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Dka or Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a relative ‘hunger’ state in the body even with very high glucose levels in the blood. The ketoacidotic state can occur in one of three instances.

Causes

Infections

Not taking the insulin doses by a diabetic patient

Undiagnosed diabetic patients

DKA gives rise to 4 metabolic derangements. By understanding how these derangements have manifested will give us vital insight about preventing such episodes and managing a patient with DKA without going into potentially lethal complications.

Pathophysiology

1. Hyperglycaemia

In DKA the absolute or relative insulin deficiency will prevent the muscles, fat tissue and liver from using blood glucose. Due to the insulin deficiency, other counter regulatory hormones will increase its activity and more and more fat tissues will be broken down and converted into glucose. This phenomenon usually happens when the body is in a state of hunger and will make already worsened blood glucose levels to rise. The free fatty acids that have been release from fat tissues will be oxidised.

2. Ketosis

The reason for the ketosis is the build up of Ketone bodies in the blood due to beta-oxidation of free fatty acids. These Ketone bodies can appear in blood, urine and even in the breath as a fruity smell.

3. Acidosis

The accumulation of Ketone bodies will make the blood acidic and thus the acidosis will result. The reason for this is the depletion on buffers inside and outside the cells.

4. Dehydration with electrolyte depletion

The hyperglycaemia would promote osmotic diuresis which leads sodium, potassium, phosphates and water to be depleted from the body with excessive urination along with glucose and ketones.

Symptoms

Patients with DKA will show following symptoms due to the above explained phenomena.

Breathlessness

Tiredness

Dehydration

Decreased perspiration

Increase thirst

Excessively urination

Nausea, vomiting

Confusion

Loss of consciousness

Apart from the above symptoms, the patients might show signs of underlying infection such as fever, rashes..etc. Out of all the infections, Urinary Tract Infections seems to be the most common culprit for DKA in susceptible individuals.

Diagnosis

Diagnosis will be made using a combination of history, examination and investigative findings.

In general, DKA patients will have a blood glucose level of >300 mg/dL. The DKA will results in Bicarbonate levels of less than 15 mEq/L and pH of less than 7.3. These values can even be worse in severe DKA patients.

Following investigation would be done on a DKA patient.

Blood glucose levels

Serum

Electrolytes

Full Blood Count

Serum Osmolality Arterial Blood Gas levels Urine Full Report Ketone levels Blood urea and nitrogen ECG

These tests may have to be repeated when the treatment starts.

Treatment

The treatment will initially focus on stabilizing the patient by adequately hydrating. Therefore Normal Saline intravenous drip will be given relatively fast. At the same time the patient will often be given oxygen. In severe cases the patients may need to be intubated.

Following correction of the fluidity, an insulin containing drip will be started in order to bring the glucose levels down. In doing so the clinicians will be watching for the blood potassium levels as that can deplete suddenly with insulin and affect the heart function. Once the sugar levels are in manageable levels the drip will be changed in to a dextrose drip with probably added potassium.

At the same time any underlying infections will be treated with antibiotics.

Complications

Due to the metabolic derangement, several life threatening complications can manifest in DKA patients.

Cerebral Oedema

Pulmonary Oedema

Hypokalaemia and cardiac events

Hypoglycaemia and comma

Prognosis

The mortality rate is less than 2 percent in DKA patients.