Diabetic Ketoacidosis
Disclaimer
Modern medical science based case discussion for doctors & hospitals.
Case
A 48 Yr patient comes with abdominal pain, nausea and vomiting, K/C/o Diabetes mellitus
Dry mucous membranes, confused
RBS 450
Urinary Ketones +ve
(If RBS >= 200, do dipstick test to rule out the hyperglycemia or Diabetic Ketoacidosis)
Ref. https://www.nature.com/articles/s41572-020-0180-2.pdf
Diagnosis
Hyperglycemia (250-800)
Low Bicarb < 18
Low pH < 7.3
High Anion Gap Acidosis
Increased Osmolality
Increased BHB (Beta-hydroxybutyrate), Serum Ketones
Urinary Ketones
Cause
Non-compliance with insulin
Infection
Type 1 > Type 2
Mechanism
Stress – Sugary Hormones (cortisol, Glucagon, Growth Hormone, Catecholamines)
Insulin deficiency
Sugar is high
Body thinks that we are starving
Starts making ketones for energy
Sugar causes osmotic diuresis
Intracellular dehydration – 6 lit deficit
Pseudohyponatremia
Hypokalemia
What will you do?
Admit in ICU. Monitor, RBS & SpO2
Don't ever give Insulin in this case!!!
First, We will give IV Fluids – BSS/NS
Send for ABG, Blood Chemistry, ECG, CBC
And… Wait for Potassium
NO INSULIN till Potassium is verified on paper from tests
Once you know that K is > 3.5 then only start insulin 0.1 U/kg
70 kg man = 7 Units/hr
Fluid Resuscitation
20 ml/kg isotonic Crystalloid
ECG – Potassium
Search for the Cause
Did he skip insulin?
Any infection
Target of Insulin Infusion
Is not correction of Hyperglycemia
It is correction of Acidosis HCO3 > 15, pH > 7.3 & Anion Gap < 12
If RBS < 250, add Dextrose to Fluids
Treatment of Acidosis?
Yes, you can give Sodabicarb
Only if patient is in cardiac arrest, severe Hyperkalemia, or severe hypotension
What about Intubation?
Please don't Intubate, RR 30
Senior most expert can decide and Intubate within few seconds in case it is unavoidable
Check Mental status hourly
If altered Sensorium, consider cerebral edema
Stop IV, Elevate Head end
Osmotic Diuresis (Mannitol)
Summary
Start with Fluid NS
First Correct Potassium
Insulin till Acidosis Resolves
No Sodabicarb
Watch for Cerebral Edema