42 Questions
What is the potential consequence of delayed treatment of DKA?
Death
In which type of diabetes is DKA more common?
Type 1 diabetes
What is the minimum serum bicarbonate level in DKA?
15 mEq/dL
Which of the following is NOT a biochemical characteristic of DKA?
Blood glucose < 200 mg/dL
What is the typical pH level in DKA?
< 7.3
Which of the following can cause DKA?
Pancreatic damage
What is the typical blood glucose level in DKA?
> 300 mg/dL
What is the common complication of DKA?
Dehydration
What is the primary reason for the patient's hyperglycemia?
Impaired glucose utilization in cells
What is the consequence of the renal threshold of glucose being exceeded?
Glucosuria
Which of the following is NOT a counter-regulatory hormone effect?
Insulin secretion
What is the result of the body using fats as fuel instead of glucose?
Ketosis
What is the effect of osmotic diuresis in DKA?
Dehydration and polydipsia
Which laboratory result is indicative of DKA?
Urine glucose (4+) and acetone (2+)
What is the consequence of insulin deficiency in adipose tissue?
Increased lipolysis
What is the primary source of energy for the body in DKA?
Fats
What is a potential issue with creatinine assays in diabetic ketoacidosis?
They may not reflect true renal function due to cross-reactivity with ketone bodies
Why may a diagnosis of pancreatitis be mistakenly made in a patient with diabetic ketoacidosis?
Due to the elevation of serum amylase
How often should blood tests for glucose be performed in a patient with diabetic ketoacidosis?
Every 1-2 hours until stable, then every 4-6 hours
What is the primary goal of fluid replacement in diabetic ketoacidosis?
To correct fluid deficits and dehydration
What is the recommended approach to correcting electrolyte abnormalities in diabetic ketoacidosis?
Starting potassium replacement early to prevent depletion
What is the typical dehydration rate in diabetic ketoacidosis?
10%
What is the recommended initial hydrating fluid in diabetic ketoacidosis?
Isotonic saline
What is the primary difference between diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome?
The level of consciousness
What is the primary cause of DKA in diabetic children?
Omission of insulin
Which of the following is NOT a clinical manifestation of DKA?
Hypoglycemia
What is the most common precipitating factor for DKA?
Infection
What is the primary driver of the initial presentation of DKA in diabetic children?
Ketoacidosis
What is the typical respiratory pattern seen in patients with DKA?
Deep and labored breathing
Which laboratory test is NOT commonly used to assess DKA?
Lipid profile
What is the primary reason for the altered level of consciousness seen in patients with DKA?
Hyperosmolarity
What is the most common cause of abdominal pain in patients with DKA?
Pancreatitis
What is the primary goal of laboratory assessment in patients with DKA?
To determine the severity of DKA
What is the most likely diagnosis for a 22-year-old male presenting with a 3-day history of emesis and lethargy?
Diabetic ketoacidosis
What is the primary cause of metabolic acidosis in DKA?
Excess of ketone bodies
What is the effect of vomiting on the state of dehydration in DKA?
It worsens the state of dehydration
What is the effect of acidosis on potassium levels in DKA?
It leads to an overall depletion of potassium
What is the effect of osmotic diuresis on potassium levels in DKA?
It leads to an overall depletion of potassium
What is the cause of hyperosmolality in DKA?
Progressive hyperglycemia
What is the effect of dehydration on kidney perfusion in DKA?
It worsens kidney perfusion
What is the significance of a high WCC in DKA?
It may be seen in the absence of infections
What is the significance of an elevated BUN in DKA?
It may be elevated with prerenal azotemia secondary to dehydration
Study Notes
Diabetic Ketoacidosis (DKA)
- DKA is a serious acute complication of Diabetes Mellitus that carries significant risk of death and/or morbidity, especially with delayed treatment.
- It can be the presenting complaint in new diabetic patients, especially Type 1 Diabetes, and can also occur in Type 2 Diabetes.
Biochemical Characteristics
- DKA exists when:
- Venous pH < 7.3
- Serum bicarbonate < 15 mEq/dL
- Blood glucose > 300 mg/dL
- Anion gap > 10
- Presence of ketonemia/ketonuria
- This is usually accompanied by severe dehydration and electrolyte imbalance.
Triggering Factors
- Precipitating factors for DKA include:
- Omission of insulin
- Intercurrent illness (> 80%) such as infection, myocardial infarction, cardiovascular accident, and pregnancy
- Other stressors such as mental stress, depression, and trauma
Clinical Manifestations
- Initial presentation of DKA may include:
- Polyuria
- Polydipsia
- Polyphagia
- More severe cases may include:
- Abdominal pain or rigidity
- Altered level of consciousness and coma
- DKA can also cause Kussmaul respirations, fruity acetone breath, and dehydration.
Clinical Presentation
- Due to hyperglycemia:
- Polyuria
- Polydipsia
- Polyphagia
- Due to ketonemia:
- Anorexia
- Nausea
- Vomiting
- Due to acidosis:
- Abdominal pain
- Kussmaul respirations
- Due to hyperosmolarity:
- Altered level of consciousness
Laboratory Assessment
- Urine and serum ketones
- Blood glucose
- Arterial blood gases
- Serum urea and creatinine
- Serum electrolyte
- Serum osmolality
- Complete blood count
- Electrocardiogram
- Blood and urine culture (when infection is suspected)
Pathophysiology
- Hyperglycemia results from:
- Blockage of intracellular glucose transport
- Counter-regulatory hormone effects
- Ketone bodies will cause metabolic acidosis, which is aggravated by lactic acidosis caused by dehydration and poor tissue perfusion.
- Vomiting and dehydration worsen the state of dehydration.
- Electrolyte abnormalities are secondary to their loss in urine and trans-membrane alterations following acidosis and osmotic diuresis.
Treatment
- Careful replacement of fluid deficits
- Correction of acidosis and hyperglycemia via insulin administration
- Correction of electrolyte imbalance
- Treatment of underlying cause
- Monitoring for complications of treatment
- Manage DKA in the ICU or special care room of the pediatric inpatient ward if ICU is not available.
Hyperglycemic Hyperosmolar Syndrome (HHS)
- Pathophysiology:
- Dehydration
- Acidosis
- Hyperosmolality
- Diminished cerebral oxygen utilization
- Impaired consciousness and comatose state
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