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Diabetes Ketoacidosis ( DKA )

Diabetic ketoacidosis ( DKA ) is a complex disordered metabolic state characterized by hyperglycaemia , acidosis and ketonaemia ( Joint British Diabetes Societies Inpatient Care Group March 2013 )
 
How common -Frequent and life threatening complication of type 1 diabetes DKA is also increasingly recognised in patients with type 2 diabetes Data from UK has shown that most cases of DKA were associated with type 1 DM but one in five cases of DKA were in patients with type 2 diabetes True incidence is difficult to establish Population based studies have show the range from 4.6 to 8 episodes per 1000 patients with diabetes It has near 100 % fatality if not treated or recognised Mortality rate has reduced with better understanding , recognition and treatment In US the USDSS has reported an increase in hospitalization rates for DKA during 2009-14 most notably in people < 45 In UK DKA incidence was highest for patients aged 18-24 yrs with short duration of diabetes < 1 yr It should be noted that DKA is the leading cause of mortality among children and young adults with type 1 diabetes – accounting for about 50 % of deaths in this population
 
 
 
What happens ? absolute/ relative insulin deficiency is accompanied by an increase in counter-regulatory hormones which are
- glucagon
- cortisol
- growth hormone
- epinephrine
 Hormonal imbalance enhances hepatic gluconeogenesis and glycogenolysis resulting in further severe hyperglycemia

Hyperglycemia is the result of 3 processes (1 ) increased gluconeogenesis (2 ) accelerated glycogenolysis (3 ) impaired peripheral utilization of glucose
 Body cells are starving of glucose despite hyperglycemia
 Insulin cannot provide enough glucose so the cells tap into the fat stores for fuel – the acidic products of fat metabolism lead to acidosis
 Beta oxidation of the free fatty acids leads to ketones , acetoacetate and beta hydroxybutyrate – Ketoacidosis ( as the cells are starving they are unable to use ketones for fuel hence an increased ketone production and decreased peripheral use – causes metabolic acidosis AKA ketoacidosis )
 Acetoacetic acid is metabolized to produce acetone -this accumulates in the blood. Acetone released in respiration and produces the characteristic fruity breath odour

 Dissociation of ketoacids causes metabolic acidosis and accumulation of ketoacids leads to an increased anion gap
 Glucose is an osmotically active particle and pulls water out of the filtrate into the urine.
 The osmotic diuresis leads to urinary loss of water and glucose and also a loss of ketones , sodiu , potassium and phosphate in urine- patients are dehydrated with marked electrolyte imbalances.
 
Precipitating event- missed doses of insulin / non-compliance undiagnosed or untreated diabetes
DKA can be the first presentation of diabetes infections ( often UTIs ) other stressors for e.g MI , alcohol , pancreatitis drugs like steroids , thiazides , sympathomimetic agents may contribute towards DKA as they affect carbohydrate metabolism psychological problems complicated by eating disorders no identifiable cause
 
Presentation – symptoms typically develop over a short durationsymptoms of hyperglycemia may be present for longer but the acute metabolic alterations typical of DKA usually evolve within a short time frame -typically < 24 hrs these may include
- polydipsia ( hyperglycaemia causes fluid shifts in the cells leading to dehydration )
- polyuria ( kidneys capacity to handle glucose is overwhelmed – glycosuria ) 
- polyphagia ( cells are starving for energy and the body stores of carbohydrates , fats and proteins are depleted )
- weight loss ( patients are using body stores of carbohydrates , fats and protein and loss of body fluids )
- vomiting / nausea
- abdominal pain ( particularly in children due to gastric distension or stretching of the liver capsule )
- fatigue change in mental state ( confusion ) or profound lethargy / coma
 
features of dehydration tachycardia and hypotension ( hypovolemia from fluid loss ) Kussmaul repiration – patient attempts to blow off CO2 to normalize blood pH Ketotic breath fever is generally normal unless an infection is present altered consciousness and confusion ECG changes may happen due to electrolyte imbalances
 
Ketonaemia > or = 3.0 mmol/ L Significant ketonuria – which is more than 2 + on standard urine sticks Blood glucose > 11.0 mmol/L ( 198.202 mg/ dl ) OR
Known diabetes mellitus Bicarbonate ( HCO3 ) < 15 mmol / L ( 91.52 mg / dL ) and / or venous pH < 7.3 )
 
DKA is a medical emergency – admit promptly if you suspect this
 
What causes death ? Cerebral oedema – most common cause of mortality in young children and adolescents severe hypokalaemia ( in adults ) Adult respiratory distress syndrome Pulmonary oedema Co-morbid conditions
 
Management – Most units would have DKA protocols Treatment involves
- correction of dehydration with fluid replacement with the aim of restoration of circulatory volume , clearance of ketones and correction of electrolyte imbalances
- correction of hyperglycemia
- treatment of comorbid precipitating events Frequent patient monitoring Frequent laboratory testing
Patient Information
Recognising diabetic ketoacidosis PIL from University of Southampton NHS Foundation Trust https://www.uhs.nhs.uk/Media/UHS-website-2019/Patientinformation/Diabetes/Diabetic-ketoacidosis-patient-information.pdf
American Diabetes Association on DKA https://www.diabetes.org/diabetes/complications/dka-ketoacidosis-ketones
Diabetes Org UK has an easy to understand page on DKA https://www.diabetes.org.uk/guide-to-diabetes/complications/diabetic_ketoacidosis
Diabetes Education Online on DKA https://dtc.ucsf.edu/living-with-diabetes/complications/diabetic-ketoacidosis/
Information for clinicians
Flowchart for management of DKA ( Hospital )people younger than 18 https://dtc.ucsf.edu/living-with-diabetes/complications/diabetic-ketoacidosis/
Don’t forget the bubbles – paeds education blog DKA by Dani Hall- excellent work https://dontforgetthebubbles.com/diabetic-ketoacidosis/
 
References

  1. DIABETIC KETOACIDOSIS ANAESTHESIA TUTORIAL OF THE WEEK 128
    6TH APRIL 2009 William English, North Bristol NHS Trust, Bristol, UK
    Peter Ford, Royal Devon and Exeter Hospital, Exeter, UK.
  2. Hyperglycemic Crises in Adult Patients With Diabetes
    Abbas E. KitabchiGuillermo E. UmpierrezJohn M. MilesJoseph N. Fisher
  3. Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic Crises: Diabetic Ketoacidosis (DKA), And Hyperglycemic Hyperosmolar State (HHS) [Updated 2018 May 17]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279052/
  4. Bedaso, A., Oltaye, Z., Geja, E. et al. Diabetic ketoacidosis among adult patients with diabetes mellitus admitted to emergency unit of Hawassa university comprehensive specialized hospital. BMC Res Notes 12, 137 (2019). https://doi.org/10.1186/s13104-019-4186-3
  5. Increasing Hospitalizations for DKA: A Need for Prevention Programs
    Priyathama VellankiGuillermo E. Umpierrez
  6. Farsani SFBrodovicz KSoleymanlou N, et al
    Incidence and prevalence of diabetic ketoacidosis (DKA) among adults with type 1 diabetes mellitus (T1D): a systematic literature review
  7. Joint British Diabetes Societies Inpatient Care Group The Management of Diabetic
    Ketoacidosis in Adults Second Edition Update: September 2013
  8. Understanding the presentation of diabetic ketoacidosis by Joseph Mistovich https://www.ems1.com/ems-products/ambulance-disposable-supplies/articles/understanding-the-presentation-of-diabetic-ketoacidosis-NekpEYII8WCE32Jn/

  9. Mumme, Laura E. (2015) “Diabetic Ketoacidosis: Pathophysiology and Treatment” The Kabod 2( 1 (2015)), Article 3. Retrieved from
    http://digitalcommons.liberty.edu/kabod/vol2/iss1/3

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