A 16-year-old girl is brought into A&E after several episodes of vomiting.

She is also becoming drowsy and

difficult to rouse. She had a history of thirst and polyuria in the previous days, and had abdominal pain with
her nausea and vomiting. Her parents say she has vomited her last meals but there has been no bile or blood
in the vomitus.

What is ketoacidosis?
Diabetic ketoacidosis (DKA) – DKA is defined by the presence of all of the following in a
patient with diabetes:

 Hyperglycemia – Blood glucose >200 mg/dL (11 mmol/L)

 Metabolic acidosis – Venous pH <7.3 or serum bicarbonate <15 mEq/L (15
mmol/L)
 Ketosis – Presence of ketones in the blood (>3 mmol/L beta-hydroxybutyrate) or
urine ("moderate or large" urine ketones).

type 2 diabetics do not suffer this complication as ketogenesis is inhibited with even a tiny amount of
insulin

During an illness, the body makes more corticosteroid in response to the physiological stress. Cortisol
acts to antagonize the action of insulin, thus the normal insulin requirements go up during illness. Type 1
diabetics should therefore increase their insulin doses when they are unwell

History:
vomiting, abdominal pain (SOCRATES), polydipsia, polyuria, headache, and, in more extreme cases, decreased
consciousness and Kussmaul breathing (hyperventilating).

Examination:

Hyperventilation (represent the respiratory compensation for metabolic acidosis)

fruity breath odor
clinical signs of volume depletion- tachycardia, poor peripheral perfusion, and decreased skin
turgor, dry mucous membranes.

Investigations:

CBC  elevated glucose

Electrolytes  high creatinine (dehydration), sodium may be low (pseudo-hyponatremia) due to
high glucose.
Urinalysis  ketones production, glucosuria.
ABG  acidosis, low PaCO2 (indicates metabolic acidosis “compensation” – confirmed by low
bicarbonate), if bicarbonate is normal or high this suggests renal compensation.
Calculate anion gap Anion gap = Serum sodium – (Serum chloride + bicarbonate).
Raised anion gap  suggests the presence of extra acid groups in the blood (ketone bodies,
lactate).
Normal anion gap  suggests loss of alkali (bicarbonate in diarrhea).

Management:

IV fluids (normal saline)

IV insulin infusion (not a bolus) to suppress ketosis.
Monitor potassium (may drop due to insulin)
Patient should be transferred to SC insulin once ketones and acidosis subsides
Complication: