4. Hyperglycaemia
DKA is a state of insulin deficiency
It is also a state of relative excess of glucagon and other
hyperglycaemic hormones: catecholamines, cortisol, growth
hormone etc
This is likely to be triggered by conditions that result in one of these
hormones being elevated
Infection
Pregnancy
Medications (prescribed or non-prescribed)
Trauma
Burns
5. Ketosis and acidosis
Due to enhanced gluconeogenesis there is significant
lipolysis
Free fatty acids are metabolised into ketone bodies
(acetoacetate and beta hydroxybutyrate) which accumulate
Ketone bodies dissociate into ketone anions and hydrogen
The bodies buffering capacity is exhausted leading to excess
hydrogen ions
7. Electrolyte imbalance
Potassium
One third will have K >5.5
All are potassium deplete (~300-600meq)
Osmotic diuresis
Sodium
Increased osmolality dilutes extracellular sodium
Osmotic diuresis causes increased extracellular sodium
Phosphate
Most will develop phosphate depletion but ?importance of this
8. The context
•
No hospital wide policy on DKA
•
Unclear DKA proforma
•
Ward to ward variations in
practise
9. The new model
Standardised diagnosis
Check for high risk criteria
Standard fluid orders
Fixed rate insulin dosing
Maintain basal dose insulin
10. Why the change?
Wide variability makes assessment of outcomes difficult
Cerebral oedema in children +/- young adults
Pulmonary oedema
Hypo/hyperkalaemia
Hypoglycaemia
12. High risk criteria
Any of the following should prompt early senior input and
NOSA/ICU review
Ketones >6
Bicarbonate <10
pH < 7.1
SpO2 <92%
GCS <15
SBP <90
Pulse <60 or >100
13. Standard fluid orders
Normal saline over 1, 2, 3, 4, 5, 6 hours
Add 40mmol KCl to second and subsequent bags with K <5.5
14. Fixed rate insulin + basal
No sliding scale until ketoacidosis resolved
0.1units/kg/hr of actrapid in standard concentration
Don’t switch it off until you switch it off!
Continue basal insulin regime (lantus/protophane/levemir)
and consider basal pump function
As previously, restart usual SC dosing then switch off infusion
30 min later.
17. Mr JL
63yo M
pH 7.19, pCO2 26, HCO3 9
T1DM since age 14, nil prior
Na 133, K 5.9, Creat 185
DKA, usually on pump
Widely metastatic colorectal
cancer on informal trial
chemotherapy
Recent chesty cough
Priority one with reduced
conscious state
HR 100, BP 80/-, SpO2 90%
NRBM, T38.2, BSL 35
Fingerprick ketone 6.0
18. Ketones >6
Bicarb <10
pH <7.1
GCS <15
SBP <90
Pulse >100 or <60
Patient severely unwell so
standard protocol does not
apply
However, don’t throw out the
whole idea of the protocol
19. Changes to protocol
Patient likely to require HDU bed
and early review by inpatient team
Continous monitoring
Strict fluid balance chart
More liberal initial fluid
resuscitation
More regular blood testing
BUT
Fixed dose insulin
Ongoing fingerprick ketone
measurement
20. Mr JG
30yo M
pH 7.28, pCO2 37, HCO3 17
T1DM since childhood
Na 139, K 4.0, Creat 60
Polysubstance abuse
BSL 25
Priority 3 with abdominal
Ketones 4
pain
Obs normal
21. Ketones >6
Bicarb <10
pH <7.1
GCS <15
SBP <90
Pulse >100 or <60
Patient has mild DKA with no
high risk features, therefore
suitable for standard protocol
22. Useful resources
Joint British Diabetes Societies guideline for the
management of diabetic ketoacidosis (2011), Diabetic
Medicine 28: 508-515