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Diabetic ketoacidosis

Background knowledge 🧠

Definition

  • Diabetic ketoacidosis (DKA) is a serious, potentially life-threatening complication of diabetes mellitus.
  • Characterised by hyperglycaemia, ketosis, and metabolic acidosis.
  • Occurs primarily in type 1 diabetes mellitus, but can also occur in type 2.
  • Requires urgent medical treatment.

Epidemiology

  • Incidence: higher in type 1Β diabetes mellitus.
  • DKA is a common initial presentation in newly diagnosed type 1Β diabetes.
  • Can occur at any age but more common in youngerΒ patients.
  • Increased risk in patients with poor glycaemic control or those who miss insulin doses.
  • Mortality rate has decreased with improved treatment protocols.

Pathophysiology

  1. Insulin deficiency leads to increased lipolysis, releasing free fatty acids.
  2. Ketogenesis in the liver produces ketone bodiesΒ (beta-hydroxybutyrate, acetoacetate).
  3. Accumulation of ketone bodies leads to metabolic acidosis.

Aetiology

  • Absolute or relative insulin deficiency.
  • Increased counter-regulatory hormones (glucagon, cortisol, catecholamines).
  • Triggers:
    • Infection.
    • Stress.
    • Inadequate insulin therapy.
    • Myocardial infarction.
    • Trauma.

Clinical Features 🌑️

Symptoms

  • Polyuria (frequent urination).
  • Polydipsia (excessive thirst).
  • Nausea and vomiting.
  • Abdominal pain.
  • Fatigue and weakness.
  • Altered mental status (confusion, drowsiness).
  • Symptoms of underlying infection (if present).
  • Weight loss.
  • Dehydration symptoms (dry mouth, skin).

Signs

  • Tachycardia.
  • Hypotension.
  • Kussmaul respirations (deep, laboured breathing).
  • Fruity breath odour (acetone).
  • Dehydration signs (dry mucous membranes, reduced skin turgor).
  • Altered consciousness (lethargy, coma).
  • Abdominal tenderness.
  • Signs of infection (fever, cough, etc.).
  • Hyperglycaemia (blood glucose > 11 mmol/L).
  • Ketosis (positive urine or serum ketones).
  • Metabolic acidosis (low bicarbonate, pH < 7.3).

Investigations πŸ§ͺ

Tests

  • Blood glucose levels (typically > 11 mmol/L).
  • Serum ketones (beta-hydroxybutyrate).
  • Arterial blood gases (metabolic acidosis).
  • Electrolytes (hyperkalaemia, hyponatremia).
  • Urinalysis (glucosuria, ketonuria).
  • Renal function tests (creatinine, urea).
  • Complete blood count (leucocytosis).
  • Infection screen (blood cultures, chest X-ray).
  • ECG: to detect hyperkalaemia effects.
  • Plasma osmolality.

Diagnostic criteria

  • Glucose >11mmol/LΒ (NB. glucose may be normal in some circumstances – β€˜euglycaemic DKA’, e.g. if taken insulin recently, on SGLT-2 inhibitor, during pregnancy).
  • pH <7.3Β orΒ HCO3– Β <15mmol/L.
  • Capillary ketones >3mmol/LΒ (orΒ ++ urinary ketones).

Management πŸ₯Ό

Management

  • Fluid replacement (IV 0.9% saline).
  • Insulin therapy (fixed rate IVΒ insulin infusion).
  • Electrolyte management (potassium replacement).
  • Monitoring of blood glucose and electrolytes.
  • Address underlying cause (e.g., antibiotics for infection).

Learn more here.

Complications

  • Cerebral oedema.
  • Hypokalaemia.
  • Hypoglycaemia (from overcorrection).
  • Acute respiratory distress syndrome (ARDS).
  • Acute kidney injury.
  • Thromboembolism.
  • Infections.
  • Death (if untreated or severe).

Prognosis

  • GoodΒ with prompt and appropriate treatment.
  • Mortality rate < 1% with proper management.
  • Higher risk in elderly and those with comorbid conditions.
  • Long-term prognosis depends on overall diabetes management.
  • Regular follow-up and patient education reduce recurrence.

Key Points

  • DKA is a medical emergencyΒ requiring prompt treatment.
  • Characterised by hyperglycaemia, ketosis, and metabolic acidosis.
  • Management includes fluids, insulin, and electrolyte replacement.
  • Early recognition and treatment are crucial to prevent complications.
  • Follow local guidelines for management (e.g., NICE guidelines).
  • Patient education is essential to prevent recurrence.

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