CMT05210: INTERNAL
MEDICINE
Session 6: Diabetic
Ketoacidosis
Learning objectives
At the end of this session each participant should be
able to;
• Define diabetic ketoacidosis
• Explain epidemiology and risk factors for diabetic
ketoacidosis
• Describe pathogenesis of diabetic ketoacidosis
• Explain clinical features of diabetic ketoacidosis
• Explain complications of diabetic ketoacidosis
• Describe management diabetic ketoacidosis
• Provide measures to prevent and control of diabetic
ketoacidosis
diabetic ketoacidosis
• diabetic ketoacidosis This is a complication of
diabetes occurring due to metabolic
decompensation leading to severe dehydration,
altered level of consciousness, acidosis,
ketonemia and ketonuria and electrolyte
imbalance, Dyspnea, tarchypnea.
• It is more common in type 1 that type 2 Diabetes
melitus.
When you suspect DKA, confirm diagnosis
immediately.
Note; All patients minimum should be admitted in
hospital for intensive management.
diabetic ketoacidosis
• Possble precipitating factors are;
• Skipping insulin dose/Inadequate insulin
• Infection (pneumonia/UTI/gastro
enteritis/sepsis)
• Infarction (cerebral ， coronary ，
mesentenceric)
• Pregnancy
• Stress, Drugs (cocaine)
• Diagnosis criteria;
• Ketocidosis (pH < 7.3),
• ketonuria ≥ 2+ on Ketostix
• hyperglycaemia RBG >11mmol/L OR known DM
Note; Glasgow Coma Scale less than 12, systolic BP
below 90mmHg and pulse over 100 or below 60bpm
Clinical features of Diabetic
ketoacidosis
Consider the following symptoms:
• Vomiting/Nausea, Dehydration, Fruit odor on the
breath, abdomina pain, Obtundation
• Kussmaul breathing (deep labored breathing)
• Hypotension, Tachycardia, Confusion, Coma
• Polyuria (excessive urination) Hyperglycaemia
• Also other features of Diabetes; Hyperglycaemia,
Glycosuria (Sugar in urine), Polydipsia (excessive
thirst), Polyuria (excessive urination), Polyphagia
(constant hunger), Weight loss, blurred vision,
recurrent infection Fatigue, also slow healing Diabetic
wounds.
Investigations
These should be done hourly
• Random blood glucose
• Urine dipstick,
• Arterial Blood gases,
• Serum electrolyte panel (sodium & potassium)
Also do the following investigations as they deem necessary
• Blood culture and sensitivity
• MRDT / BS for Malaria
• BUN – Blood urea nitrogen
• Urinalysis
• Full blood picture (Leukocytosis)
• Chest X-ray and ECG.
Management
Management Principles;
• admission in high dependency area of Medical
ward or ICU.
• Correction of fluid loss with intravenous fluids
• Correction of hyperglycemia with insulin
• Correction of electrolyte disturbances,
particularly hypokalemia
• Correction of acid-base balance but most of
time corrected
• Treatment of concurrent infection, if present
Fluid therapy in DKA.
• For adults give;
• administer 1-3 L during the first hour
• administer 1 L during the second hour
• administer 1 L during the following 2 hours
• administer 1 L every 4 hours depending on the degree of
dehydration
• For Children we Assume 10% dehydration, thus give;
• Total fluid is 100 ml/kg/24 hrs + maintain fluid volume
• When blood glucose falls to 14 mmol/L or bellow
START 5% Dextrose 500mls 4hrly (1000mls 8 hourl),
• If a patient still dehydrated Continue Normal saline or
Ringer’s solution as well.
• Note; Overrehydration can cause Cerebral edema
Correction of hyperglycemia.
• Give Soluble insulin 8 IU (0.1 IU/kg) IM and 8 IU IV
at begining.
• Then give 8 IU (0.1 IU/kg) IM soluble insulin bolus
hourly, Then Check blood glucose 2hourly.
• Expect a fall in capillary blood glucose of
3.0mmol/L/hour: increase the insulin rate by 1.0
IU/hour increments hourly until glucose falls at this
rate.
• When blood glucose falls to 14 mmol/L or bellow give
soluble insulin 4 IU SC 4 hourly OR IM 2 hourly and
continue until the patient is able to eat again then
• change to twice or thrice daily insulin from as total
dose of 0.5–0.75 IU/kg/day.
• When DKA resolves, continue with normal dosing.
Evaluation
• Define Diabetic Ketoacidosis
• Explain the clinical features of Diabetic
Ketoacidosis.
• Describe the treatment of Diabetic
Ketoacidosiss.
.
References
• Davidson, S, (2014) - Principles and Practice of
Medicine, 22nd Edition, Churchill Livingstone.
• Longmore, M, et al, (1999), Oxford Handbook of
Clinical Medicine, 6th Edition, Oxford
• Swash, M., & Glynn, M. (2007). Hutchinson’s Clinical
Methods: An Integrated Approach to Clinical Practice:
22nd Edition. Philadelphia, PA: Saunders Elsevier
• Trouse, (2000) Short textbook of Medicine University
Press
• MoHCDGEC Standard treatment guidelines & national
essential medicines list tanzania mainland 2017
• MoHCDGEC/ NACTE (2016). Curriculum for
Technician Certificate (NTA Level 5) Curriculum,
Dodoma.
