Diabetic Ketoacidosis

Diabetic ketoacidosis is a life threatening medical emergency where decreased levels of insulin result in burning of fatty acids and production of ketone bodies which cause several manifestations like vomiting, abdominal pain, shortness of breath and occasionally coma.

Clinical Features

The patient presents with symptoms while examination reveals signs :-

Symptoms

These include the following symptoms for diabetic ketoacidosis :-

• Nausea
• Vomiting
• Altered mental function
• Shortness of breath

Signs

The signs of Diabetic ketoacidosis or DKA include the following :-

1. Tachycardia
2. Dry mucous membrane
3. Dehydration
4. Hypotension
5. Kussmaul respiration
6. Tachypnea
7. Abdominal tenderness
8. Fever
9. Fruity odour of breath
10. Acute Abdomen

Other Causes of Acute Abdomen:

• Acute intermittent porphyria
• Addisonian crisis
• Sickle cell anaemia
• Renal papillary necroses
• Basal pneumonia
• Inferior wall MI
• DKA
• Abdominal migraine
• Abdominal epilepsy
• Tabetic crisis

Pathogenesis

The pathogenesis of diabetic ketoacidosis revolves around decreased insulin action and metabolic disorders as explained below :-

Investigations

The tests for diabetic ketoacidosis reveal following :-

• Hyperglycemia – Blood sugar is 400-600 mg%
• TLC – Leucocytosis
• K+ – increases due to shifting of Potassium from intracellular to extracellular compartment due to decreased insulin)
• Blood urea – increase due to intravascular fluid depletion
• Serum osmolality – 300-320 mosm/kg

Calculations for Serum Osmolality

[2 X (serum Na + serum K) + plasma glucose (mg%)/8 + BUN (mg%)/2.8] [2 X (135 + 5) + (90/18 + 14/2.8)] =(2 X 140) + (5 + 5) =290 Normal serum osmolality is 280 to 300 mosm/lit.

• Plasma ketones – positive
• Metabolic acidosis – Low HCO3- with increased anion gap
• Hypertriglyceridemia-Hyperlipoproteinemia
• Hyperamylasemia
• Pseudohyponatremia- There is reduction of 1.6 meq of serum sodium for each 100mg/dL rise in serum glucose. Therefore, when we treat a case of DKA, as the blood glucose level falls, then measured serum sodium rises.

Complications

Complications of Diabetic ketoacidosis are as follows :-

• Cerebral oedema (most dangerous complication, seen mostly in children)
• Venous thrombosis
• ARDS
• MI
• Acute gastric dilatation

Treatment

Management of diabetic ketoacidosis comprises of :-

• Fluids – 0.9% saline
• Insulin – Regular Insulin is given I.V in DKA
• Treat precipitating events – Non-compliance, infection by antibiotics
• K+ Replacement – initially, when patient comes, he is hyperkalemic, later on, when patient is treated with insulin, serum Potassium levels goes down, and may require potassium replacement
• Injection HCO3 I.V if Ph<7