Diabetic Ketoacidosis

DIABETIC KETOACIDOSIS

INTRODUCTION

Diabetic ketoacidosis (DKA) is a very serious complication of diabetes mellitus, a metabolic disorder that is characterized by hyperglycemia, metabolic acidosis, and increased body ketone concentrations. The most common causes of DKA are infection and poor compliance with medication regimens. Other causes include undiagnosed diabetes, alcohol abuse, and a multitude of medical conditions such as cerebrovascular accident (CVA), complicated pregnancy, myocardial infarction, pancreatitis, and stress. Diabetic ketoacidosis is a complicated pathology. Early recognition of DKA, a good understanding of the pathological processes of DKA, and aggressive treatment are the keys to successful treatment. With good care, DKA can be managed and the patient will survive.

OBJECTIVES

When the student has finished studying this module, he/she will be able to:

1. Identify the correct definition of DKA.
2. Identify a basic function of insulin.
3. Identify the insulin derangements of types I and II diabetes.
4. Identify the basic cause of DKA.
5. Identify two specific causes of DKA.
6. Identify the two pathogenic mechanisms that produce the signs/symptoms of DKA.
7. Identify metabolic consequences of increased hormone concentrations in DKA.
8. Identify the criteria used to diagnose DKA.
9. Identify common signs and symptoms of DKA.
10. Identify laboratory abnormalities seen in DKA.
11. Identify complications of DKA.
12. Identify the three most important therapies for treating DKA.
13. Identify the correct roles of sodium bicarbonate and phosphate in treating DKA.
14. Identify an important rule for using potassium replacement in DKA.
15. Identify an important rule for switching from IV to subcutaneous insulin.

EPIDEMIOLOGY

Most cases of DKA are seen in patients with type I diabetes, but approximately 10%-30% of all cases of DKA occur in patients with type II diabetes.1 The incidence of DKA appears to be

References: 1. Wilson JF. In the clinic: Diabetic ketoacidosis. Annals of Internal Medicine. 2010; 152:ITC-1-ITC-16. 2. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32:1335-1343. 3. Wolfsdorf J, Glaser N, Sperling MA. Diabetic ketoacidosis in infants, children, and adolescents: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29:1150-1159. 4. Hamdy O. Diabetic ketoacidosis. eMedicine. September 9, 2009. Available at: http://emedicine.medscape.com/article/118361. Accessed December 24, 2010. 5. Hamdy O. Diabetic ketoacidosis. eMedicine. September 9, 2009. Available at: http://emedicine.medscape.com/article/118361. Accessed December 24, 2010, 6 7. Rucker DW. Diabetic ketoacidosis. eMedicine. June 4, 2010. Available at: http://emedcine.medscape.com/article/766275. Accessed December 24, 2010. 8. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32:1335-1343. 9. Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. 2001;24:131-153. 10. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32:1335-1343. 11. Hamdy O. Diabetic ketoacidosis. eMedicine. September 9, 2009. Available at: http://emedicine.medscape.com/article/118361. Accessed December 24, 2010. 12. Wilson JF. In the clinic: Diabetic ketoacidosis. Annals of Internal Medicine. 2010; 152:ITC-1-ITC-16. 13. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32:1335-1343. 14. Miles JM, Gehrich JE. Glucose and ketone body kinetics in diabetic ketoacidosis. Clinical Endocrinology & Metabolism. 1983;1:303-319. 15. Glaser NS, Wooton-Gorges SL, Buonocore MH, Marcin JP, Rewers A, Strain J., et al. Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatric Diabetes. 2006;7:75-80. 16. Wolfsdorf J, Glaser N, Sperling MA. Diabetic ketoacidosis in infants, children, and adolescents: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29:1150-1159. 17. Haringhuizen A, Tjan DHT, Grool A, van Vugt R, van Zanten ARH. Fatal cerebral oedema in adult diabetic ketoacidosis. The Netherlands Journal of Medicine. 2010;68:35-37. 18. Wilson JF. In the clinic: Diabetic ketoacidosis. Annals of Internal Medicine. 2010; 152:ITC-1-ITC-16. 19. Goyal N, Miller JB, Sankey SS, Mossallam U. Utility of initial bolus insulin in treatment of diabetic ketoacidosis. Journal of Emergency Medicine. 2010;38:422-427. 20. Rucker DW. Diabetic ketoacidosis. eMedicine. June 4, 2010. Available at: http://emedcine.medscape.com/article/766275. Accessed December 24, 2010. 21. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32:1335-1343. 22. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32:1335-1343. 23. Wilson JF. In the clinic: Diabetic ketoacidosis. Annals of Internal Medicine. 2010; 152:ITC-1-ITC-16. 24. Kitabchi AE, Umpierrez GE, Fisher JN, Murphy NB, Stentz FB. Thirty years of personal experience in hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Journal of Clinical Endocrinology & Metabolism. 2008;93:1541-1552. 25. Wilson JF. In the clinic: Diabetic ketoacidosis. Annals of Internal Medicine. 2010; 152:ITC-1-ITC-16. 26. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32:1335-1343.