1. DIABETIC KETOACIDOSIS- DIAGNOSIS
AND MANAGEMENT
jason zachariah

2. WHEN TO SUSPECT DKA?
 Altered consciousness is the most common
cause for seeking medical attention. It may
range from mild disorientation to frank coma.
 Insidious increased thirst and urination are
common early symptoms.
 Nausea and vomiting, diffuse abdominal
pain.
 Generalized weakness and fatiguability.

3.  Symptoms of possible intercurrent infection-
fever, dysuria, malaise and arthralgia
 History of rapid weight loss is a symptom in
patients who are newly diagnosed with type
1 diabetes

4. PHYSICAL FINDINGS
 Signs of dehydration- weak and rapid pulse,
dry tongue and skin, hypotension, and
increased capillary filling time.
 Odour of breath: characteristic acetone
odour
 Signs of acidosis: kussmaul or sighing
respiration, abdominal tenderness, and
altered sensorium

5.  Signs of intercurrent illnesses: MI, UTI,
pneumonia and perinephric abscess.

7. CARDINAL BIOCHEMICAL FEATURES
 Hyperglycemia >250mg/dl
 Hyperketonemia
 Metabolic acidosis- pH<7.3, HCO3 <15meq/L

8. INVESTIGATIONS:
 Venous blood: glucose, urea, electrolytes-
(Na,K,HCO3)
 Arterial blood gases
 Urine-ketone bodies
 Infection screen- CBP, blood and urine
culture, C-reactive protein, Chest Xray

9. URINE
 Highly positive for glucose and ketones.
Rarely ketones may test negative in urine,
because laboratory tests can detect only
acetoacetate, while predominant ketone in
severe untreated DKA is beta
hydroxybutyrate. As clinical condition
improves, it tests positive because of its
breakdown to acetoacetate.

10. BLOOD AND PLASMA
 Glucose: may be as low as 250 mg/dL to as
high as more than 800 mg/DL
 Sodium: The osmotic effect of hyperglycemia
moves extracellular water to intravascular
space. For each 100mg/dL of glucose over
100mg/dL, the serum sodium is lowered by
approximately 1.6 mEq/L. When the glucose
level falls, serum sodium will rise.-
pseudohyponatremia

11. BLOOD (CONT’D)
 Potassium: elevated H+ drives the
intracellular potassium to extracellular
compartment and secondary aldosteronism
drives the K+ cells from the kidney into urine.
 Serum potassium levels do not reflect
the state of total body potassium.

12. BLOOD (CONT’D)
 Bicarbonate: used in conjunction with anion
gap to assess degree of acidosis
 CBC- high WBC counts>15000 or marked
left shift suggests underlying bacterial
infection
 ABG: pH<7.3

13. BLOOD (CONT’D)
 Osmolarity: =2(Na+)meq/L + glucose mg/dL
+BUN mg/dL by 4
Usually >330 mOsm/kg H20. If osmolarity is
less than this in a comatose patient, search
for another cause of obtundation
 Phosphorus: phosphate levels
 High anion gap a usual finding.
Anion gap= Na-(Cl+HCO3)

14. OTHER TESTS
 Ecg- DKA maybe precipitated by a cardiac
event
 Chest Xray- to rule out pulmonary infection

15. MONITORING
 Repeated monitoring of biochemistry is
critical. Potassium needs to be checked
every 1 to 2 hours during initial treatment.
Glucose and other electrolytes should be
checked every 2 hours or so.

17. DIFFERENTIAL DIAGNOSIS
 Lactic acidosis- serum glucose,ketones nl,
lactate>5mm
 Saturation ketosis: urine ketone +ve, blood
ketone –ve, arterial pH usually normal
 Alcoholic ketoacidosis: history of alcohol
being main energy source for few days, strip
test often -ve, normoglycemia or
hypoglycemia common

18. DIFFERENTIAL DIAGNOSIS
 Uremic acidosis- normoglycemia
 Rhabdomyolysis: increased CPK
 Salicylate toxicity: normoglycemia, ketones
negative