Diabetic Ketoacidosis (DKA)

Description

• Life-threatening acute metabolic complication of diabetes.

• Develops due to absolute or relative insulin deficiency.

• More common in Type 1 Diabetes Mellitus (T1DM) than Type 2 (T2DM).

• May be the first presentation of diabetes.

• Requires high-level care (ICU/HDU).

Triggers / Precipitating Factors

• Non-compliance with treatment (missed doses, underdosing).

• Infections, commonly pneumonia and urinary tract infections.

• Pancreatitis.

• Cardiovascular events (acute myocardial infarction, stroke).

• Stress: surgery, trauma, burns.

• Psychological or emotional trauma.

• Drugs: corticosteroids, thiazides, sympathomimetics, pentamidine.

• SGLT-2 inhibitors may cause euglycaemic DKA.

Signs and Symptoms

• Polyuria and polydipsia (dehydration).

• Nausea, vomiting, abdominal pain.

• Fruity/acetone breath.

• Kussmaul respiration (deep, rapid breathing).

• Altered mental status: confusion, lethargy, or coma.

Investigations

Diagnostic Criteria

• Plasma glucose ≥13.9 mmol/L.

• Urine ketones ≥2+.

• Arterial blood gas: high anion gap metabolic acidosis (pH <7.3, bicarbonate <15 mmol/L, anion gap >12 mmol/L).

• Blood ketones: β-hydroxybutyrate ≥3 mmol/L.

Additional Blood Tests

• Electrolytes: Na⁺, K⁺, Cl⁻, ionised calcium, phosphorus, magnesium.

• Full blood count with differential.

• Renal function: urea, creatinine.

• Arterial blood gases.

• ECG and CXR as indicated.

Treatment

General

• Follow ABCDE approach.

• Treat shock if present.

Fluid Replacement

• Estimate 6–8 L fluid deficit over 24 hours.

• Normal saline (NS) preferred; Ringers Lactate (RL) acceptable.

• Initial regimen: 1 L NS over 1 hour, 1 L over 2 hours, 1 L over 4 hours.

• Reassess before continuing fluids.

• Target urine output ≥0.5 mL/kg/hr.

• Switch to 5–10% dextrose when glucose <13.9 mmol/L.

• If glucose <4 mmol/L, give 20–25 g of 50% dextrose diluted 1:1 to 25%, repeat every 25 minutes until glucose ≥4–6 mmol/L.

• Maintain blood glucose at 11.1–13.8 mmol/L during treatment.

• Continue until urine ketones are negative and pH/bicarbonate normalize.

Insulin Administration

• Soluble insulin 0.1 IU/kg/hr IV or subcutaneously (max 10 IU).

• Begin only after adequate hydration and serum potassium >3.5 mmol/L.

• Hold insulin if K⁺ <3.5 mmol/L and correct hypokalemia.

• Target glucose drop: 3–4 mmol/L per hour. Rapid drops may cause cerebral edema.

• Reduce insulin by half when glucose <13.9 mmol/L.

• Hold insulin if glucose <4 mmol/L; give 50% dextrose every 25 min until glucose >6 mmol/L.

Potassium Replacement

• 20 mmol KCl in 500 mL NS/RL after every 2 L fluid.

• Monitor serum potassium every 1–2 hours.

• Maintain K⁺ 3.5–5.5 mmol/L.

Other Measures

• Nasogastric tube for persistent vomiting or altered mental status.

• Low molecular weight heparin for thrombo-prophylaxis unless contraindicated.

• ECG monitoring.

• Treat precipitating causes.

Indicators of Resolution

• Urine ketones negative (trace ketones indicate resolving DKA).

• Blood pH ≥7.35 and bicarbonate ≥15 mmol/L.

• Serum β-hydroxybutyrate <0.3 mmol/L.

Post-DKA Insulin Therapy

• Commence basal-bolus insulin when patient can feed orally.

• Continue IV insulin if vomiting or unable to feed.

• Overlap IV insulin 30–60 min after starting subcutaneous insulin to prevent treatment interruption.

Complications

• Thromboembolism (e.g., stroke).

• Pulmonary edema.

• Acute kidney injury.

• Cerebral edema (especially in children).

Hyperosmolar Hyperglycaemic State (HHS)

Description

• Medical emergency with high mortality, mostly in elderly T2DM.

• Characterized by:

  • Severe dehydration (hypovolemia).

  • Extreme hyperglycemia (>30 mmol/L).

  • High serum osmolality (>320 mOsm/kg).

  • Minimal or no ketones.

  • No significant acidosis (pH >7.3, HCO₃⁻ >15 mmol/L).

Precipitating Factors

• Similar to DKA: infection, stress, drugs, trauma, surgery.

Treatment

Fluid Replacement

• Estimated fluid loss: ~12 L.

• Replace 50% in first 12 hours, remainder over next 12 hours.

• NS preferred.

• Regimen: 1–1.5 L in first hour, 1 L over 2 hours, 1 L over 4 hours.

• Monitor hydration via urine output (>0.5 mL/kg/hr).

• Adjust further fluid based on electrolytes and clinical status.

Insulin Therapy

• Begin only after hydration improves.

• Soluble insulin 0.1 IU/kg/hr IV or subcutaneously.

Potassium Replacement

• Follow same protocol as DKA.

Supportive Measures

• Thrombo-prophylaxis with LMWH.

• ECG monitoring.

• Treat underlying precipitating factors.