Diabetic Ketoacidosis - University of Wisconsin–Madison

Diabetic Ketoacidosis

R. Sorkness Pharmacy Practice 550- Fluid & Electrolyte Therapy

Fall 2017

Reading Assignments

? Maletkovic, Diabetic Ketoacidosis and Hyperglcemic Hyperosmolar State, Endocrinol Metab Clin N Am 2013; 42:677-695

? Excellent summary of pathogenesis, definitions, and assessment

? Kitabchi, ADA Concensus Statement: Hyperglycemic Crises in Adult Patients with Diabetes, Diabetes Care 2009; 32:1335-1343.

? Concise summary, with treatment guidelines

? Please review the sections on Hyperosmolar Syndromes, AcidBase, and Intracellular Ions

Key Concepts about DKA

? Ketoacid production is a normal component of fatty acid metabolism, which is controlled by insulin

? Although ketoacidosis occurs most frequently in diabetics with hyperglycemia, it is not caused by elevated glucose levels

? Insulin activity is opposed by the counterregulatory hormones: primarily glucagon, but also cortisol, Epi, NE, & growth hormone

? These are elevated during physiological stresses- e.g. infection, trauma, surgery, myocardial infarction; high dose steroid therapy

? Even type-2 diabetics may develop DKA if elevated C-R hormones

? The 2 primary ketoacids are acetoacetate and -OH-Butyrate

? KA production is inhibited by insulin Rx, but it usually takes 18-24 hrs to clear the existing KAs

Ketoacidosis

? Excessive lipolysis and fatty acyl-

Co A due to reduced insulin /

increased counterregulatory

hormones (glucagon, GH, cortisol,

epinephrine, norepinephrine)

X

? Lipogenesis pathways inhibited by the hormone environment

? Accumulating acetyl-CoA favors formation of ketone bodies, mostly -OH-butyrate, also acetoacetate and small amounts of acetone

Therapy of DKA

? ECF Depletion- isotonic fluids ? Hyperosmolality- treat hyperglycemia and free water deficit ? Metabolic Acidosis- suppress ketoacid production

and support clearance ? Intracellular Ion Imbalance- restore ECF/ICF equilibrium and replace deficits

Fluid Resuscitation

? Typically DKA patients have ECF depletion due to hyperglycemiainduced osmotic diuresis over the preceding days

? There is also a shift of ICF-to-ECF due to hyperglycemia, so that the physical exam may underestimate the volume deficit

? The first priority of DKA therapy is to administer 0.9% NaCl to restore hemodynamic stability and renal perfusion

? In adults, 1-2 liters are given in the first hour

? Urine output may increase dramatically once renal perfusion is restored, and this will continue until hyperglycemia is reduced

? Important to replace urine output, as well as to correct ECF fluid deficit

Insulin Therapy

? Usually regular insulin is given, by the i.v. route ? Begin insulin after the 1st hour of normal saline infusion ? Adults- 0.1 u/kg bolus, and 0.1 u/kg/hr infusion, or start infusion at

0.14 u/hr without the initial bolus ? Children- more common to start infusion without a bolus dose ? If serum potassium concentration ................
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