27-03: Diabetic Ketoacidosis

GENERAL CONSIDERATIONS

Diabetic ketoacidosis (DKA) is a disorder primarily in patients with type 1 diabetes but can occur in patients with type 2 diabetes who have severe illness. DKA may be the initial manifestation of type 1 diabetes or may result from increased insulin requirements in type 1 diabetes patients during the course of infection, trauma, myocardial infarction, or surgery. It is a life-threatening medical emergency with a mortality rate just under 5% in individuals under 40 years of age, but with a more serious prognosis in older adults, who have mortality rates over 20%. The National Data Group reports an annual incidence of five to eight episodes of DKA per 1000 diabetic persons. Ketoacidosis may develop in patients with type 2 diabetes when severe stress such as sepsis or trauma is present. DKA is one of the more common serious complications of insulin pump therapy, occurring in approximately 1 per 80 patient-months of treatment. Many patients who monitor capillary blood glucose regularly ignore urine ketone measurements, which signals the possibility of insulin leakage or pump failure before serious illness develops. Poor compliance, either for psychological reasons or because of inadequate education, is one of the most common causes of recurrent DKA.

CLINICAL FINDINGS

A. Symptoms and Signs

The appearance of DKA is usually preceded by a day or more of polyuria and polydipsia associated with marked fatigue, nausea, and vomiting. If untreated, mental stupor ensues that can progress to coma. Drowsiness is fairly common, but frank coma only occurs in about 10% of patients. On physical examination, evidence of dehydration in a stuporous patient with rapid deep breathing and a “fruity” breath odor of acetone strongly suggests the diagnosis. Hypotension with tachycardia indicates profound fluid and electrolyte depletion, and mild hypothermia is usually present. Abdominal pain and even tenderness may be present in the absence of abdominal disease. Conversely, cholecystitis or pancreatitis may occur with minimal symptoms and signs.

B. Laboratory Findings

Typically, the patient with moderately severe DKA has a plasma glucose of 350–900 mg/dL (19.4–50 mmol/L), serum ketones at a dilution of 1:8 or greater or beta-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]), and elevated blood urea nitrogen and serum creatinine levels (Table 27–10). Acidosis may be severe (pH ranging from 6.9 to 7.2 and serum bicarbonate ranging from 5 mEq/L to 15 mEq/L); PCO₂ is low (15–20 mm Hg) related to compensatory hyperventilation. Fluid depletion is marked, typically about 100 mL/kg. In euglycemic ketoacidosis, the patient can have severe acidosis and fluid ...