Picture the scene…
You are asked to assess a patient with poorly controlled type 1 diabetes who has vomiting and diffuse abdominal pain…
In this session we will cover the presentation, initial management and complications of patients presenting in diabetic ketoacidosis
Task 1 – Read
Read this blogpost on DKA from RCEM Learning.
Task 2 – Read
Read through this example treatment protocol then use it to help with the clinical cases
Task 3 – Discuss
This part of the teaching session should be lead by an experienced clinican. The cases provided are merely examples and if possible the learners should be encouraged to discuss patients they have seen in their clinical practice.
Case 1 – A young man with vomiting and abdominal pain
A 21 year old male presents to hospital with vomiting and abdominal pain. He is visiting friends at Uni. He has a heart rate of 122, blood pressure of 110/71 and respiratory rate of 34. His VBG is shown below.
1,Describe the findings on the VBG?
The VBG shows a metabolic acidaemia with a compensatory respiratory alkalosis.
There is a raised lactate with normal strong ion difference. It also shows hyperkalaemia and hyperglycaemia, with a significant base deficit and low bicarbonate level.
2, How do you diagnosis DKA and what are the common underlying causes?
The UK diagnostic criteria for DKA1 are:
- Ketonaemia >3.0mmol/l or urine ketones >2
- Blood glucose >11mmol/l or known diabetes
- Bicaronate >15 and/or venous pH <7.3
Common underlying causes include:
- Insulin non-adherence, inadequate dosing or insulin pump failure
- Substance misuse/alcohol
- Medications ( steroids, atypical antipsychotics, sympathomimetics, anti retroviral, SGLT-2 inhibitors)
3, How would you manage his hyperkalaemia?
DKA treatment will likely cause potassium to drop significantly.
The initial hyperkalaemia will resolve rapidly and should not require any additional treatment, beyond the usual management (insulin pushes potassium back into cells).
It is likely that you will be replacing potassium later during treatment, despite the initial hyperkalaemia.
A dose of calcium chloride/gluconate can be considered if there are ECG changes or if there is expected to be a delay in starting insulin therapy.
3, Does he have any high risk features?
High risk groups include:
- Younger (18-25)
- Heart or renal failure
High risk features include:
- Oxygen sats <92%
- Systolic BP <90
- Pulse >100
- GCS <12
- Blood ketones >6
- Bicarbonate <5mmol/l
- pH <7
- Potassium <3.5mmol/l
- Serum osmolarity >320
Case 2 – A patient with confusion and blood ketones of 3.8mmol/l
A 29 year old female with poorly controlled diabetes presents to ED with vomiting and confusion. She has a heart rate of 110, blood pressure of 100/64 and respiratory rate of 38. Her blood ketone level is 3.8mmol/l. Her VBG is shown below.
1, How do we explain her profound acidaemia?
This patient has a pH of 6.82 despite a blood ketone level of only 3.8mmol/l. She also has a respiratory rate of 38, resulting in a respiratory alkalosis with a venous pCO2 of 1.75. Her lactate is normal at 1.9mmol/l.
Looking at her electrolyte levels, she has a reduced strong ion difference of 20, with a raised chloride resulting in a hyperchloremic acidosis. This will have a significant contribution towards her overall metabolic derangement.
2, What fluids would you consider for her initial management?
UK guidelines recommend 0.9% sodium chloride as the initial fluid of choice for DKA. This is predominantly due to an absence of evidence that alternative fluids are superior, combined with a greater familiarity and availability of ‘normal saline’.
In this case, the patient already has a raised chloride level, and 0.9% sodium chloride may not be the best choice, containing 154mmol/l of chloride. This may initially worsen the hyperchloremia and lower the pH in the early phases of resuscitation2.
Alternative fluids include Hartmanns and PlasmalyteTM, both of which have a lower chloride content, but are also relatively hypotonic when compared to 0.9% sodium chloride. Remember to be guided by local guidelines and policies.
3, How would you monitor for improvement during the initial resuscitation?
The mainstay of treatment of DKA is a fixed rate insulin infusion of 0.1units/kg/hr.
Long acting sub-cutaneous insulin should be continued, and fluid resuscitation should be guided by the haemodynamic status of the patient.
DKA will often result in significant fluid depletion and careful attention should be put towards managing fluid balance.
DKA is a hypercoagulable state, and prophylactic low-molecular weight heparin should be given unless contraindicated.
Treatment progress should be monitored with hourly blood glucose and ketone levels, and 2 hourly VBG in the early stages of treatment.
The goals of treatment should be a reduction in blood ketone levels of 0.5mmol/hr with a maintenance of potassium of 4 – 5.5mmol/l. In the absence of a blood ketone meter, an increase in venous bicarbonate of 3mmol/l/h can be used as a surrogate.
When the blood glucose level drops below 14, an infusion of 10% glucose should be started to allow the insulin infusion to continue.
4, What are the most serious complications of DKA?
The most serious complication of DKA is cerebral oedema. This is more common in children and young adults3 and may be caused by rapid changes in serum osmolarity, although the exact pathophysiology in unclear.
Suspect cerebral oedema in any patient being managed for DKA who has a drop in their level of consciousness or signs of raised ICP such as worsening headache or vomiting.
Management involves the use of osmotically active agents such as mannitol and hypertonic saline, and urgent referral to critical care for neuroprotection.
Task 4 – Summary
In this session, we have covered the diagnosis and initial management of diabetic ketoacidosis. We have discussed the high risk groups and clinical features, and have touched on some of the controversies around choice of fluids. We have also gone over common blood gas abnormalities seen in DKA.
Following on from this session, I would encourage you to read your local DKA guideline, and consider how you would approach the management of the patient who is not improving in the way you would expect.
Task 5 – Reflect
In order to embed today’s learning further, reflect on what you have learnt and record in your portfolio whether it has had any impact (or is expected to have any impact) on your performance and practice.
Was this a topic that you were confident you knew already? Which parts were new to you? Were there elements that you will use on your next clinical shift.
Dscuss this session with your colleagues – were there people who missed it who you can share the highlights with?
- 1The Management of Diabetic Ketoacidosis in Adults. Joint Bristish Diabetes Societies Inpatient Care Group, 2013.
- 2Van Zyl DG, Rheeder P, Delport E. Fluid management in diabetic-acidosis–Ringer’s lactate versus normal saline: a randomized controlled trial. QJM 2011; : 337–43.
- 3Edge JA, Ford-Adams ME, Dunger DB. Causes of death in children with insulin dependent diabetes 1990-96. Archives of Disease in Childhood 1999; : 318–23.