Diabetic Ketoacidosis

Basics

Severe metabolic derangement in patients with diabetes mellitus secondary to insulin deficiency and/or stress hormone excess
Clinical features include hyperglycemia, ketosis, metabolic acidosis, dehydration, and electrolyte deficits.

Diabetes ketoacidosis (DKA) occurs more commonly in type 1 diabetes (T1D) but can also occur in type 2 diabetes (T2D).
20–40% of children with new-onset T1D present in DKA
Risk of DKA in established T1D is 1–10% per patient per year (most episodes caused by insulin omission/diabetes mismanagement).
DKA accounts for majority of diabetes-related deaths in childhood (most secondary to cerebral edema/brain injury).

For T1D presenting as DKA:
- Very young children (<5 years)
- Ethnic minority
- Inadequate health insurance
- A missed diagnosis of diabetes in preceding clinic visits is frequent in DKA patients (~35%).
For DKA in established diabetes:
- Adolescence
- Lack of health insurance
- Poor glycemic control
- Ethnic minority
- Low socioeconomic status (SES)

Prompt diagnosis of new-onset diabetes (e.g., urinalysis in patients with poor weight gain, polyuria, influenza-like symptoms, vomiting)
Patient/parental education regarding ketone testing (with any symptoms of illness or unexplained high blood glucose level)
Strict supervision of long-acting (glargine, detemir) insulin injections by parents
Detection and avoidance of insulin pump interruptions by frequent blood glucose testing and strict protocols for changing infusion sets

Excess of counterregulatory “stress” hormone concentrations (glucagon, cortisol, and epinephrine) in relation to insulin concentrations occurs, either as a result of insulin absence (new-onset diabetes or insulin omission) or illness (raising stress hormone levels).
Imbalance between counterregulatory hormones and insulin results in increased glycogenolysis and gluconeogenesis and decreased peripheral glucose uptake (causing hyperglycemia) as well as lipolysis and ketogenesis (causing ketosis).
Hyperglycemia causes osmotic diuresis resulting in dehydration and electrolyte losses.
Ketogenesis results in metabolic acidosis, causing vomiting and tachypnea.
Dehydration causes poor tissue perfusion, raising lactate levels and is contributing to metabolic acidosis.

Insulin deficiency
- New diagnosis of diabetes
- Insulin omission (diabetes mismanagement or insulin pump malfunction)
Acute illness (leading to rise in counterregulatory hormone levels)

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