dka
• Ketotic breath—‘rotten apples, pear drops’.
• Hyperventilation—over breathing.
• Tired, unwell.
• Dehydration, weight loss.
• Tachycardia, hypotension.
• Vomiting ± coffee grounds—due to haemorrhagic gastritis.
• Abdominal tenderness.
• Gastric retention.
• Full bladder or polyuria—if not, very dry.
• Evidence of diabetic complications.
• Evidence of precipitating condition.
• Coma; rare—either very ill or other cause.
• N.B. should not be hypoxic—this means there is a lung problem.
Causes of dka
• Infection—most common cause.
• Too little or no SC insulin.
• IV insulin not started as prescribed, not running, or stopped without giving SC insulin.
• Psychological factors.
• Too much food, especially sugars.
• Lack of education (patient or staff)— insulin omission by patient or staff in vomiting patients.
• New diabetes mellitus .
• Alcohol abuse.
• Exercise with insulin lack
• Acute coronary syndrome
• Any illness.
• Gynaecological problems.
• Stress—exclude other causes.
Diagnosis of dka
• History—exclude DKA in any vomiting insulin-treated diabetic patient.
• Examination—may find little, may be dehydrated and hypotensive.
• Capillary glucose > 11 mmol/l—if shut down use venous blood on strip strip—or known type 1 diabetes with lower glucose level.
• Urine ketones positive. Blood ketones ≥ 3 mmol/l.
• Venous pH < 7.3 (arterial blood testing is not required for pH testing as the venous/arterial difference is minimal. Arterial blood may be needed for checking oxygen saturation).
• Bicarbonate < 15 mmol/l.
• DO NOT DELAY TREATMENT AWAITING LABORATORY RESULTS.
Management of dka
• Resuscitation: airway, breathing, circulation
• Aim door to needle time < 15 min
• Good IV access
• Take venous bloods
• 1000 ml 0.9 % sodium chloride IV over 1 hr
• After IV fluids flowing, start FRIII 0.1 units/kg/hr soluble insulin (e.g. Actrapid®, Humulin S®)
• Protect pressure areas, especially feet
• Inform diabetes registrar or consultant diabetologist
• Finger-prick capillary blood glucose + ketone (beware cold fingers, always send blood for laboratory venous glucose as meters have an upper limit to readings)
• Venous blood pH unless hypoxic on pulse oximetry.
• Urgent laboratory venous glucose, U&E, creatinine, FBC.
• Use point-of-care (POCT) biochemistry system (e.g. blood gas analyser) quality-controlled by laboratory to monitor progress.
• Later LFT, TFT, lipids, blood cultures, CRP.
• Dipstick urine.
• MSU, throat swab, microbiology swab any lesion.
• Pregnancy test.
• 12-lead ECG with continuous cardiac monitor thereafter.
• Chest X-ray.
• Consider abdominal X-ray Aims of treatment Start initial resuscitation within 15 mins. Then:
• Gradual return to normal.
• Rehydrate over 24 hrs; use IV fluid and insulin to correct DKA.
• Aim for:
• a glucose fall of 3 mmol/l/hr
• a blood ketone fall of ≥0.5 mmol/l/hr
• a venous bicarbonate rise of 3 mmol/l/hr
• a gradual venous/arterial pH rise over 24 hrs
• Consider ICU/HDU for each patient (see Table 12.1)
• Good IV access
• Oxygen if hypoxic (unless respiratory disease risking CO2
• Nasogastric tube if severe vomiting, gastric retention (occurs in severe DKA and may cause aspiration), coma. Take care with NG tube insertion—this may trigger cardiac arrest in severe DKA, presumably from vagal stimulation
• Consider urinary catheter if incontinent or not passed urine within 1 hr, immobile, coma
• IV fluids