Diabetic Ketoacidosis (DKA)

Overview

• Acute metabolic complication of diabetes.
• Characterized by:
  • Hyperglycemia
  • Hyperketonemia
  • Metabolic acidosis

Causes and Occurrence

• Mostly occurs in Type 1 Diabetes Mellitus.
• Can appear in Type 2 during unusual physiologic stress.
• Triggers include:
  • Acute infections (pneumonia, UTI, COVID-19)
  • Myocardial infarction, stroke, pancreatitis
  • Pregnancy, trauma, missed insulin doses
• Medications causing DKA:
  • Corticosteroids, Thiazide diuretics, Sympathomimetics, SGLT-2 inhibitors

Pathophysiology

• Insulin deficiency leads to metabolism of triglycerides and amino acids instead of glucose.
• Increased counterregulatory hormones (glucagon, catecholamines, cortisol).
• Lipolysis increases serum glycerol and free fatty acids.
• Hepatic gluconeogenesis stimulated by glucagon.
• Mitochondrial ketone production due to lack of insulin.
• Metabolic acidosis due to ketone accumulation.
• Osmotic diuresis causes significant water and electrolyte loss.

Symptoms and Signs

• Symptoms: Nausea, vomiting, abdominal pain
• Severe cases: Lethargy, somnolence, hypotension, tachycardia
• Breathing: Rapid and deep (Kussmaul respirations)
• Fruity breath due to acetone exhalation
• Complications: Acute cerebral edema (mostly in children)

Diagnosis

• Arterial pH < 7.30, anion gap > 12, serum ketones.
• Blood glucose level > 200 mg/dL.
• Consider euglycemic DKA in alcohol overuse or cirrhosis.

Treatment

• Main treatment goals:
  • Rapid intravascular volume repletion
  • Correction of hyperglycemia and acidosis
  • Prevention of hypokalemia
• Intensive care setting recommended.
• Volume Repletion:
  • Adults: Rapid IV infusion of normal saline.
  • Children: Fluid therapy based on body weight.
• Insulin Therapy:
  • Regular insulin IV bolus, then continuous infusion.
  • Withhold insulin if potassium < 3.3 mEq/L.
• Monitoring:
  • Regular monitoring of electrolytes and glucose.
  • Adjust treatment based on lab & clinical assessments.
• Complications:
  • Monitor and treat cerebral edema if suspected.

Prognosis

• Overall mortality rate < 1%.
• Higher risk in older patients and those with life-threatening illnesses.
• Main causes of death: Circulatory collapse, hypokalemia, infection.

Key Points

• DKA is a serious diabetic complication requiring prompt diagnosis and treatment.
• Maintain vigilant monitoring and adjustments in therapy to prevent complications.
• Early detection and management of triggers or underlying illnesses are crucial.