Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a syndrome defined by a constellation of clinical findings and laboratory abnormalities (typically blood glucose >250, pH <7.30, serum HC03 - <15 to 20 mmol/L, and ketonemia > 1:4 dilution). Between 60% and 80% of DKA occurs in known diabetics; the remaining 20% to 40% occurs with the onset of diabetes. Relative or absolute
insulin deficiency is the cause of DKA.

As a result of insulin deficiency, peripheral glucose uptake is impaired and hepatic gluconeogenesis increases, resulting in hyperglycemia. As the glucose concentration rises, the renal threshold for glucose is exceeded; glucosuria ensues, creating an osmotic diuresis, which in turn leads to volume depletion. A serum glucose greater than 400 in a patient with normal renal function implies a significant total body water deficit. Increasing serum osmolarity causes progressive obtundation. Fat cells, without the action of insulin, release fatty acids into the blood, which are converted by the liver into ketoacids. Acidosis accounts for the symptoms of tachypnea, Kussmaul respirations, nausea, vomiting, and abdominal pain.

Causes

The most common cause of DKA is an infection, such as pneumonia. Another common cause is inadequate insulin therapy.

Other possible causes include:

• Heart attack
• Alcohol or drug abuse
• An inflammation of the pancreas
• Physical or emotional trauma
• Insufficient fluid intake, particularly during hot weather
• The most common scenarios are underlying or concomitant infection (40%), missed insulin treatments (25%), and newly diagnosed, previously unknown diabetes (15%).
• Urinary tract infections are the single most common infection associated with DKA, but many other associated illnesses need to be considered as well.
• Myocardial infarction
• Stress
• Surgery
• Heavy use of concentrated carbohydrate beverages such as sodas and sports drinks

Symptoms

Symptoms vary with severity of the DKA episode.

• Polydipsia and polyuria
• Weight loss
• Fatigue ++++
• Muscle cramps +++
• Abdominal pain, nausea, and vomiting +++
• AMS ++: confusion and lethargy to coma ++

Signs

• Vital signs: tachypnea ++++, tachycardia ++++, hypotension ++, hypothermia
• Evidence of volume depletion: dry oral mucosa, dry skin ++++
• AMS (50% to 60%): drowsiness to coma
• Kussmaul respirations ++++
• Odor of acetone on breath +++
• Abdominal tenderness without rebound +++ or less commonly with rebound and guarding +

Treatment

• If you have diabetes, you should monitor your blood sugars at least 3-4 times a day. Check these levels more often if you feel ill, if you are fighting an infection, or if you have had a recent illness or injury.
• Treat moderate elevations in blood sugar with additional injections of a short-acting form of insulin. Most people with diabetes have previously arranged with their physicians a regimen of extra insulin injections for home treatment if blood sugar levels begin to rise.
• Be on the watch for signs of infection and keep yourself well hydrated by drinking non-sugary fluids throughout the day.