DKA-Diabetic ketoacidosis bloodwork

Essentials lab finding:

• Hyperglycemia greater than 250 mg/dL (13.9 mmol/L).
• Metabolic acidosis with blood pH < 3;
• serum bicarbonate less than 15 mEq/L.
• Serum positive for ketones.

Can be caused by:

• More common among type 1 diabetes patients during the course of infection, trauma, myocardial infarction, or surgery due to increased insulinrequirements
• Under severe stress type 2 diabetes patient can also develop DKA

Symptoms and Signs

• polyuria and polydipsia
• marked fatigue, nausea, and vomiting
• Abdominal Pain &tenderness may occur
• Drowsiness
• Dehydration

Physical examination

• rapid deep breathing
• “fruity” breath odor of acetone
• Hypotension with tachycardia indicates profound fluid and electrolyte depletion
• mild hypothermia

 

Laboratory Findings

In a glance: Urine and plasma glucose elevated, plasma and urine ketones, low bicarbonate

• plasma glucose of 350–900 mg/dL
• serum ketones at a dilution of 1:8 or greater
• β-hydroxybutyrate more than 4 nmol/L
• Hyperkalemia (serum potassium level of 5–8 mEq/L)
• slight hyponatremia (serum sodium of approximately 130 mEq/L)
• Hyperphosphatemia (serum phosphate level of 6–7 mg/dL [1.9–2.3 mmol/L])
• Elevated blood urea nitrogen (BUN) and serum creatinine levels
• Acidosis may be severe (pH ranging from 6.9 to 7.2 and serum bicarbonate ranging from 5 mEq/L to 15 mEq/L);
• PCO₂is low (15–20 mm Hg) due to hyperventilation.
• Fluid depletion is marked, typically about 100 mL/kg.
• Serum osmolality elevated [normal range in 280-300]
• Elevated Anion Gap

Goals of Treatments

• mild ketoacidosis can be treated in the emergency department
• moderate or severe ketoacidosis require admission to the ICU or step-down unit.
• Therapeutic goals are to restore plasma volume and tissue perfusion, reduce blood glucose and osmolality toward normal, correct acidosis, replenish electrolyte losses, and identify and treat precipitating factors.

Treatments

• Fluid Replacement: 9% normal saline preferred; usually patients require 4-5l; when glucose falls to 250 mg/dL change to 5% glucose solution
• Insulin Replacement: start with regular insulin 0.1 U/kg bolus and 0.1 U/kg/hr; goal to lower the glucose concentration by about 50–70 mg/dL/h
• Potassium: level usually elevated (intracellular extracellular); give potassium 10-30 mEq/hr in 2nd & 3rd hour of treatment
• Sodium Bicarbonate: use has been questioned; not usually required