Ketoacidosis

Question 1

what is the the definition of ketoacidosis?

Answer 1

Ketoacidosis is a state of uncontrolled catabolism (break down) associated with insulin deficiency

Question 2

what is the epidemiology of ketoacidosis?

Answer 2

46 to 80 per 10,000 person‐years among patients with diabetes

Question 3

what is the aetiology of ketoacidosis?

Answer 3

Insulin deficiency is a necessary precondition, therefore usually occurs in type 1 diabetes patients, rarely seen in type 2

Question 4

what are the risk factors for ketoacidosis?

Answer 4

• Stopping insulin therapy
• Infection e.g. UTI
• Surgery
• MI
• Pancreatitis
• Undiagnosed diabetes

Question 5

what is the brief pathophysiology of ketoacidosis?

Answer 5

• unrestrained increase in heptic gluconeogenesis and peripheral uptake by tissues is reduced
• osmotic diuresis by the kidneys and consequent dehydration and loss of electrolytes
• peripheral lipolysis leads to in increase in circulating free fatty acids, broke down to acetyl-coA, converted to ketone bodies in mitochondria
• accumulation of ketone bodies leads to metabolic acidosis

Question 6

what are the key presentations of ketoacidosis?

Answer 6

Fruity breath, dehydration, drowsiness, vomiting, sunken eyes, dry tongue, deep rapid respiration, coma, abdominal pain, low temperature

Question 7

what are the signs of ketoacidosis?

Answer 7

Hyperglycaemia, raised plasma ketones, acidaemia, metabolic acidosis

Question 8

what are the symptoms of ketoacidosis?

Answer 8

Dry mouth and skin
Thirst
Peeing often
Severe stomach pain
Rapid or difficult breathing
Drowsiness
Vomiting and nausea
Fruity breath 
Rapid pulse
Headache

Question 9

what are the first line investigations for ketoacidosis?

Answer 9

measure blood sugar, measure plasma ketones, pH of blood, bicarbonate levels

Question 10

what are gold standard investigations for ketoacidosis?

Answer 10

• urine stick test to measure sugar and ketones in urine
• measure creatinine and urea
• measure total body K+
• FBC may show raised white blood cell count
• blood cultures, chest x-rays, urine microscopy and culture, ECG

Question 11

what are the differential diagnoses for ketoacidosis?

Answer 11

alcoholic ketoacidosis, hyperosmolar hyperglycaemic state, lactic acidosis

Question 12

how is ketoacidosis managed?

Answer 12

• Immediate ABC management
• Replace the fluid loss with 0.9% saline
• Restore electrolyte loss (K+)
• Restore acid-base balance over 24hrs - normally done by kidneys once circulating volume has been restored
• Replace the deficient insulin: Give insulin + glucose (to prevent hypoglycaemia) which both inhibit gluconeogenesis and thus ketone production
• Monitor blood glucose closely
• Therapy can lead to a shift of K+ into cells resulting in hypokalaemia so treat this

Question 13

how is ketoacidosis monitored?

Answer 13

• High dependency setting,
• Electrolytes and venous bicarbonates measured at least every 1-2 hours
• Monitor fluid hourly
• capillary blood glucose every hour
• plasma glucose checked regularly
• when plasma glucose is <12mmol/l, use 5% dextrose rather than saline to avoid over-rapid correction and hypoglycaemia

Question 14

what are the complications fo ketoacidosis?

Answer 14

• Cerebral oedema
• Pulmonary oedema
• Iatrogenic hypoglycaemia
• Iatrogenic hypokalaemia
• Cardiac dysrhythmia
• Myocardial suppression
• Venous thromboembolism.
• Myocardial infarction
• Diabetic retinopathic changes
• Hypophosphataemia
• Adult respiratory distress syndrome

Question 15

what is the prognosis of ketoacidosis?

Answer 15

• Death rate lower amongst first world hospitalised patients. (0.67%)
• Prognosis worsens with age
• Coma at presentation, hypothermia or persistent oliguria are bad prognosis factors
• Cerebral oedema remains the main cause of death from ketoacidosis