DKA is a serious complication that arises from uncontrolled diabetes, characterized by the body’s production of ketones.It occurs when there is deficiency of insulin in body and blood sugar levels are too high for too long.When there is deficiency of insulin body breaks fat for energy production and as a result of this process ketones are produced.It predominantly affects individuals with Type 1 diabetes but can also occur in those with Type 2 diabetes under specific circumstances.
Symptoms of DKA
Recognizing the symptoms of DKA is pivotal for early intervention.
- Fruity-smelling breath due to production of ketones
- excessive thirst /Dry skin/Dry mucous membrane
- frequent urination
- Tiredness
- Tachycardia or increased heart rate
- Hypotension or decreased BP
- Hypothermia or Decreased Temperature
- Flushed face
- Deep and fast breating- Shortness of breath
- Confusion and Disoriantation
- Muscle Cramps
- abdominal pain
- confusion
- Decreased perspiration
- Missed insulin dose
- Coma occurs if Dehydration or acidosis is present
Sign And Symptoms Of DKA with Infection Include:
- Fever
- Chest Pain
- Artharlgia
- Cough
It is mandatory to evaluate patient for infections such as MI, UTI, pneumonia, and perinephric abscess.
Diagnosing DKA
Healthcare professionals play a pivotal role in diagnosing DKA through various medical tests and procedures. Understanding the diagnostic process is key to prompt and accurate identification.
Physical Examination Of DKA
- Shallow and rapid breating that changes to deep breaking as acidosis worsen
- weak and rapid pulse
- dry tongue and skin
- hypotension
- increased capillary refill time.
Lab Investigations For DKA
- Urine ketone Test
- BSR level
- ABGs
- CBC
- BUN and Creatinine
- Urine and blood culture if infection is suspected
- Serum potassium is usually elevated because of a shift of potassium from the intracellular to the extracellular space caused by acidosis and insulin deficiency.However after insulin administration it depletes quickly and requires repletion.
- Magnesium levels are often low and requires repletion as well.
- ECG : Detect ischemic changes, Peaked T waves show hyperkalemia, and low T waves with U wave indicating hypokalemia.
- CXR to rule out consolidation or DKA due to pneumonia
- Serum pancreatic enzymes is mildly elevated in DKA due to disorder in carbohydrate metabolism.CT can be used to distinguish pancreatitis from DKA.
- Deranges Lipid Profile
- Urine Culture to rule out DKA due to UTI
Criteria For Diagnosis Of DKA
- BSR > 250mg/dl
- pH<7.3
- Bicarbonate < 15 mEq/l
- Presence of ketonemia or ketonuria
Treatment Options
Treatment of DKA includes
- Fluid resuscitation
You can use isotonic sodium chloride solution or lactated Ringer solution.
The recommended schedule for restoring fluids is as follows:
- Administer 1-3 L during the first hour.
- Administer 1 L during the second hour.
- Administer 1 L during the following 2 hours
- Administer 1 L every 4 hours, depending on the degree of dehydration and central venous pressure readings
- Reversal of the acidosis and ketosis
- Maintanance Of blood sugar levels:Rapid-acting insulins (eg, insulin aspart, insulin glulisine, insulin lispro).Intravenous insulin by continuous infusion is preferred.Hourly insulin infusion at 0.14 U/kg/hr is enough.Uncomlicated mild DKA can be treated at subcutaneous insulin lispro at a dose of 0.3 U/kg initially, followed by 0.1 U/kg every hour until blood glucose was less than 250 mg/dl. Then insulin dose was decreased to 0.05 or 0.1 U/kg given every hour until the resolution of DKA.
- Reduction in the plasma glucose concentration to normal
- Replenishment of electrolyte and volume losses:(eg, potassium chloride).Insulin causes potassium level to drop, it can effect heart and muscles.Patients with serum potassium levels of less than 3.3 mmol/L need initial management with fluid resuscitation and potassium replacement while delaying commencement of insulin until after potassium levels are above 3.3 mmol/L, to avoid cardiac arrhythmias.Potassium level should be maintained between 4 to 5 mmol/l.The administration of 20 to 30 mEq of potassium per liter of fluids is sufficient for most patients; however, lower doses are required for patients with acute or chronic renal failure.
- Identification the underlying cause
Complications Of DKA
- Hypoglycemia Or Low Blood Sugar
- Hypokalemia Or Low Potassium Level:Insulin causes potassium level to drop, it can effect heart and muscles.
- Cerebral edema: It occurs when you try to adjust sugar level too quickly.It is more common in newly diagnosed diabetic childrens.
- Cardiac Arrest
- Renal Shutdown