Dr Idris MBBS BU

OVERVIEW
• Diabetic ketoacidosis is a serious complication of diabetes
that occurs when your body produces high levels of blood
acids called ketones.
• The condition develops when your body can't produce
enough insulin.
• Insulin normally plays a key role in helping sugar (glucose) a
major source of energy for your muscles and other tissues
enter your cells. Without enough insulin, your body begins
to break down fat as fuel.
• This process produces a buildup of acids in the bloodstream
called ketones, eventually leading to diabetic ketoacidosis if
untreated
 The Stats

• DKA is reason for 50% of diabetic admissions

• Tends to occur in patients less than 19 yo
• Type 1 DM > Type 2 DM
• Death occurs in 2% of presenting patients
 Causes of DKA?

 Underlying Infection (40%)

 Non-compliance with insulin regimen (25%)
 New onset diabetes (15%)
 Medical or surgical stress (20%)
 AMI
 Sepsis
 “weak and dizzy”
 Syncope Altered mental status
 What Is Insulin?

 Anabolic regulatory hormone

 Released by pancreas (or administered as
supplemental medication) in response to elevated
blood sugar
 Causes blood sugar to be utilized for fuel, with
excess stored as muscle and fat
 Inhibits release of glucagon
 Inhibits gluconeogenesis and glycogenolysis
Criteria for diagnosing DKA
The criteria for diagnosing DKA typically include:
• [Link]: Blood glucose levels greater than 250 mg/dL
(13.9 mmol/L).
• [Link]: Presence of ketones in the blood or urine.
• [Link]: pH of less than 7.3 and bicarbonate levels less than
18 mEq/L.
Additional signs and symptoms include:
• Dehydration (e.g., dry mouth, increased thirst)
• Nausea and vomiting
• Fruity-smelling breath (due to acetone, a type of ketone)
• Confusion or altered mental status
• Rapid and deep breathing (Kussmaul respirations)
 Case scenario

 Case A 19-year-old female

with a known history of
Type 1 Diabetes presents
with a 2-day history of
increased thirst, frequent
urination, nausea, vomiting,
and fruity-smelling breath.
She also reports feeling
fatigued and confused.
 ROS & PE

Review of Systems Physical Exam

• Confusion Tc 37.2, HR 115, BP 108/50,
• Vomiting RR 28, SaO2 98
• Frequent urination Patient appears pale
• LMP 5 weeks ago Tachypneic, but not in distress
• Systems otherwise neg Poor skin turgor and capillary
refill
No focal deficits, A/O x 3, but
intermittently sleepy during
questioning
 What Should We Order?
Diagnostics
• CBC • RBG
• Electrolytes • RFT
• HBa1C
• Urinalysis
• LFTs
• urine preg • Lipase
• ABG w/ lactate • EKG ??
 Labs Are Back!
• WBC 14 • Glucose 786
• Na 126 • pH 7.12
• Cl 92 • CO2 23
• HCO3 8 • Lactate 4.2
• Urea 30 • B-Hob 6.2
• Cr 1.9 • UA: large ketones and glucose
• K 3.7 • Ucg neg
• preg Neg
 What Do You Think Of The
Labs?
• Blood glucose of 786 ---- hyperglycaemia
• WBC of 14 indicate infection
• K 3.7 (actually much lower intracellularly)
• ABG ---- anion gap metabolic acidosis with incomplete
respiratory compensation
• Acute kidney injury (pre-renal dehydration)
• Lots of serum B-Hob ---- persistent vomiting
So Now What Do We Do?

Treatment of DKA
– ABC’s IV, O2,
– IV Fluids
– Insulin Therapy
– Correction of other electrolytes
– Monitoring: Close monitoring of blood glucose, ABG(pH
levels), electrolytes, and ketones every 1-2 hours.
IV Fluids in DKA
MOST HOSPITAL WARD/ER PROTOCOL AS FOLLOW:
1. First 1 L .9% N/S is given in 3O minutes .
2. 2nd 1 L .9% N/S is given in 1 hour.
3. Then 3rd drip of 1L 0.9% N/S is given into 2 hr Add 20ml (20-40mEq/L) of KCL to each Liter of
0.9% of N/S once K is <5.5
4. Then 4th drip of 1L 0.9% N/S + KCL 20ml is given into 3 hr
5. Then 5th drip of 1L 0.9% N/S + KCL 20ml is given into 4 hr
 If pH=7.0 or <7.0 despite adequate IV fluid resuscitation: administer IV Inj
Sodium Bicarbonate x 2vial (50ml/cc) in 500ml 0.45% N/S x over 1 hours. Acidosis
usually resolves with fluids and insulin therapy, the use of bicarbonate is usually
not necessary
 Current study: Sodium Bicarbonate should be avoided unless pH<7.O
 5% Dextrose if RBS value is <200-250 mg/dL at the rate 125ml IV/hour
 If RBS value is >250mg/dL changed dextrose into 0.9% N/S
 Insulin Administration
Initial Insulin Therapy:
 IV Insulin: A continuous intravenous (IV) insulin infusion is the
preferred method of insulin administration in DKA. It allows for
precise control of blood glucose levels.
 In many protocols, an initial bolus dose of insulin (0.1 units/kg
body weight) is given, although this practice may vary. The aim
is to rapidly reduce blood glucose levels.
 Infusion Rate: After the loading dose, a continuous insulin
infusion is typically started at a rate of 0.1 units/kg/hour. This
helps lower blood glucose levels at a controlled and gradual
pace.
 Electrolytes
 Potassium levels should be closely monitored, as
insulin can drive potassium into cells, potentially
causing hypokalemia.
 If potassium levels are low (typically below 3.3
mEq/L), potassium should be replaced before
initiating insulin therapy. If potassium is in the normal
range, insulin therapy can proceed, but potassium
replacement is continued as needed.
 More on Potassium

Beware of :-
 If K > 6  don’t give more
 If K 4.5-6  consider 10 mEq infusion with fluids
 If K 3-4.5  give 20 mEq infusion with fluids
 If K < 3  give K before giving insulin
 Criteria to Resume Oral Intake
in DKA:

1. Patient is clinically stable:

Alert, oriented, and able to safely swallow
No nausea, vomiting, or abdominal pain
2. Hemodynamically stable (normal BP and heart rate)
3. Adequate hydration restored:
Patient is no longer volume depleted
4. Transition to subcutaneous insulin is planned or initiated:
Usually starts just before or at the time of stopping IV insulin.
Begin with light, easily digestible foods and monitor blood glucose closely.

Early feeding can help facilitate transition from IV to subcutaneous insulin and maintain
glucose control.
 Indications of shifting IV insulin into
SC insulin in DKA patient

Shifting from IV insulin to subcutaneous (SC) insulin in DKA should be done

only when DKA has resolved and the patient is stable.

Indications to shift from IV to SC insulin in DKA:
1. Resolution of DKA:

Serum bicarbonate > 15 mEq/L

Venous pH > 7.3

Blood glucose < 200 mg/dL (with resolution of acidosis)
2. Patient can eat:

Tolerating oral intake (important for coordinating with SC insulin action)
Cont...
3. SC insulin plan in place:
Long-acting insulin (e.g., glargine, ) given at least 1–2 hours before
stopping IV insulin to prevent rebound hyperglycemia.
4. Monitor Glucose Closely
Check blood glucose every 1–2 hours during the transition.
Adjust insulin dosing as needed based on trends.
 Why Do DKA Patients Die?

Because We Kill Them!

How Do We Kill DKA Patients?

 Cerebral Edema
 Not respecting the K levels
 Not monitoring glucose levels enough
 CHF from over-aggressive fluid administration
 Cerebral Edema in DKA
 Occurs almost exclusively in patients < 20 yo
 Mortality approaches 40%
 Correlation with HCO3 administration
 Causes paradoxical cerebral acidosis as lipid soluble CO2
crosses blood-brain barrier
 Initial symptom is headache
 Onset 12-24 hrs from treatment onset
 Rapid deterioration of mental status
DIABETIC KETOACIDOSIS NURSING CARE
PLANS

 The nursing care plan for clients with Diabetic

Ketoacidosis includes provision of information about
disease process/prognosis, self-care, and treatment
needs, monitoring and assistance of cardiovascular,
pulmonary, renal, and central nervous system (CNS)
function, avoiding dehydration, and correcting
hyperglycaemia and hyperglycemic complications.
 Here are four (4) nursing care plans (NCP) for
Diabetic Ketoacidosis :

1. Risk For Fluid Volume Deficit

2. Risk For Infection
3. Deficient Knowledge
4. Imbalanced Nutrition: Less Than Body
Requirements
1- Risk For Fluid Volume Deficit
 Assess precipitating factors such as other illnesses, new-
onset diabetes, or poor compliance with treatment
regimen.
 Assess skin turgor, mucous membranes and thirst.
 Monitor hourly intake and output.
 Monitor vital signs:
 Assess neurological status every two (2) hours.
 Weigh client daily.
 Monitor laboratory.
 Monitor ABG for metabolic acidosis.
 Insert indwelling urinary catheter as indicated. .
 Administer fluid as indicated
 Administer IV potassium and other electrolytes as
indicated.
 Administer bicarbonate as indicated.
 Administer an IV bolus dose of regular insulin,
followed by a continuous infusion of regular insulin.
2- Risk For Infection
 Assess for signs of infection and inflammation.
 Observe client’s feet for ulcers, infected toenails, or other
medical problems. Due to impaired circulation in diabetes, foot
injuries are predisposed to poor wound healing.
 Observe aseptic technique during IV insertion and medication
administration.
 Provide skin care. .
 Encourage proper hand washing technique.
 Encourage adequate oral fluid intake (2-3 liters a day unless
contraindicated).
 Encourage deep breathing exercise;
 Administer antibiotics as indicated.
3- Imbalanced Nutrition: Less Than
Body Requirements
 Determine client’s dietary program and usual pattern.
 Monitor weight daily or as indicated.
 Auscultation bowel sounds, note the presence of
abdominal pain/abdominal bloating, nausea or
vomiting.
 Maintain on NPO status, as indicated.
 Recognize signs of hypoglycemia
 Monitor laboratory studies (Serum glucose, pH, HCO3,
acetone). Perform finger stick glucose testing.
 Administer glucose solution, e.g., dextrose and half normal
saline.
 Administer regular insulin by intermittent or continuous IV
method.
 Collaborate with a dietician for initiation of resumption of
oral intake
 Provide a diet consisting of 60% Carbohydrates, 20% fats,
20% proteins in designated number of meals. Administer
medication as prescribed to control nausea and vomiting.
4- Deficient Knowledge
 Establish empathy and trust.
 Explain the signs and symptoms of diabetic
ketoacidosis
Discuss the following with the client:
 Normal blood glucose level.
 Risk factors.
 Client’s type of diabetes.
 The relationship between elevated glucose level and insulin
deficiency.
 Baseline knowledge enables the client to make informed lifestyle
choices.
 Demonstrate proper blood glucose testing using the
glucometer. Instruct client to check the urine for
ketones once blood glucose reaches 250 mg/dL or
higher.
Teach signs of hypoglycemia:
– Dizziness. - Nervousness
– Sweating. - Hunger.
– Pallor. - Diaphoresis.
– Tremors.
 These are signs of excessive insulin dosage, resulting
in hypoglycemia.
 Teach client that polyuria, polydipsia, and polyphagia
are signs of hyperglycemia which may requires dosage
adjustment of insulin.
 Explain the importance of having a dietary plan:
 Limit intake of simple sugar, fat, salt and alcohol.
 Increase intake of whole grains, fruits, and vegetables.
 Medical nutrition therapy is important in managing
diabetes and preventing the rate of development of
diabetes complications.
THANK
YOU