DKA
Is caused by an absence or markedly
inadequate amount of insulin.
This deficit in available insulin results in
disorders in the metabolism of
carbohydrate, protein, and fat.
The three main clinical features of DKA
are
• Hyperglycemia
• Dehydration and electrolyte loss
• Acidosis
PATHOPHYSIOLOGY OF DKA
CAUSES
Three main causes of DKA are
decreased or missed dose of insulin,
illness or infection, and undiagnosed
and untreated diabetes
Other potential causes of decreased
insulin include patient error in drawing
up or injecting insulin
hormones—glucagon, epinephrine,
norepinephrine, cortisol, and growth
hormone
PREVENTION
Never eliminate insulin doses when
nausea and vomiting occur
Drinking fluids every hour is important
to prevent dehydration.
Blood glucose and urine ketones must
be assessed every 3 to 4 hours.
Patients are taught to have foods
available for use on sick days.
CLINICAL MANIFESTATIONS
Polyuria and polydipsia (increased thirst).
Blurred vision, weakness, and headache.
Orthostatic hypotension (SBP 20 mm Hg
or more on changing of position).
Frank hypotension with a weak, rapid
pulse.
C/M
Gastrointestinal symptoms such as anorexia,
nausea, vomiting, and abdominal pain.
The abdominal pain and physical findings
seems acute abdomen
Acetone breath (a fruity odor),
Kussmaul respirations,
The patient may be alert, lethargic, or
comatose.
ASSESSMENT AND DIAGNOSTIC FINDINGS
BGL 300 - 800 mg/dL (16.6 to 44.4 mmol/L).
Low serum bicarbonate (0 to 15 mEq/L) and low
pH (6.8 to 7.3) values. A low partial pressure of
carbon dioxide (PCO2; 10 to 30 mm Hg
Increased levels of creatinine, blood urea
nitrogen (BUN),
After rehydration, continued elevation in the
serum creatinine and BUN levels suggests
underlying renal insufficiency.
MANAGEMENT
In addition to treating hyperglycemia,
management of DKA is aimed at
correcting dehydration, electrolyte loss,
and acidosis.
1. REHYDRATION
Important for maintaining tissue perfusion.
Fluid replacement enhances the excretion
of excessive glucose by the kidneys.
The patient may need as much as 6 to 10
L of IV fluid to replace fluid losses caused
by polyuria, hyperventilation, diarrhea,
and vomiting.
REHYD…
Initially, 0.9% normal saline at a rate, usually 0.5 to
1 L/h for 2 to 3 hours.
Half-strength normal saline (0.45%) solution may be
used for patients with hypertension or hypernatremia
and those at risk for heart failure.
0.45% normal saline used for continued rehydration,
When BGL reaches < 300mg/dl, (D5W) may be used
to prevent a precipitous decline in the blood glucose
level
2. RESTORING ELECTROLYTES
Cautious but timely potassium replacement
is vital to avoid dysrhythmias that may occur
with hypokalemia. As much as 40 mEq/h may
be needed for several hours.
Because extracellular potassium levels
decrease during DKA treatment, potassium
must be infused even if the plasma
potassium level is normal.
REVERSING ACIDOSIS
The acidosis that occurs in DKA is reversed with
insulin, which inhibits fat breakdown
Insulin is usually infused intravenously at a slow,
continuous rate (eg, 5 units/h)
Hourly blood glucose values must be measured
IV fluid solutions
with higher concentrations of glucose are used
when BGL reach 250 to 300 mg/dL
Regular insulin, the only type of insulin approved for
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