Diabetic Ketoacidosis

Descriptive text is not available for this imageBASICS

DESCRIPTION

  • 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.

EPIDEMIOLOGY

  • Diabetes ketoacidosis (DKA) occurs more commonly in type 1 diabetes (T1D) but can also occur in type 2 diabetes (T2D).
  • 30–40% 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).

ETIOLOGY

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

RISK FACTORS

  • For new-onset diabetes presenting as DKA:
    • Very young children (<5 years)
    • 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
    • Suboptimal glycemic management
    • Low socioeconomic status (SES)

GENERAL PREVENTION

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

PATHOPHYSIOLOGY

  • Excess of counterregulatory “stress” hormone concentrations (glucagon, cortisol, and epinephrine) in relation to insulin concentrations occurs, either because 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 contributing to metabolic acidosis.

COMMONLY ASSOCIATED CONDITIONS

  • Acute illness as a precipitating factor
  • Autoimmune disorders (especially hypothyroidism) for persons with T1D

There's more to see -- the rest of this topic is available only to subscribers.