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DKA: its sweet AND sour - VA NR 7/22/19 - Kirkpatrick

Updated: Aug 6, 2019

Dr. Kirkpatrick presented a case of a 64 yo M w/ generalized malaise, nausea, and vomiting.

He has lost 60 lbs over the last 6 months. No PMH as he hasn't seen a doctor in >40 years.

His initial labs showed a well-compensated pure AGMA (128- (89+10)) and a glucose of 490, as well as ketonuria and an A1C of 16.5%. He was Dx'd and treated for DKA.


What is it?

Lack of sufficient insulin to internalize glucose for utilization. Insufficient insulin to ward of lipolysis and beta hydroxylation -> ketone body formation in order to supply vital organs with energy.


Causes: med non-compliance, infection, MI, pancreatitis, surgery/trauma, etc.


Sxs:

Nausea/vomiting

Anorexia

Polyuria, polydipsia

Abdominal pain

± AMS

Kussmaul respirations

Acetone odor on pt’s breath


Lab Findings: (diagnostic criteria 1-3)


1. Blood glucose level > 250 mg/dL (usucally)

2. Metabolic acidosis*

a.Bicarb < 15 mEq/L

b. pH < 7.3

3. Ketosis (in urine: Ketonuria, or in blood: ketonemia)

4. Hyperkalemia (body has absolute hypOkalemia however)

5. Hyponatremia (usually PSEUDOhyponatremia because elevated glucose falsely lowers sodium)


*Anion gap present due to ketone presence. Concurrent NAGMA, Metabolic alkylosis can also be present. Respiratory compensation is hyperventilation.


Compared w/ HHS:



Pathogenesis of DKA:



DKA Treatment Plan Overview


1.Volume repletion

2.Reversal of metabolic consequences of insulin insufficiency

3.Correction of electrolyte & acid-base imbalances

4.Recognition and treatment of precipitating cause

5.Avoidance of complications...


Rare DKA Complications


1. ARDS


2. Cerebral Edema

a. during therapy, in young people

b. Presentation:

- Severe headache

- Incontinence

- Change in arousal/behavior

- Pupillary changes

- Seizures

- Bradycardia

c. Rx: IV Mannitol 1-2 g/kg


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