James talks to Dr Barbara Depczynski about diagnosing diabetic ketoacidosis (DKA).
Summary Writer: Nicholas Malouf
Editor: James Edwards
Interviewee: Barbara Depczynski
Barbara Depczynski is a senior staff specialist in endocrinology at Prince of Wales Hospital. Barbara’s major interests are type 2 diabetes, inpatient diabetes management, pituitary disease and PCOS. Barbara Depczynski serves on ACI In Hospital Diabetes Management Working Group. She is involved with both under graduate and post graduate teaching.
With Dr Barbara Depczynski, Senior Staff Specialist in Department of Endocrinology at Prince of Wales Hospital, New South Wales, Australia
Diabetic Ketoacidosis (DKA) is the triad of ketosis, metabolic acidosis and hyperglycaemia. DKA occurs secondary to an absolute lack of insulin action (and low insulin-to-glucagon ratio). This allows unrestrained gluconeogenesis and ketogenesis. The resultant hyperglycaemia induces an osmotic diuresis (leading to dehydration and electrolyte losses) and the production of ketone bodies creates a high anion gap metabolic acidosis.
The diagnosis of DKA is biochemical. By definition pH must be <7.3 and ketones must be present. Of course, in most cases BSL is elevated (>20) however there is a euglycaemic form of DKA. There is a textbook clinical picture of dehydration, Kussmaul (deep, laboured) breathing, and abdominal pain.
DKA is distinguished from Hyperosmolar Hyperglycaemic State (HHS), formerly Hyperosmolar Non-ketotic coma, is where there is relative (not absolute) lack of insulin action. In HHS, osmotic diuresis does occur, however, there is enough insulin activity to suppress lipolysis and ketogenesis. Dehydration often develops over a longer period of time in HHS.
52-year-old male comes to the ward from ED with renal colic secondary to a calculus. His past medical history indicates type 2 diabetes requiring basal Lantus and tds bolus Novorapid. He has been made NBM in preparation for surgery and all insulin has been withheld. On the morning of surgery his BSL is 21.
The patient has hyperglyacemia, ketonuria, ketonaemia and a metabolic acidosis.
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