Diabetic Ketoacidosis Hypoglycemia: DR MD Mamunul Abedin Shimul

Diabetic Ketoacidosis
Hypoglycemia
Dr Md Mamunul Abedin Shimul
Medical Officer
Dept of Medicine
250 bed General Hospital, Jamalpur
DKA
 Diabetic ketoacidosis (DKA) is a medical emergency, principally
occurring in people with type 1 diabetes.
 Mortality is higher in developing countries and among non-
hospitalized patients.
 May be the presenting feature of diabetes
 May be precipitated by stress, particularly infection, in those with
established diabetes. Sometimes, DKA develops because of errors in
self-management.
DKA- Cardinal Features
The cardinal biochemical features of DKA are:
 Hyperketonaemia (≥ 3.0 mmol/L) or ketonuria
 Hyperglycaemia (blood glucose ≥ 11mmol/L)
 Metabolic acidosis (venous bicarbonate < 15 mmol/L
and/or venous pH < 7.3 (H+ > 50 nmol/L))
DKA- Pathophysiology
 Hyperglycaemia causes an osmotic diuresis, leading to
dehydration and electrolyte loss.
 Ketosis is caused by insulin deficiency, exacerbated by
stress hormones (e.g. catecholamines), resulting in
unrestrained lipolysis and supplying FFAs for hepatic
ketogenesis.
DKA- Pathophysiology
 When ketosis exceeds the capacity to metabolise acidic
ketones, these accumulate in blood. The resulting acidosis
forces H+ ions into cells, displacing K+ ions, which are lost in
urine or through vomiting.
 Patients with DKA have a total body K+ deficit but this is not
reflected by plasma K+ levels, which may initially be raised due
to disproportionate water loss.
 Once insulin is started, however, plasma K+ can fall
precipitously due to dilution by IV fluids, K+ movement into
cells, and continuing renal loss of K+.
DKA- Water & Electrolyte Loss
DKA- Clinical Features
DKA- Clinical Features
DKA- Investigations
The followings are important but should not delay IV fluid and
insulin replacement:
 Urea &Electrolytes,
 Blood glucose,
 Plasma bicarbonate (< 12 mmol/L indicates severe acidosis).
 Urine and Plasma for Ketones.
 ECG.
 Infection screen: FBC, blood/urine culture, CRP, CXR.
DKA- Emergency management
 Establish IV access, assess patient and perform initial investigations
0 – 60  Commence 0.9% Sodium Chloride:
min
-If systolic BP > 90 mmHg, give 1 L over 60 mins
-If systolic BP < 90 mmHg, give 500 mL over 10–15 mins, then
re-assess; if BP remains < 90 mmHg, repeat and seek senior review.
 Commence insulin treatment:
50 U human soluble insulin in 50 mL 0.9% NaCl infused
intravenously at 0.1 U/kg body weight/hour
-Continue with SC basal insulin analogue if usually taken by
patient.
 Perform further investigations.
0 – 60
 Establish monitoring schedule:
min
-Hourly capillary blood glucose and ketone testing
-Venous bicarbonate and potassium after 1 and 2 hrs, then
every 2 hrs for first 6 hrs
-Plasma electrolytes every 4 hrs
-Clinical monitoring of O2 saturation, pulse, BP, respiratory
rate and urine output every hour
 Treat any precipitating cause
60 mins  IV infusion of 0.9% sodium chloride with potassium chloride
to added as indicated below:
06 hours 1 L over 2 hrs
1 L over 2 hrs
1 L over 4 hrs
1 L over 4 hrs
1 L over 6 hrs
 Add 10% glucose 125 mL/hr IV, when glucose < 14 mmol/L
(252 mg/dL)
60 mins
to  Be more cautious with fluid replacement in
06 hours -older or young people,
-pregnant patients and
-those with renal or heart failure;
 if plasma sodium is > 155 mmol/L, 0.45% sodium chloride
may be used
60 mins  Adjust potassium chloride infusion:
to
06 hours
06 to 12  Clinical status, glucose, ketonaemia and acidosis
hours should be improving; request senior review if not
 Continue IV fluid replacement
 Continue insulin administration
 Assess for complications of treatment (fluid
overload, cerebral oedema)
 Avoid hypoglycaemia
12 to 24  By 24 hrs, ketonaemia and acidosis should have
hours resolved (blood ketones < 0.3 mmol/L, venous
bicarbonate > 18 mmol/L)
 If patient is not eating and drinking:

-Continue IV insulin infusion at lower rate of 2–3
U/hr
-Continue IV fluid replacement and biochemical
monitoring
12 to 24  If ketoacidosis has resolved and patient is able to
hours eat and drink:
-Re-initiate SC insulin with advice from
diabetes team; do not discontinue IV insulin until 30
mins after SC short-acting insulin injection
Additional
Procedures
 Consider urinary catheterisation if anuric after 3 hrs or incontinent
 Insert NG tube if obtunded or there is persistent vomiting
 Insert CV line if cardiovascular system is compromised, to allow fluid
replacement to be adjusted accurately; also consider in older patients,
pregnant women, renal or cardiac failure, other serious comorbidities
and severe DKA
 Measure ABG; repeat chest X-ray if O2 saturation < 92%
 Institute ECG monitoring in severe cases
 Give thromboprophylaxis with LMWH

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Diabetic Ketoacidosis

 If patient is not eating and drinking:

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