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Pathophysiology
DKA is associated with a relative or absolute insulin deficiency
and a severely elevated blood glucose level, typically greater than
300 mg/dL. Due to the lack of insulin, peripheral cells are unable
to take up glucose. Even though the blood has an extremely
elevated amount of circulating glucose, the cells are basically
starving.
Diagnosis
Arterial pH
Serum ketones
Calculation of anion gap
Prognosis
Mortality rates for DKA are between 1 and 10%. Shock or coma on
admission indicates a worse prognosis. Main causes of death are
circulatory collapse, hypokalemia, and infection. Among children
with cerebral edema, 57% recover completely, 21% survive with
neurologic sequelae, and 21% die.
Treatment
IV 0.9% saline
IV insulin
Correction of any hypokalemia
The most urgent goals are i) rapid intravascular volume repletion,
ii) correction of hyperglycemia and acidosis, and iii) prevention of
hypokalemia. Identification of precipitating factors is also
important. Treatment should occur in intensive care settings
because clinical and laboratory assessments are initially needed
every hour or every other hour with appropriate adjustments in
treatment.
When plasma glucose becomes < 200 mg/dL (< 11.1 mmol/L) in
adults, 5% dextrose should be added to IV fluids to reduce the risk
of hypoglycemia. Insulin dosage can then be reduced to 0.02 to
0.05 unit/kg/h, but the continuous IV infusion of regular insulin
should be maintained until the anion gap has narrowed and blood
and urine are consistently negative for ketones. Insulin
replacement may then be switched to regular insulin 5 to 10 units
sc q 4 to 6 h.
Key Points
Acute physiologic stressors (eg, infections, MI) can trigger
acidosis, moderate glucose elevation, dehydration, and severe K
loss in patients with type 1 diabetes.
Acute cerebral edema is a rare (about 1%) but lethal
complication, primarily in children and less often in adolescents
and young adults.
Diagnose by an arterial pH < 7.30, with an anion gap > 12 and
serum ketones in the presence of hyperglycemia.
Acidosis typically corrects with IV fluid and insulin; consider
HCO3 only if marked acidosis (pH < 7) persists after 1 hr of
therapy.
Withhold insulin until serum K is 3.3 mEq/L
CLINICAL VIGNETTES
A. a chest x-ray
B. an endotracheal intubation
C. an intravenous fluid replacement with insulin
D. methadone
E. a pulmonary artery catheter insertion