Diabetic Ketoacidosis

Diabetic Ketoacidosis (DKA) is caused when there is not enough insulin in the body to provide cells with glucose for energy. This results in a breaking down of fat for energy which causes the complications of DKA.

Etiology and Physiology
Occurs mainly in Type I DM although may occur with Type II. Glucose levels may be in excess of 1,000 although there is not set range for glucose and DKA. It is relative to where the patient's glucose usually is. As glucose increases the kidney's will try and correct this imbalance by excreting more glucose and with it H2O and electrolytes. Fat is broken down in an attempt to get energy for metabolism. Fat is converted by the liver into ketones which are acidic leading to acidosis.

Signs and Symptoms
In general the patient is in acidosis so pH is lowered as are electrolytes, they are dehydrated and respirations are labored. Labs
 * Dehydration with electrolyte loss
 * K+ may be elevated
 * Headache (due to dehydration and electrolyte loss)
 * Weakness, coma.
 * Confusion
 * Kussmaul respirations (deep but not labored, causes low PaO2. Body is trying to reverse acidosis by blowing off CO2).
 * Polyuria and polydipsia
 * Hypotension
 * Tachycardia c weak pulse
 * Abdominal pain
 * Nausea and Vomiting
 * pH < 7.35
 * Seizurecomadeath
 * pH will be low < 7.35
 * Na and K may be low. K+ may be high or low.
 * Osmolality may or may not be increased. On the test it will probably be normal or slightly elevated. This due to loss of fluids and electrolytes so osmolality may be normal. If it is increased it will not be to the same extent as with HHNK.
 * PaCO2 will be <35, low due to increased respirations.

Treatment
There three goals of treatment. Correct the volume, correct the electrolyte imbalance then correct the glucose imbalance. Glucose comes last in this process as giving it first can cause severe hypokalemia and further increase osmolality (dehydration). It's important to know that insulin will also move potassium and H2O into cells. This can result in potassium being depleted rapidly and a worsening of dehydration (high osmolality). Be alert for these imbalances when giving insuling to someone with DKA.
 * 0.9% IV NS to correct fluid balance and provide cardiac support.
 * 0.45% NS to correct hyponatremia by pulling Na+ out of the cells into plasma
 * K+ to correct low plasma levels. May be given if levels are normal.
 * Monitor K+ frequently as it may fluctuate during therapy.
 * Insulin drip to correct hyperglycemia and acidosis.
 * Hourly glucose checks.
 * Assess vitals, urine output and breath sounds.