DIABETIC KETOACIDOSIS

History
DKA should always be concerned when a
diabetic patient comes with:
• Polyuria/polydipsia/polyphagia
• Vomiting
• Abdominal pain
• Dehydration
• Decreased of consciousness
 Precipitating Factors
• DKA can occur spontaneously in type 1 diabetes
with omission of insulin, but it rarely occurs in
type 2 diabetes without any precipitating factor.
• Precipitating factors in type 2 diabetes:
– Infections
– Myocardial infarction
– Stroke
– GI bleeding
– Pancreatitis
– Surgical procedures
 Diagnostic Criteria
DKA can be confirmed when:
Diabetic Keto Acidosis
1. Blood glucose >250 mg/dL
2. High ketones
– Serum ketones >0.6 mmol/L
– Urine (+) for ketones
3. Anion gap metabolic acidosis
– pH <7.30
– HCO3 < 18 mEq/L
– Anion gap > 10-12
 Differential Diagnosis
DKA can be confirmed when all 3 conditions are
met. If blood glucose is <250 mg/dL but BGA
shows metabolic acidosis with high ketones,
other differential diagnoses should be taken into
consideration:
• Starvation ketosis
• Alcoholic ketoacidosis (AKA)
• Other causes of high anion gap metabolic
acidosis
 Treatment
In treating DKA, there are 4 main points to be
remembered:
1. IV Fluids: if not contraindicated, give IV fluids
1.0L/hour
2. Insulin: 0.15U/kg as iv bolus, then 0.1U/kg/hour.
Blood glucose should fall by 50-70 mg/dL in the first
hour. Glucose target: 150-200 mg/dL. It should not be
stopped before DKA resolution.
3. Potassium:
– K <3.3: hold insulin
– K 3.3-5.0: give insulin and KCl
– K >5.0: give insulin only, monitor serum K
4. Bicarbonate: correction is made only when pH is <7.0
 DKA Resolution
Criteria for resolution of DKA:
• Glucose <200 mg/dL
• Serum bicarbonate > 18 mEq/L
• Venous pH >7.3
 Insulin Switch
• Once DKA is resolved, subcutaneous insulin can
be started.
• Continue intravenous insulin infusion for 1-2
hours after injection of subcutaneous insulin. This
overlap is necessary to ensure adequate plasma
insulin levels.
• Intravenous insulin infusion should not be
stopped when DKA is not resolved. Ketonemia
takes longer to clear than hyperglycemia.
– In case of glucose <150 mg/dL in unresolved DKA,
decrease insulin infusion rate and D5 or D10 can be
added to IV fluids.
 “Look Under the Sheets”
• DKA in type 2 diabetes can never be resolved
if the precipitating factor is not treated
promptly.
• Diagnosis of DKA in type 2 diabetes should
always be accompanied by other diagnoses as
its trigger.
THANK YOU