DKA

Question 1

DiGNOSIS OF DKA

Answer 1

Blood Glucose >11mmol/L /Diabetic
AND
Blood Ketones>3mmol/L Urine>2+
AND
pH<7.3 / Bicarbonate<15 mmol

Question 2

Management Plan

Answer 2

Fluids NB. Give 1L as initial first step. Will need ongoing replacement.

• Insulin – fixed rate until BM <14. Don’t hold long acting insulin.
• Consider parameters that would indicate a need for ICU.
• Risk of cerebral oedema and fluid overload.

Monitoring for
response
* Glucose
* Ketones
* PH
* Bicarb
* Potassium

Question 3

ABC Px of DKA

Answer 3

2 IV
1- fixed rate IV insulin infusion + IV fluids +/- KCL
2- IV Fluids infusion 1L 0.9% soduim chloride over 1h

if on regular Insulin( Tresiba) , prescribe 1-regular basal Insulin, 2-Subcutanous Insulin and 3-Glucose monitoring regularly

If on Mealtime Bolus Insulin( NovaRapid), perscribe 1-Subcutanous insulin and 2-glucose monitoring record

Question 4

Severe DKA indicators for High dependency Admission

Answer 4

1-Blood-Ketones > 6.0 mmol/L
2-V/A pH < 7.1 / Bicarb < 5 mmol/L
3-Serum K+ < 3.5 mmol/L
4-Systolic BP < 90 mmHg
5- Pulse Rate > 100 / < 60 bpm
6- O2 Sat < 92%
7- GCS < 12 / Abnormal AVPU

Question 5

Monitoring goals for Admitted DKA

Answer 5

0-Potassium (K+)
1-Bicarbonate: rise of 3mmol/h
2- Glucose fall of 3mmol/h not more than 5mmol/h, if so add 10% dextrose
3- Ketones min fall 0.5mmol/l/h, if less increase insulin infusion

Question 6

DKA resolution when

Answer 6

Blood ketones < 0.6 mmol/L
Venous pH > 7.3
For At least 6 hours

Question 7

How to stop the protocol?

Answer 7

When?
* Blood ketones < 0.6 mmol/L + Venous pH >7.3 irrespective of blood glucose for 6 hours.
* How?
Give regular insulin pre-meal, give meal and 1 hour later stop IV insulin (don’t stop

Question 8

In Primary Adrenocortical insufficiency; high ACTH , Pigmentation, hyperkalemia and hyponatraemia, Managment?

Answer 8

ACTH Stimulation Test ,cause?, Treat Hydrocortisone & Fludrocortisone

Question 9

In Secondry Adrenocortical insufficiency; deficincy of Glucocorticoids & androgens only (mineralcorticoroids present)
Low ACTH , Pallor, hyponatraemia Only may be Cushingoid
Managment?

Answer 9

ACTH Stim Test
Treat w Hydrocortisone

Question 10

Presents with :
High ACTH,
pigmentation, Hyperkalaemia and
hyponatraemia

Answer 10

Primary (adrenal
gland affected)
* Autoimmune adrenalitis
* TB, HIV
* Infarction
* Cancer
* Adrenalectomy
* Drugs, eg ketoconazole
* Adrenoleukodystrophy

Question 11

Presents with:
Low ACTH & Pallor
Hyponatraemia only

Answer 11

Secondary (pituitary)
ACTH deficiency

• Exogenous steroids
  withdrawal
• Surgery
• Radiation
• Stroke
• Head injury
• Tumor

Question 12

Addissions disease

Answer 12

ACTH excess, Dark skin, Stress and salt cravings, Na+ low hyponatremia hyperkalemia, orthostatic hypotension, weight loss easily fatigued mc80% Abdo pain, low cortisol

Question 13

Synacthen Test method

Answer 13

Method
At baseline, time 0 minutes, take cortisol
Give I.M. Synacthen 250mcg (adult dose)
At 30 and 60 minutes take cortisol (serum/gold topped tube).

Interpretation:
Basal Cortisol level should be greater than 180nmol/L
30min or 60min Cortisol should be greater than 420nmol/L (whatever the basal level)

The increment should be at least 170nmol/L, apart from in severely ill patients where adrenal output is already maximal.

If ACTH >200ng/L then diagnosis is primary adrenal failure.

If ACTH <10ng/L then diagnosis is secondary adrenal failure

Question 14

In patients with both hypothyroidism and adrenal insufficiency an adrenal crisis
can be precipitated if thyroid hormone replacement is initiated before steroid
therapy.

Answer 14

in pnts with adrenal insufficiency free T4 levels = low-normal but TSH levels are high.
This usually normalizes with steroid replacement

Question 15

Adrenal crisis

Answer 15

Hx: Fatigue, lack of energy, abdominal pain, weight loss, nausea & vomiting, dizziness with postural changes,
collapse, tan, leg spasms

Exam: Hypotension (≥20 mmHg drop in BP from supine to standing position) in severe cases hypovolaemic
shock, abdominal tenderness and guarding, confusion, somnolence, in severe cases delirium or coma

Lab findings:
*Hyponatraemia (in primary and secondary adrenal insufficiency)
*Hyperkalaemia (in primary adrenal insufficiency)
*Pre-renal failure (increased serum creatinine due to hypovolaemia)
*Normochromic anaemia, sometimes also lymphocytosis and eosinophilia
*Hypoglycaemia (primarily in affected children; can cause long-term neurological deficits, if not promptly treated

Question 16

Adrenal crisis

Answer 16

Emergency management
* Hydrocortisone (immediate bolus injection of 100 mg
hydrocortisone i.v. or i.m. followed by continuous intravenous infusion of 200 mg
hydrocortisone per 24 h (alternatively 50 mg hydrocortisone per i.v. or i.m. Injection
every 6 h)

• Rehydration with rapid intravenous infusion of 1L of isotonic saline
  infusion within the first hour, followed by further intravenous rehydration as required
  (usually 4–6 L in 24 h; monitor for fluid overload in case of renal impairment and in
  elderly patients)
• Contact an endocrinologist for urgent review of the patient, advice on further tapering
  of hydrocortisone, investigation of the underlying cause of disease including diagnosis of
  primary vs secondary adrenal insufficiency

Question 17

Beware high TSH levels in those with adrenal insufficienc avoid precipitating an
adrenal crisis by giving Eltroxin before steroid replacement is started.

Answer 17

ACTH HIGH Synacthen test