1. Diabetic Ketoacidosis
Irene N. Sills, MD
Albany Medical Center
Albany, NY

2. Diabetic Ketoacidosis
Presentation of new onset diabetes about 30% of the time
Is a life-threatening emergency
The metabolic abnormalities must be corrected in a careful, vigilant fashion

3. Diabetic Ketoacidosis
Pathophysiology
Diagnosis
Treatment
Complications of treatment
When the acidosis is resolved

4. Diabetic Ketoacidosis
Abnormal metabolic state
Due to insulin deficiency
In patient with type 1 diabetes
Characterized by hyperglycemia and acidosis

5. Hyperglycemia Ketone production
Ketone utilization
Osmotic diuresis HYPERKETONEMIA
DEHYDRATION vomiting
Decreased GFR
Hydrogen ion production
exceeds utilization
ACIDOSIS

6. Endogenous Compensation for Acidosis
Chemical buffering by extracellular (bicarbonate) and intracellular buffers (protein, organic and inorganic phosphates, hemoglobin)
Control of CO2 levels by alveolar ventilation rate
Control of blood bicarbonate concentration by changes in H+ excretion (excretion of titrable acidity and ammonium) and reabsorption of bicarbonate

7. Diabetic Ketoacidosis
Failure to take insulin (total insulin deficiency)
Relative insulin deficiency
infection
trauma
surgery
stress
dehydration **
Hormones that lower glucose: INSULIN
Hormones that raise glucose: catecholamines, cortisol, glucagon, growth hormone

8. Physical Exam Signs of dehydration Kussmaul type breathing
Acetone odor
Blood pressure and pulse
Temperature
Ileus and gastric atony
State of consciousness

9. Laboratory 1 Glucose 400-500 mg/dl, but may vary
Arterial pH less than 7.3; bicarbonate less than 15mM/L
Sodium usually normal, but may be low
Potassium initially elevated
Serum ketones positive
Serum osmolality elevated

10. Laboratory 2 Anion gap elevated: Na- (Cl + HCO3)
Creatinine spuriously elevated
Hemoglobin and hematocrit elevated
WBC may be elevated

11. Therapy 1. Correction of the dehydration (PRIORITY)
2. Correction of the hyperglycemia

12. Dehydration Immediately decreases levels of “anti-insulin” hormones
Insulin resistance exacerbates the insulin deficiency
Rehydration will decrease stress hormones
Rehydration will improve kidney perfusion

13. Dehydration
DKA is a hypertonic state and should be corrected over hours
If clinically in shock, cc/kg .9NS or plasma expander over minutes
Fluids should be no more hypotonic than .45 NS
Maintenance fluid may be .9NS until serum glucose is less than 300 mg/dl when glucose containing solution is added

14. Dehydration
Deficit replacement should be given EVENLY over hours
IV infusion rate usually calculates to one and a-half times maintenance
On-going losses should be replaced
Potassium should be added when patient voids
Bicarbonate is usually not needed

15. Insulin Regular (novolog) insulin U100 0.05 - .1U/kg/hr
If glucose is < mg/dl and acidosis is persisting, it is better to increase the glucose in the infusion rather than decrease the insulin

16. Monitoring Serum glucose hourly
Electrolytes, calcium, phosphorous every 2-4 hours
Flowsheet with accurate I’s and O’s, vital signs, insulin doses, mental status checks, and laboratory results

17. Complications of therapy
Hypokalemia
Inadequate rehydration
Hypoglycemia
Cerebral edema and other CNS catastrophes

18. Hypokalemia Vomiting Renal losses exacerbated by hyperaldosteronism
Insulin and pH correction moves potassium into the cells
Danger if the initial potassium is less than 3.6 meq/L

19. Inadequate Rehydration

20. Hypoglycemia

21. Cerebral edema Paradoxical development of CSF and CNS acidosis
Altered CNS oxygenation
Unfavorable osmotic gradients
A decline in the true sodium

22. Cerebral Edema Develops 4-12 hours after therapy begun
Biochemically all is well
If early mental status changes are not noticed, a child will develop neurologic changes leading to herniation and compromised cardiorespiratory status

23. Cerebral Edema
NEJM: Cerebral edema that was not clinically expected developed in a small group of children
CT scans while in DKA and after resolution
Ventricular narrowing during therapy
Perhaps, some degree of swelling in all children

24. Cerebral Edema Prevention
Slow rehydration with slow changes in osmolality
Serum sodium should rise as serum glucose falls
Hourly mental status checks

25. After Resolution IV insulin until it is time for meal
Twice daily short acting/intermediate acting insulin (or usual insulin dose)
Approximately .75 units/kg
2/3’s in am; 1/3 in pm
2/3’s intermediate acting; 1/3 short acting
Lunch: .2 units/kg short acting

26. Team Management Physician Certified diabetes educator Dietician
Psychologist or social worker

27. Insulin Rapid acting - Humalog or Novolog Short acting - Regular
Intermediate acting - NPH, Lente
Long acting - Ultralente
New, peakless - Glargine (Lantus)

28. Target Blood Glucose Levels
Prebreakfast
Prelunch and dinner
Prebedtime snack
Younger child
mg/dl
mg/dl
mg/dl
mg/dl

29. Principles of Meal Planning
Meet nutritional requirements
Well balanced meals and
snacks
Healthful fat consumption
Avoid obesity
Incorporate social and cultural factors
Artificial sweeteners

30. Constituents of Meal Plan
Carbohydrate
Protein
Fat
50-60% calories
15-20% calories
25-35% calories

31. Monitoring Hemoglobin A1c Home glucose monitoring Glucowatch
Subcutaneous sensor

32. Have a good day! good day
Have