DIABETIC KETOACIDOSIS
DIABETIC KETOACIDOSIS
1. Diabetic ketoacidosis
A) Define
B) Enlist the aetiology, pathophysiology, clinical manifestation, diagnostic evaluation.
C) Explain the management
INTRODUCTION
Diabetic ketoacidosis is most common in people with type 1 diabetes, but may
also occur in those with type 2 diabetes. Diabetic ketoacidosis (DKA) is a state of inadequate
insulin levels resulting in high blood sugar and accumulation of organic acids and ketones in the
blood. It is also common in DKA to have severe dehydration and significant alterations of the
body's blood chemistry
a) DEFINITION DIABETIC KETOACIDOSIS
DKA is caused by an absence or markedly inadequate amount of insulin. This deficit in
available insulin results in disorders in the metabolism of carbohydrate, protein, and fat.
The three main clinical features of DKA are:
• Hyperglycemia
• Dehydration and electrolyte loss
• Acidosis
EPIDEMIOLOGY
DKA accounts for 14% of all hospital admissions of patients with diabetes.
Almost 50% of diabetes-related admissions in young persons are related to DKA
it is estimated to be 1 out of 2000.
The incidence is roughly episodes per 100 patient years of diabetes
b) Enlist the aetiology, pathophysiology, clinical manifestation, diagnostic evaluation
ETIOLOGY
The most common scenarios for diabetic ketoacidosis (DKA)
Infection (40%),
Missed insulin treatments (25%) and
Newly diagnosed, previously unknown diabetes (15%).
Other associated causes make up roughly 20% in the various scenarios
Causes of DKA in type 1 diabetes mellitus include the following :
Poor compliance with insulin
Bacterial infection and intercurrent illness (Klebsiellapneumoniae)
Medical, surgical, or emotional stress
Idiopathic (no identifiable cause)
Mechanical failure of the insulin infusion pump
Causes of DKA in type 2 diabetes mellitus include the following
Intercurrent illness (eg, myocardial infarction, pneumonia, prostatitis, UTI)
Medication (eg, corticosteroids, pentamidine, clozapine)
DKA also occurs in pregnant women, either with preexisting diabetes or with diabetes diagnosed
during pregnancy
PATHOPHYSIOLOGY
Early
Polydipsia, polyuria
Fatigue, malaise, drowsiness
Anorexia, nausea, vomiting
Abdominal pain, muscle cramps
Later
Kussmaul's respirations (deep respirations)
Fruity, sweet breath
Hypotension, weak pulse
Stupor and coma
c) Explain medical management
MEDICAL MANAGEMENT
Immediate management – Within the First Hour
Initial Assessment
Airway and breathing - correct hypoxemia.
IV access.
Monitor ECG, O2 saturations, pulse, BP, respiratory rate, conscious level and fluid
balance.
Laboratory blood glucose, bedside BM, urea and electrolytes, serum bicarbonate,
arterial blood gases.
Other Interventions/Actions
NG tube if impaired consciousness or protracted vomiting.
Urinary catheter: if cardiac failure, persistent hypotension, renal failure or no urine
passed after 2 hours.
CVP line: consider if elderly with concomitant illness, cardiac failure or renal failure.
Give standard venous thromboembolism prophylaxis.
Antibiotics: only if infection is proven or strongly suspected. Remember that raised
WBC and fever occur with metabolic acidosis.
Screen for myocardial infarction if > 40 years old
Admits patient to a high dependency area.
Nursing Diagnoses
Deficient Fluid Volume related to hyperglycemia
Ineffective Therapeutic Regimen Management related to failure to increase insulin during
illness
Patient Education and Health Maintenance
Teach patients how to avoid DKA by self-testing for urinary ketones when their blood
glucose is high or when they have unexplained nausea or vomiting and adjusting their
insulin regimens on sick days.
It is essential to educate patients in the prevention of diabetic ketoacidosis (DKA) so that
a recurrent episode can be avoided.
The patient education program needs to ensure that patients understand the importance of
close and careful monitoring of blood glucose levels, particularly during infection,
trauma, and other periods of stress.
Complication
Cerebral edema
Cardiac dysrhythmia
Pulmonary edema
Nonspecific myocardial injury may occur in severe DKA.
Microvascular changes consistent with diabetic retinopathy
Prognosis
Excellent: especially in younger patients if intercurrent infection are absent
The worst prognosis: is usually observed in patient who are older with sever intercurrent
illnesses, eg; myocardial infarction, sepsis, or pneumonia, especially when they are
treated outside an ICU.
Sign of poor prognosis: deep coma at the time of diagnosis, hypothermia and oliguria.
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