Diabetic Ketoacidosis (DKA)
📌 Definition: A life-threatening complication of Diabetes Mellitus (usually Type 1) characterized by the triad:
1. Hyperglycemia
2. Ketosis
3. Metabolic Acidosis
1. Hyperglycemia
2. Ketosis
3. Metabolic Acidosis
1. Pathophysiology
It starts with Insulin Deficiency (absolute or relative) + an excess of counter-regulatory hormones (Glucagon, Cortisol, Catecholamines).
The Sugar Problem
Insulin ↓ → Gluconeogenesis ↑ → Hyperglycemia → Osmotic Diuresis → DehydrationThe Acid Problem
Lipolysis ↑ → Free Fatty Acids → Liver Ketogenesis → AcidosisPrecipitating Factors ("The 5 I's")
- Infection: (Most common) Pneumonia, UTI.
- Insulin deficiency: Missed doses, pump failure.
- Infarction: Myocardial Infarction, Stroke.
- Infant (Pregnancy): Or new-onset diabetes.
- Iatrogenic/Drugs: Steroids, surgery.
2. Clinical Features
| System | Symptoms & Signs |
|---|---|
| General | Polyuria, polydipsia, weight loss, severe dehydration. |
| Respiratory | Kussmaul Breathing (Deep, rapid breaths to remove CO₂). Fruity breath odor (Acetone). |
| Gastrointestinal | Nausea, vomiting, abdominal pain (may mimic acute abdomen). |
| Neurologic | Confusion, lethargy → Coma. |
🌡️ Note: Temperature may be normal or low even with infection due to peripheral vasodilation.
3. Diagnostic Criteria (ADA)
- 🩸 Glucose: > 250 mg/dL (Note: Euglycemic DKA possible)
- 🧪 pH: < 7.3 (Acidosis)
- 📉 Bicarbonate: < 18 mmol/L
- 👃 Ketones: Positive in urine or serum
- ⚡ Anion Gap: Elevated (>12)
4. Management Protocol
Goal: Treat the underlying cause + correct the metabolic mess.
1. Fluids (Priority #1)
Start with 0.9% Normal Saline.
- Rate: 15–20 mL/kg in 1st hour (~1L).
- Maintenance: Switch to 0.45% NS or D5-NS later based on corrected sodium.
2. Insulin
IV Regular Insulin
- Dose: 0.1 u/kg bolus → 0.1 u/kg/hr.
- Target: Drop glucose by 50–70 mg/dL/hr.
- Twist: Add Dextrose (D5) when glucose < 200 mg/dL to prevent hypoglycemia while clearing ketones.
☠️ POTASSIUM (K⁺) SAFETY RULES
Insulin pushes K⁺ into cells. If you give insulin to a hypokalemic patient, you may cause fatal arrhythmia.
- K⁺ > 5.3: Safe to start insulin.
- K⁺ 3.3 – 5.3: Add K⁺ to IV fluids immediately.
- K⁺ < 3.3: HOLD INSULIN. Replete K⁺ first!
Other Electrolytes
- Bicarbonate: Generally NOT recommended unless pH < 6.9.
- Phosphate: Replace only if < 1.0 mg/dL or cardiac dysfunction present.
5. Resolution Criteria
DKA is resolved when ALL of the following are met:
✅ Blood Glucose < 200 mg/dL
✅ Serum Bicarb ≥ 15 mmol/L
✅ Venous pH > 7.3
✅ Anion Gap Normalized
✅ Serum Bicarb ≥ 15 mmol/L
✅ Venous pH > 7.3
✅ Anion Gap Normalized
Next Step: Start Subcutaneous (SC) insulin and overlap with IV insulin for 1–2 hours before stopping the drip.
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