Diabetic Ketoacidosis

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Diabetic Ketoacidosis (DKA)

Life threatening medical emergency – result of severe insulin deficiency and increased counter regulatory hormones (glucagon, cortisol, growth hormone, catecholamines), leading to a marked increase in glucose production, release of free fatty acids into the circulation and hepatic fatty acid oxidation  forms ketone bodies (200-300 times normal levels are found). Most common cause of death in those with diabetes under the age of 30 - almost all cases are in Type 1. Around 3-5% of cases are fatal.

Biochemical features – hyperglycaemia (from decreased glucose utilisation and increased liver gluconeogenesis), hyperketonaemia (from increased lipolysis) and metabolic acidosis

Aetiology/Precipitating factors:
New presentation (account for about 10%); intercurrent infection (metabolic decompensations occur; also - loose appetite  stop taking insulin); illness (eg myocardial infarction, stroke, pulmonary embolism); withdrawal of insulin or inappropriate adjustments in insulin dose (initiated by patient or medical advice; major dietary indiscretion; significant emotional stress; pregnancy.

Clinical features:
Develops over a few days; polyuria; nocturia; thirst; weight loss (due to dehydration and catabolic effects of counter regulatory hormones); muscular weakness (due to dehydration and hypokalaemia); leg cramps (usually minor); hypotension (from acidosis mediated peripheral vasodilation); tachycardia; nausea; vomiting; abdominal pain and tenderness; dehydration (causes decreased skin turgor, postural hypotension and tachycardia); kussmaul respiration (deep, rapid breathing following stimulation of medullary respiratory centre from metabolic acidosis); blurred vision (due to osmotic changes in lens); ketotic breath (odour of acetone); hypothermia; confusion and drowsiness; coma (in 10% and associated with worse prognosis)

Diagnosis – history; blood glucose; urinary ketones  provisional diagnosis  start treatment
Further laboratory investigations indicated for electrolyte etc levels

Consequences of ketoacidosis – cerebral oedema (rare, more common in children); adult respiratory distress syndrome (usually under 50yrs – show signs of dyspnoea, cyanosis and tachypoena); thromboembolism (due to increased coagulability and blood viscosity); disseminated intravascular coagulation (rare)

Management:
Delays in initiating management can lead to considerably worse outcomes.
Hospitalisation – monitoring of blood pressure, urine output, blood glucose, electrolytes; fluids for rehydration (maybe IV); insulin (IV infusion); electrolyte replacement to restore balance (especially potassium); determine cause; antibiotics if infection.
Counselling and education following recovery

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