Complete Guide to DKA: Clinical Features, Diagnostic Approach & Treatment Protocols..

  

DIABETIC KETOACIDOSIS (DKA)

CLINICAL PRESENTATION OF DKA:

Ø Rapid onset (<24hr) in contrast to HMS (Insidious/days)

Ø Classic features of DM: Polydipsia, Polyuria

Ø Sign of dehydration (Dry mucous membranes, decreased skin turgor), hypotension, and shock

Ø Hyperventilation: rapid, deep breathing (Kussmaul Respirations)

Ø "Fruity" breath odor of acetone (nail polish remover smell in the breath) strongly suggests the diagnosis

Ø Hyperviscosity Syndrome:

a.      CNS features: ASOC, Lethargy, drowsiness, confusion, coma, convulsions, and CVA

b.    Eyes features: Blurring of vision

c.      Cardiovascular features: Angina, myocardial infarction, ischaemic heart disease (IHD)

d.     Gastrointestinal tract features: Epigastric pain, mesenteric ischaemia, acute abdominal pain (according to the area of vessel involvement, abdominal tenderness, Nausea and vomiting

 

DIAGNOSTIC APPROACH

Ø Check Blood sugar level (BSL): > 250 mg/dL (> 13.9 mmol/L)

Ø About 10% of patients with DKA will be euglycemic (e.g., glucose <250 mg/dL)

Ø Elevated Serum BUN (blood urea nitrogen) and serum creatinine level

Ø Serum electrolytes: deranged

Ø Check Anion gap = (Na+K)-(CI+ HCO₃^-) or Na-(CI+HCO₃^-,)

v Normal value 10-12 mmol/L, Anion gap will be high in DKA

Ø Check for the presence of ketones in urine (ketonuria) → test urinalysis.

Ø Serum beta-hydroxybutyrate: >4 nl/L (B-hydroxybutyrate most common ketone produced in DDKA. Serum measurement is more sensitive than urine ketone)

Ø Check ABGs: high anion gap metabolic acidosis

v Severe acidosis: pH ranging from 6.9 to ≤ 7.30

v Serum bicarbonate (HCO3): value may be ranging from 5 mEq/L to 15 mEq/L

v pCO2: Low 15 to 20 mmHg, related to compensatory hyperventilation

Ø Diagnostic workup to evaluate the underlying cause: HbA1c, CBC, serum LDH, LFTs, serum amylase and serum lipase, serum procalcitonin, blood culture, urine culture.

Ø Radiology if indicated: CT scan abdomen, Chest X-ray, and ECG.

DIAGNOSTIC CRITERIA

Ø Hyperglycemia: Blood sugar level > 250 mg/dL

Ø Ketonuria: Moderate to large urine ketones

Ø Ketonemia: Positive blood ketone

Ø Acidosis: Blood pH <7.3

Ø Serum bicarbonate: < 18 mmol/L

DKA VS HHS

DKA: hyperglycemia, high anion gap metabolic acidosis, ketonuria/ketonemia

Hyperosmolar hyperglycemic state (HHS): Hyperglycemia, hyperosmolality, and dehydration without ketonuria, also known as Hyperosmolar Non-ketotic coma (HONK)

Formula for Hyperosmolarity=2(Na+K) + BUN/28 + BSL/18

Average serum osmolarity: 275-295 mosmol/L

Severity of DKA
Grade	Arterial pH	Serum bicarbonate	Anion gap	Mental status
Mild	>7.24-7.30	15-18 mEq/L	> 10 mEq/L	Alert
Moderate	7.0 – 7.24	10- 15 mEq/L	> 12 mEq/L	Alert or Drowsy
Severe	< 7.0	< 10 mEq/L	> 12 mEq/L	Stuporous

TREATMENT OF DIABETIC KETOACIDOSIS (DKA)

1. Airway: Ensure the patient is maintaining their own airway, sit the patient up to prevent acidosis.

2. Breathing: Check SpO, & correct hypoxia with supplementary 0, watch for Kussmaul breathing, which may be present to compensate for metabolic acidosis

3. Circulation:

Ø Maintain 2 large-bore intravenous lines (18 or 20 gauge)

Ø Vitals Monitor: B.P, pulse rate, Respiratory rate, Temperature, SpO2 x 4 hourly

Ø Monitor labs: Blood sugar level x 1 hourly, electrolyte levels, and ABGs every 4 hours

Ø Insulin therapy: Pak. "Brands (Humulin-R/Actrapid/Insuget-R)

1. In Regular Insulin x 5-10 units x IV (0.14mg/kg) +5-10 units x Subcutaneous 10.4mg/kg)

2. Regular Insulin Infusion: 60 units (0.1mg/kg/hour) of Regular insulin injection in 100ml 0.9%。 prepared in 100ml IV chamber x IV x 10 mic drops/minute, should be start if K⁺⁺>3.5

3. Not to start IV Insulin if K⁺⁺ level is <3.3, Maintain serum potassium between 4-5 mEq/L.

4. Continuous IV insulin infusion until the anion gap is normal.

5. Once the anion Gap is normal, then shift the Patient to Subcutaneous (S/C) insulin.

 

Ø Fluid replacement therapy: Extracellular fluid loss is replaced by 0.9% N/S (isotonic solution), intracellular fluid loss is replaced by Dextrose 5% OR 10%. (Fluid of choice is 0.9% N/S or 0.45% N/S)

·        0.9% Normal saline (N/S) should be infused rapidly to provide 1L/hour over the first 1-2hours

·        Next 24-48 hours: Adjust Intravenous fluid rate and composition according to CVP, urine output, blood glucose, and corrected sodium levels.

 

o   Then 1L of 0.9% N/S in 2 hours

o   Then 1L of 0.9% N/S in 4 hours

o   Then 1L of 0.9% N/S in 6 hours

o   Then 1L of 0.9% N/S in 8 hours.

Change to 5% dextrose to maintain blood glucose <200-250 mg/dL (<13.9-16.7 mmol/L).

This will prevent the development of hypoglycemia and also reduce the chances of cerebral edema.

 

MOST HOSPITAL WARD/ER PROTOCOL AS FOLLOWS:

1) First 1-2L 0.9% N/S is given fast in 1 hour.

2) Then 3^rd drip of 1L. 0.9% N/S is given at the rate of 125drops/minute.

Add 20ml (20-40mEq/L) of KCL to each Liter of 0.9% of N/S once K is <5.5

3) Then 4th drip of 1L. 0.9% N/S + KCL 20ml is given at the rate of 88 drops/minute

4) Then 5th drip of 1L 0.9% N/S + KCL 20ml is given at the rate of 33 drops/minute

5) Then 6th drips of 1L. 0.9% N/S + KCL 20ml is given at the rate of 22 drops/minute

Ø If pH=7.0 or <7.0 despite adequate IV fluid resuscitation: administer IV Inj Sodium Bicarbonate x 2vial (50ml/cc) in 500ml 0.45% N/S x over 1 hour.

Acidosis usually resolves with fluids and insulin therapy; the use of bicarbonate is usually not necessary.

Current study: Sodium Bicarbonate should be avoided→ Oxford textbook of medicine

Ø Start 5% Dextrose if RBS value is <200-250 mg/dL at the rate 125ml IV/hour

Ø If RB5 value is >250mg/dl changed dextrose into 0.9% N/S

 

4. Disability & Exposure (Secondary Survey)

 

v Consider early HDU/ICU Admission

v NPO status in patients with high anion gap metabolic acidosis on insulin infusion

v Pass Nasogastric tube and Foley's catheter (Input/output record x 1-4 hourly)

v Monitor pupillary reflexes and GCS level

v Inj. Calcium gluconate in 100ml 0.9% N/S over 15minutes if indicated (SOS)

v Antibiotics for associated infection: Inj. Ceftriaxone 2g (Oxidil, Titan, Rocephin) in 100ml 0.9% Or Inj. Moxifloxacin 400mg/250ml (Moxiget, Avelox) x IV x OD

v PPis: Inj Omeprazole 40mg (Risek, Ruling) x IV x OD

v Give appropriate analgesic if pain and anti-emetic if nausea/vomiting