DIABETIC KETOACIDOSIS Meera Ladwa

Defined as  Blood glucose > 11mmol/L  Blood ketones > 3mmol/L (or urine ketones 2+ and above)  pH < 7.3 (or venous bicarbonate < 15mmol/L)

Only type 1?  A condition of ‘relative’ insulin insufficiency  On rare occasions, can be seen in type 2 diabetes (type 1 and a half, flatbush diabetes)

Insulin is required to enable cells to use glucose

Symptoms & Signs  Fatigue, weight loss, thirst, polyuria  Abdominal pain – can be severe  Vomiting (from gastroparesis)  Look very dehydrated  Smell of ketones  Kussmaul breathing  Often the presenting diagnosis of diabetes – so can be easily missed

Treatment  FLUIDS And  INSULIN  Large volumes of crystalloid; Initially normal saline 0.9%, 1L stat, 1L 1hour, 2 hours and 4 hours.  Fixed rate IV insulin infusion at 0.1kg/hour. Continue normal long-acting s/c insulin if they already take it.

Treatment  Potassium replacement  Look for evidence of infection (CXR, MSU) and treat  NG tube if vomiting  May need HDU/ITU if severely acidotic, drowsy or comatose, or K very low.

Conclusions  Patients with DKA can be very, very sick, but often get better very quickly  Insulin is required to stop ketone production  Once patient is eating and drinking and ketone- free, they can be switched to a subcutaneous insulin regimen.