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Hassan Mohammad AlShehri ID#2051040006
Diabetic Ketoacidosis
Pathogenesis: 
Alterations in metabolismHyperglycemia results fromIncreased gluconeogenesisConversion of glycogen to glucoseInadequate use of glucose by peripheral tissuesKetone bodies result fromBeta oxidation of FFA (increased liberation of free fatty acids due to the lossof the inhibitory action of insulin on the hormone sensitive lipase(Decreased concentrations of malonyl coA (an inhibitor of ketogenesis(
Precepitating factors:
InfectionInadequate use of insulin New onset diabetesMedical, surgical or emotional stressDrugs: Corticosterioids, thiazide diureticsPancreatitis
Clinical presentation
anorexia, N/V, along with polydepsia and polyuria for about 24 hrs. followed bystupor or comaAbdominal pain and tenderness could be presentKussmaul breathing with fruity odor “acetone”Sings of dehydration (HR increase, postural hypotension(
Diagnostic criteria for DKA
hyperglycemia >250 mg/dlketosis (ketonemia or ketonuriaacidosis pH<7.3, HCO3<15mEq/L
 supporting features are volume depletion and Kussmaul’s breathing 
Severity:
MildModerateSever Atrial pH7.25-7.37.00-<7.24<7.00Serum HCO3 15-1810-<15<10Anion gap>10>12>12Mental statusalertalert/drowsystuper/comaanion gap : Na -(Cl + HCO3) = 12
 
Managment:
Goals of treatment of DKA:
•
intravascular volume expansion
•
Decrease serum glucose
•
Clear serum of ketoacids and reach pH>7.3
•
Correct electrolyte imbalancesFluids:The initial fluid of choice is isotonic saline, which is recommend to be infused at the rateof 15–20 ml /kg body weight per hour or 1–1.5 L during the first hour.The goal is to replace half of the estimated water deficit over a period of 12- 24 hoursInsulin:IV bolus of regular insulin (0.1 U/kg body weight) and continuous infusion of regular insulin at the dose of 0.1U/kg/hr as the method of choice.The optimal rate of glucose reduction would be between 50- 70 mg/hr. If it is notachieved in the first hour, the insulin dose may be doubled continue insulinadministration until ketonemia is controlledwhen plasma glucose reaches 200 mg/dl, the hydration fluid should be changed to D5 ½ NS, and insulin rate should be decreased to 0.05 U/kg/hr.The rate of insulin should be adjusted to maintain blood glucose between 150-200Pottasium:Total body K is low even if plasma report is high.Mild to moderate hyperkalemia is frequently seen in patients with DKA, due to acidosis, proteolysis and insulinopeniaInsulin therapy, correction of acidosis, and volume expansion decrease serum potassiumconcentrationsPotassium replacement is initiated after serum levels fall below 5.3 mEq/l, in patientswith adequate urine output (50 ml/h). Adding 20–30 mEq potassium to each liter of infused fluid is sufficient to maintain a serum potassium concentration within the normalrange of 4–5 mEq/LDo not give K in first hour unless K < 3.5HCO3:Consider NaHCO3 if pH < 7.0stop the infusion at pH 7.2 to avoid alkalosis upon reversal of ketosisassociated with some adverse effects, such as hypokalemia , decreased tissue oxygenuptake and cerebral edema and delay in the resolution of ketosis
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