DKA is a medical emergency and remains a serious cause of morbidity, principally in people with type 1 diabetes.

1. Diabetic
ketoacidosis
BY- PINKY RATHEE
M.Sc. NURSING
3rd SEMESTER

2. Diabetic ketoacidosis
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.

3. DKA is a medical emergency and
remains a serious cause of morbidity,
principally in people with type 1
diabetes.
It has a mortality of 6-10%.
DKA also is often the presenting
problem in newly diagnosed patient.
(usually known NIDDM patient)

4. Characterized by
Hyperglycemia over 300 mg/dL
Low bicarbonate (<15 mEq/L)
Acidosis (pH <7.30)
Ketonemia and ketonuria

5. Etiology factors
Type I diabetes complication
Poor insulin compliance and lack of
knowledge about managing insulin
administration in acute illness.

6. Precipitating factors
Medications and drugs that affect carbohydrate
metabolism-
 CORTICOSTEROIDS
 THIAZIDES
 LOOP DIURETICS
 SYMPATHOMIMETICS
 ANTI-HYPERTENSIVES
 ANTI-HISTAMINES
 ANTIDEPRESSANTS
 ALCOHOL
 COCAINE

7. Precipitating factors
An intercurrent illness because of failure to
increase insulin to compensate for the stress
response.
 Infections (pneumonia, UTI, URI, meningitis,
cholecystitis, pancreatitis)
 Vascular disorder (MI, CVD)
 Endocrine disorders (hyperthyroidism,
cushing’s, acromegaly, pheochromocytoma)
 Trauma
 Pregnancy
 Emotional stress

8. The three main clinical features of
DKA are:-
Hyperglycemia
Dehydration
Ketosis and Acidosis
Electrolyte loss

9. Hyperglycaemia
Normally- insulin suppresses glucose
production and lipolysis in the liver.
In diabetes mellitus- Insulin deficiency
leads to hepatic glucose overproduction.
Counter-regulatory hormones, glucagon,
cortisol and catecholamines increase the
glucose level through
gluconeogenesis (formation of new
glucose)
glycogenolysis (breakdown of complex
glycogen into simple glucose).

10. Gluconeogenesis
amino acids
(from protein
breakdown)
lactate (from
muscle
glycogenolysis)
glycerol (from
increased
lipolysis)
availability of
all the
precursors

11. Ketosis
 Insulin deficiency and elevated counter-
regulatory hormones promote lipolysis in
adipose tissue and inhibit lipogenesis, leading
to increased release of fatty acids and glycerol.
 The liver is stimulated by glucagon to oxidise
free fatty acids to ketone bodies such as beta-
hydroxybutyrate and acetoacetate.
 The production of ketone bodies exceeds the
ability of tissues to utilise them, resulting in
ketonaemia.

12. Acidosis
Ketone bodies fully dissociate
into ketone anions and
hydrogen ions.
The body attempts to maintain
extracellular pH by binding the
hydrogen ions with
bicarbonate ions thus
depleting its alkali reserves .
Acidosis develops.

13. The respiratory system compensates for acidosis by
increasing the depth and rate of breathing to exhale
more carbon dioxide. This is called Kussmaul
respiration.
The breath has a fruity, acetone-like odour (“nail
polish remover”), because the acetone ketones are
exhaled. The kidneys excrete ketone bodies
(ketonuria), and large amounts of glucose spill over
into the urine leading to osmotic diuresis,
dehydration and haemoconcentration.
Even fewer ketone bodies are metabolised and
acidosis worsens. Acidosis can cause hypotension
due to its vasodilating effect and negative effect on
heart contractility.

14. Dehydration
.
Hyperglycaemia raises extracellular
fluid osmolality.
Water is drawn from the cell into the
extracellular compartment and
intracellular dehydration follows.
Total body dehydration and sodium
depletion is the result of increased
urinary output and electrolyte losses.

15. With marked hyperglycaemia the serum
glucose threshold for glucose reabsorption
in the kidneys of 10mmol/L is exceeded, and
glucose is excreted in urine (glucosuria ).
Glucosuria causes losses of water and
electrolytes such as sodium, potassium,
magnesium, calcium and phosphate
(osmotic diuresis).
Excretion of ketone anions also contributes
to osmotic diuresis , and causes additional
losses of urinary cations (sodium,
potassium and ammonium salts).

16. Insulin deficiency per se might also contribute to
renal losses of water and electrolytes, because
insulin stimulates salt and water reabsorption by the
nephron and phosphate reabsorption in the proximal
tubule.
Acidosis can cause nausea and vomiting and this
leads to further fluid loss. There is increased
insensible fluid loss through Kussmaul respiration.
Severe dehydration reduces renal blood flow and
decreases glomerular filtration , and may progress to
hypovolemic shock.

17. Electrolyte imbalance
Potassium is the electrolyte that is most affected in DKA.
Acidosis causes hydrogen ions to move from the extracellular
fluid into the intracellular space.
Hydrogen movement into the cell promotes movement of
potassium out of the cell into the extracellular compartment
(including the intravascular space). Severe intracellular
potassium depletion follows.
As the liver is stimulated by the counterregulatory hormones to
break down protein, nitrogen accumulates, causing a rise in
blood urea nitrogen. Proteolysis leads to further loss of
intracellular potassium and increases intravascular potassium .
The body excretes this mobilized potassium in urine by osmotic
diuresis, and loses additional potassium through vomiting.

19. Clinical presentation
 Feeling unwell for a short period, often less than 24
hours
 Polydipsia and increased thirst, Polyuria/ nocturia,
Polyphagia
 Weight loss
 Nausea and vomiting, vomitus can have coffee-
ground colour due to haemorrhagic gastritis
 Abdominal pain, due to dehydration and acidosis
 Weakness
 Neurologic signs: restlessness, agitation, lethargy
and drowsiness, coma. Increased osmolality is the
main factor that contributes to altered mental status

20.  Visual disturbances due to hyperglycaemia
 Deep and rapid breathing, known as Kussmaul
breathing, may have acetone odour on breath.
 Signs of dehydration due to fluid loss through
polyuria, vomiting and breathing: reduced skin
turgor, dry mucous membranes.
 Signs of hypovolemia: tachycardia, hypotension,
postural hypotension due to fluid loss over 3 litres.
 Mild hypothermia due to acidosis-induced peripheral
vasodilation.
 Fevers are rare despite infection. Severe
hypothermia is a poor prognostic sign.
 The nurse should have a high suspicion of DKA
when a patient presents with unresponsiveness and
hyperventilation. It could be first known onset of
diabetes mellitus.

21. Laboratory findings
 Initial diagnosis of DKA: serum
glucose level, acidaemia, and
presence of ketones in urine.
 Blood sugar level (BSL)
 Arterial blood gas (ABG
 Urinalysis dipstick: testing for positive
urine ketones (ketonuria) and glucose
(glucosuria)

22.  Urea and creatinine
 Serum electrolytes
 Serum osmolality
 Complete blood count (CBC)
 Serum amylase, serum lipase and liver
enzymes to detect pancreatitis.
 Blood, urine and sputum cultures to detect
source of infection.
 Cardiac enzymes to detect myocardial
infarction
 Haemoglobin A1C, an indicator for quality of
diabetes control, or new-onset diabetes.

23. Other Investigations
 12-lead ECG to detect ischaemia and
changes due to hyperkalaemia or
hypokalaemia
 Chest x-ray to detect pneumonia
 CT scan to detect neurological
changes (if stroke is suspected)

24. Management of DKA
 OXYGENATION/VENTILATION-Airway and
breathing remain the first priority. If the
patient presents with reduced
consciousness/coma (GCS<8) consider
intubation and ventilation.
 In obtund patients airway can be temporarily
maintained by insertion of Guedel’s airway.
 Airway, breathing and level of
consciousness have to be monitored
throughout the treatment of DKA.

25. FLUID REPLACEMENT- DKA patients
are severely dehydrated and can be in
hypovolemic shock.
 Fluid replacement should be initiated
immediately. Fluid resuscitation
reduces hyperglycaemia, hyper -
osmolality, and counter regulatory
hormones, particularly in the first few
hours, thus reducing the resistance to
insulin. Insulin therapy is therefore most
effective when it is preceded by initial
fluid and electrolyte replacement.

26.  Electrolyte replacement - Dehydration and osmotic
diuresis cause enormous electrolyte shifts in cells and
serum.
 Potassium is the major intracellular positive ion,
responsible for maintenance of the electro-potential
gradient of the cell membrane .
 Hyperkalaemia may result from reduced renal function,
but the patient is more likely to have total body
potassium depletion . Intracellular potassium depletion
results from a lack of insulin, intracellular dehydration,
acidosis and hydrogen ion shift.
 Vomiting can further cause potassium depletion.
 During DKA management insulin therapy, correction of
acidosis and fluid resuscitation will decrease serum
potassium levels..

27. Sodium: Early “hyponatraemia” in
DKA does not usually require specific
treatment, it is an artefact arising from
dilution by the hyperglycaemia-
induced water shifts. As excess water
moves out of the extracellular space
with the correction of hyperglycaemia,
the sodium level will return to normal.

28. Phosphate: Total body phosphate can
be low due to loss from osmotic
diuresis. Phosphate will move into cells
with glucose and potassium once
insulin therapy has started, and
phosphate replacement is likely to be
required if the serum levels are in the
low end of the normal range, or just low.

29. Insulin therapy
 Insulin is initially given as an intravenous
bolus of 0.1units/kg or a bolus of 5 or 10
units.
 Then a continuous insulin infusion of 50 units
of Actrapid in 50ml N/Saline is commenced.
 The infusion rate is 5 units/hour.
 The blood glucose level must be checked
hourly until urinary and ketones are gone,
and than can be checked less frequently (2
hourly and then later 4 hourly).

30. Monitoring and nursing care
 Vital signs: blood pressure, pulse, respirations,
pulse oximetry, level of consciousness,
temperature.
 Hourly BSL until ketones have disappeared, then 2
hourly. If BSL falls rapidly, 1/2 hourly checks may
be necessary.
 Hourly ABG to monitor pH, bicarbonate and
potassium until pH is above 7.10 then 2 hourly until
pH is above 7.30 or bicarbonate above.
 Insertion of an arterial line advised due to frequent
blood sampling.

31.  Insertion of a PICC line is useful for the number of
infusions
 Patient nil by mouth until acidosis is reversed.
Acidosis can cause nausea and vomiting. Food
intake could aggravate nausea and vomiting,
increase BSL and make it difficult to titrate dextrose
infusion to BSL.
 Assess fluid status: jugular venous pressure,
peripheral perfusion, capillary refill, mucous
membranes, pulse rate, urine output.
 Monitor other electrolytes, urea, creatinine 4 hourly.
Monitoring and nursing care

32.  Consider insertion of urinary catheter.
 Strict fluid balance.
 Urinalysis. Check urine for ketones 2-4 hourly if
catheterised or every portion voided. Be aware that
it takes longer for ketones to disappear than for
hyperglycaemia and acidosis to resolve. Check for
glucose.
 Insertion of a nasogastric tube if patient is vomiting.
 Provide oral hydration with ice chips and frequent
oral hygiene.
 Provide comfort measures and manage pain.
 Give reassurance to relieve anxiety.
Monitoring and nursing care

33. Education and prevention
 Good self- monitoring system at home:
blood glucose testing, urine ketones.
 “Sick-day” management
 Managing medications
 Management of alcohol consumption

34. Prognosis:
The presence of deep coma at the
time of diagnosis, hypothermia, and
oliguria are signs of poor prognosis

35. t
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