FN: Diabetic Ketoacidosis

Question 1

Ketogenesis

Answer 1

1. Decreased insulin leads to increased stresss hormoes and raise dglucagon
2. reduced glucose utilisation and increased fat oxidation
3. raised free fatty acids and increased ATP and generation of ketone bodies

Question 2

Dehydration

Answer 2

1. Reduced insulin and decreased glucose utilisation and increased gluconeogenesis –> severe hyperglycaemia
2. osmotic diuresis leading to dehydration
3. Also, raised ketones and vomiting

Question 3

Acidosis

Answer 3

1. Dehydration –> renal perfusion

2. Hyperkalaemia

Question 4

Precipitants

Answer 4

1. Abdo pain + vomiting
2. Gradual drowsiness
3. Sighing “kussmaul” hyperventiation
4. Dehydration
5. Ketotic breath

Question 5

Diagnosis

Answer 5

1. Acidosis (raised AG): pH 11mM (or known DM)

3. Ketonaemia >3mM (>2+ on dipstix)

Question 6

Investigations

Answer 6

1. Urine: ketones and glucose, MCS
2. Cap glucose and ketones
3. VBG: acidosis + raised K
4. Bloods: U_E, FBC, glucose, cultures
5. CXR: evidence of infection

Question 7

Subtleties

Answer 7

1. Hyponatraemia is the norm
   a. Osmolar compensation for hyperglycaemia
   b. raised/normal Na indicates severe dehydration
2. Avoid rapid decrease in insulin once glucose normalised
   a. glucose decreases faster than ketones and insulin is necessary to get rid of them.
3. Amylase is often raised (up to 10x)
4. Excretion of ketones –> loss of potential bicarbonate – hyperchloraemic metabolic acidosis after treatment

Question 8

Complications

Answer 8

1. Cerebral oedema: excess fluid administration - commonest cause of mrotality
2. Aspiration pneumonia
3. Hypokalaemia
4. Hypophosphataemia –> resp and skeletal muscle weakness
5. Thromboembolism

Question 9

Management in HDU

Answer 9

Gastric aspiration
Rehydrate
Insulin infusion
Potassium replacement

Question 10

Management

Answer 10

1. Fluids
2. Insulin infusion
3. Assessment
4. Additional measures
5. Monitoring
6. Resolution
7. Transfer to SC insulin
8. Pt. Education

Question 11

Fluids used

Answer 11

2 bags

2nd bag of fluids with potassium replacement

Question 12

Insulin infusion

Answer 12

Actrarapid 0.u/kg/h IVI (6units if no wt. mas 15u)

Question 13

Assessment

Answer 13

Hx + full examination

Investigations: capillary, urine, blood,imaging

Question 14

Additional MEasures

Answer 14

1. Urinary catheter (aim:0.5ml/kg/hr)
2. HGT if vomiting or reduced GCS
3. Thromoprophylaxis with LMWH
4. Refer to specialist diabetes team
5. Find and treat precipitating factors

Question 15

Monitoring

Answer 15

1. Hrly capillary glucose and ketones
2. VBG @ 60min, 2h and then 2hrly
3. Plasma electrolytes 4 hrly

Question 16

Aims of management

Answer 16

reduced ketones by >0.5 M/h or raised HCO3 by >3mM/h
reduced plasma glucose by >3mM/h
Maintain K in normal range
Avoid hypoglycaemia

Question 17

Resolution

Answer 17

Ketones 7.3 (HCO3 >18mM)
Transfer to sliding scale if not eating
Transfer to SC insulin when eating and drinking

Question 18

Transfer to SC Insulin

Answer 18

1. When biochemically resolved and eating
2. Start long-acting insulin the night before
3. Give short-acting insulin before breakfast
4. Stop IVI 30min after short acting

Question 19

Pt. Education

Answer 19

2. ID predisposing factors and provide action plan

2. Provision of ketone meter with education on use.