Diabetic keto-acidosis (DKA)

PATH

• May be the 1st presentation of type 1 DM.

Predisposing factors:

1- absolute insulin deficiency     ⇒      sever hyperglycemia. 2- relative insulin deficiency as      ⇒      in trauma,infection,surgery.

Clinical presentation of DKA:

1. Polyurea ⇒ polydepsia, dehydration and electrolyte imbalance leading to hypotonia and coma .
2. Anorexia and abdominal pain.
3. Nausea and vomiting.
4. Tachycardia (due to high adrenergic stress release).

Diagnosis of DKA:

1. Hyperglycemia (plasma glucose level is 500 to 700 mg/dl).
2. Ketonemia and Ketonuria as their production level exceed rate of tissue utilization.
3. Acidosis (PH< 7.3 ) (due to excess ketone bodies as hydroxy butyric acid and acetoacetic acid)

Complications of DKA:

• Cerebral edema caused by hyponatremia(most common cause of death in children )
• Vascular thrombosis ⇒ Myocardial infarction.
• Infection(due to hyperglycemia in addition to defective function of both neutrophils and macrophages with failure of migration outside thickned blood vessel wall inside inflammed tissue)

Treatment of DKA:

• Fluid replacement.
• Insulin therapy for hyperglycemia.
• Electrolyte correction.
• Acidosis correction.
• Treatment of precipitating cause

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THERA

Causes:

• Excess food intake.
• Inadequate insulin administration.
• Febrile illness or stress condition.

Manifestations:

• Dehydration and dry shrunken tongue.
• Smell of acetone in breath and sugar and ketone in urine.
• Acidotic breathing (rapid and deep) due to acidosis.
• Deep coma in late cases.

Treatment: Fluids + Regular Insulin

• Fluids: 1-2 litters of isotonic saline solution i.v. immediately, then determine the amount by urine output and clinical response of patient.

• Regular insulin: 0.3 U/kg i.v. then 0.1 U/kg/h by i.v infusion. When blood glucose reaches 300 mg/dl, switch to s.c. insulin according to urine glucose.

• Glucose 5 % is given if blood glucose falls below 300 mg/dl .

• Potassium: is given according to K+ level. It is better to be given as phosphate salt rather than KCl to correct associated phosphate depletion.

• Bicarbonate (HCO3): by i.v.i. to correct acidosis.

• Treatment of precipitating factors e.g. antibiotics for infection.

• Usually common in DM 1
• Early manifestations for children
• Abnormal increase Urine output and fluid intake
• Acetone smell