Diabetic+Ketoacidosis

=Diabetic Ketoacidosis=

What it is
Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes characterised by hyperglycemia, acidosis, and ketonuria DKA usually occurs as a consequence of absolute or relative insulin deficiency that is accompanied by an increase in counter-regulatory hormones (ie, glucagon, cortisol, growth hormone, epinephrine). This type of hormonal imbalance enhances hepatic gluconeogenesis, glycogenolysis, and lipolysis.
 * What causes it**

DKA mainly occurs in patients with type 1 diabetes, but it is not uncommon in some patients with type 2 diabetes. - DKA is much more common in young children and adolescents than it is in adults with type 1 diabetes
 * Risk Factors**


 * Patients with type 1 diabetes
 * DKA present at diagnosis of type 1 diabetes due to acute insulin deficiency (occurs in 25% of patients)
 * Poor compliance with insulin through the omission of insulin injections either due to lack of patient or guardian education or as a result of psychological stress, particularly in adolescents
 * Bacterial infection and intercurrent illness (eg, UTI, vomiting)
 * //Klebsiella pneumoniae// (the leading cause of bacterial infections precipitating DKA)
 * Medical, surgical, or emotional stress
 * Brittle diabetes
 * Idiopathic (no identifiable cause)
 * Insulin infusion catheter blockage
 * Mechanical failure of insulin infusion pump
 * Patients with type 2 diabetes
 * Intercurrent illness (eg, myocardial infarction, pneumonia, prostatitis, UTI)
 * Medication (eg, corticosteroids, pentamidine, clozapine)

Symptoms
//Biochemically, DKA is defined as an increase in the serum concentration of ketones greater than 5 mEq/L, a blood glucose level of greater than 250 mg/dL (although it is usually much higher), blood pH of less than 7.2, and a bicarbonate level of 18 mEq/L or less.//
 * History**
 * Insidious increased thirst (ie, polydipsia) and urination (ie, polyuria) are the most common early symptoms of diabetic ketoacidosis (DKA).
 * Nausea and vomiting usually occur and may be associated with diffuse abdominal pain.
 * Generalized weakness and fatigability may occur.
 * Altered consciousness in the form of mild disorientation or confusion is a possible symptom. Although frank coma is uncommon, it may occasionally occur when the condition is neglected or if dehydration or acidosis is severe.
 * Symptoms of possible associated intercurrent infection may include fever, dysuria, coughing, malaise, and arthralgia, among others.
 * Acute chest pain or palpitation may occur in association with myocardial infarction. Painless infarction is not uncommon in patients with diabetes and should always be suspected in elderly patients.
 * Patients may present with a history of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons.
 * History of rapid weight loss is a symptom in patients who are newly diagnosed with type 1 diabetes.
 * Physical**
 * Signs of dehydration - Weak and rapid pulse, dry tongue and skin, hypotension, and increased capillary refill time
 * Patient odor - Characteristic acetone odor
 * Signs of acidosis - Shallow rapid breathing or air hunger (Kussmaul or sighing respiration), abdominal tenderness, and disturbance of consciousness
 * Although these signs are not usual in all cases of DKA, their presence signifies a severe form of DKA.
 * Emphasizing that no direct correlation exists between the degree of acidosis, hyperglycemia, and the disturbances in the level of consciousness is important.
 * Signs of intercurrent illness - Myocardial infarction, urinary tract infection (UTI), pneumonia, and perinephric abscess, among others
 * Noticing that the body temperature may be within the reference range or low, even in the presence of intercurrent infection, is particularly important.
 * Search for signs of infection is mandatory in all cases.

How to Treat
//Managing diabetic ketoacidosis (DKA) in an ICU during the first 24-48 hours is always advisable. When treating DKA, the points that must be considered and closely monitored include correction of fluid loss with IV fluids; correction of hyperglycemia with insulin; correction of electrolyte disturbances, particularly potassium loss; correction of acid-base balance; and treatment of concurrent infection if present.// - Electrolyte correction with potassium - Correction of acid-base balance - Treatment of concurrent infection
 * A low-dose insulin regimen has the advantage of not inducing severe hypoglycemia or hypokalemia, as may be observed with a high-dose insulin regimen.
 * Only short-acting insulin is used for correction of hyperglycemia.
 * Subcutaneous absorption of insulin is reduced in DKA because of dehydration; therefore, using IV or IM routes is traditionally preferable.
 * A common mistake is to allow blood glucose to drop to hypoglycemic levels. This mistake usually results in a rebound ketosis derived by counter-regulatory hormones

Other advice
- Patients are not usually discharged from the hospital unless they have switched back to their daily insulin regimen without recurrence of ketosis. - When the condition is stable, pH is greater than 7.3, and bicarbonate is greater than 18 mEq/L, the patient is allowed to eat a meal preceded by an SC dose of regular insulin. Insulin infusion can be discontinued 30 minutes later. - If the patient is still nauseated and cannot eat, continue dextrose infusion and administer regular or ultra–short-acting insulin SC every 4 hours according to blood glucose level, while trying to maintain blood glucose values at 100-180 mg/dL.

Additional Resources
[|eMedicine - Diabetic Ketoacidosis]