Diabetic Ketoacidosis (DKA)

PATIENT PRESENTATION:
L.W., a 14 y.o. previously healthy female was brought to the ED by her family.  L.W. has a 2 day history of increased fatigue, thirst, frequent urination, change in breath odor, and “not feeling right”.  As reported by her parents, L.W. awoke this morning with nausea, vomiting and disorientation.  Upon admission to the ED, L.W.’s glucose was checked and was 612 and 609 respectively.  Two PIV's were placed and L.W. was started on IV Fluids.  

DIAGNOSIS:
L.W. was diagnosed with DKA secondary to Type 1 diabetes after multiple tests were run.  Glucose from finger stick was over 600.  A urinalysis was run with a result of positive ketones.  Labs and an arterial blood gas showed a metabolic acidosis with abnormal electrolytes (specifically potassium, phosphorus, sodium, and sodium bicarbonate).

TREATMENT:
The main goals of treatment for DKA are to replace lost fluids and electrolytes while suppressing high blood sugars and ketone production with insulin.  The patient was admitted to the ICU and centrally monitored.  Fluid replacement and insulin administration were the initial treatment for control over glucose levels, accompanied with electrolyte replacement and metabolic acidosis correction.  Lab values were frequently monitored (BMP, Mg, Phos, Venus Blood Gas, glucose) for dehydration, electrolytes, and possible infection.  An insulin gtt was started and was titrated per sliding scale after hourly finger glucose sticks.  Two bags of IVF were spiked and administered per glucose finger stick.  Rehydration based on water and sodium shortages was provided.  Frequent neurologic assessment was monitored for any changes in LOC.  The patient was made NPO.

IVF Bag A included 0.9% NS with KCl and KPhos IV and was administered for higher glucose levels.  Bag B of D10-NS with KCL and KPhos IV were given per MD orders for low glucose levels.  Bag A and B were split for a glucose in the middle range on provided scale.  Once the patient’s glucose levels were in normal range with a resolved metabolic acidosis and normalized labs, the patient was taken off the insulin gtt and was placed on a diabetic diet and started on SQ insulin injections.

OUTCOME/PROGNOSIS:
DKA in adolescents is often the first sign that the individual has type 1 diabetes.  After seeking medical attention, DKA will resolve and with diet control and diabetes education, the individual can have a quality life.  Prevention education is also necessary to educate the individual on how to treat themselves when ill.  These instructions include advice on how much extra insulin to take when sugar levels appear uncontrolled, proper diet when ill, how to suppress a fever and infection, and when to seek medical help.  However, in poorly controlled diabetes or diabetics with an illness, DKA can be a common event which can cause damage to the body and if not medically controlled can lead to death.

FUN FACTS and PATHOPHYSIOLOGY
DKA is a potentially life-threatening complication and it is treated as a medical emergency.  It is seen predominantly in those with type 1 diabetes but rarely can occur in individuals with type 2 diabetes in some circumstances.  There is a shortage or absolute lack of insulin and the body will switch to burning fatty acids which produces acidic ketone bodies that cause metabolic acidosis.  DKA is not always the complication of diabetes.  It can also result from alcohol excess and starvation (both glucose levels may be normal to low)

Three stages of severity:
Lack of insulin and excess of glucagon lead to increased release of glucose by the liver.  Glucose spills over into the urine - taking water with it leading to dehydration.  Fatty acids are used and converted into ketone bodies. Ketone bodies that are acids (ketoacids) produce metabolic acidosis.  The ketoacids are initially buffered with bicarbonate buffering system.  Once buffering can no longer maintain a reasonable pH, the patient will compensate with hyperventilation (Kussmaul respirations) to correct acidosis. 
Case created by Lauren Walker, 2010.