March 22, 2015

Diabetic Ketoacidosis – Part 2

Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but it does happen in some patients with type 2 diabetes. I think people with type 1 diabetes should learn the symptoms because in five type 1 patients I know, only three of them could name most of them while the other two just shook his/her head.

The most common early symptoms of DKA are the insidious increase in polydipsia (excessive thirst) and polyuria (passing of an excessive quantity of urine). Now I will list the other signs and symptoms of DKA:
  • Malaise, generalized weakness, and fatigability
  • Nausea and vomiting; may be associated with diffuse abdominal pain, decreased appetite, and anorexia
  • Rapid weight loss in patients newly diagnosed with type 1 diabetes
  • History of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons or history of mechanical failure of insulin infusion pump
  • Decreased perspiration
  • Altered consciousness (e.g., mild disorientation, confusion); frank coma is uncommon but may occur when the condition is neglected or with severe dehydration/acidosis
Signs and symptoms of DKA associated with possible intercurrent (occurring while another disease or illness is in progress) infection is as follows:
  • Fever
  • Coughing
  • Chills
  • Chest pain
  • Dyspnea
  • Arthralgia
Patients may present with a history of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons. Decreased perspiration is another possible symptom of DKA. Altered consciousness in the form of mild disorientation or confusion can occur. Although frank coma (clinically evident) is uncommon, it may occur when the condition is neglected or if dehydration or acidosis is severe.

On examination, general findings of DKA may include the following:
  • Ill appearance
  • Dry skin
  • Labored respiration
  • Dry mucous membranes
  • Decreased skin turgor (the state of being swollen or distended)
  • Decreased reflexes
  • Characteristic acetone (ketotic) breath odor
  • Tachycardia
  • Hypotension
  • Tachypnea
  • Hypothermia
In addition, patients displaying ketoacidosis should be evaluated for signs of possible intercurrent illnesses such as MI, UTI, pneumonia, and perinephric abscess. Search for signs of infection should be mandatory in all cases. Perinephric abscess is the capsule of connective tissue that envelops the kidney.

Initial and repeat laboratory studies for patients with DKA include the following:
  • Serum glucose levels
  • Serum electrolyte levels (e.g., potassium, sodium, chloride, magnesium, calcium, phosphorus)
  • Bicarbonate levels
  • Amylase and lipase levels
  • Urine dipstick
  • Ketone levels
  • Serum or capillary beta-hydroxybutyrate levels
  • ABG measurements
  • CBC count
  • BUN and creatinine levels
  • Urine and blood cultures if intercurrent infection is suspected
  • ECG (or telemetry in patients with comorbidities)
Note that high serum glucose levels may lead to dilutional hyponatremia; high triglyceride levels may lead to factitious low glucose levels; and high levels of ketone bodies may lead to factitious elevation of creatinine levels.

To be concluded in the next blog.

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