Updated: 3/8/2019

Diabetic Ketoacidosis (DKA)

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  •  A 12 year old boy, previously healthy, is admitted to the hospital after 2 days of polyuria, polyphagia, nausea, vomiting and abdominal pain. Vital signs are: Temp 37C, BP 103/63 mmHg, HR 112, RR 30. Physical exam shows a lethargic boy. Labs are notable for WBC 16,000, Glucose 534, K 5.9,  pH 7.13, PCO2 is 20 mmHg, PO2 is 90 mmHg.
Introduction
  • Complication of type I diabetes
    • result of ↓ insulin, ↑ glucagon, growth hormone, catecholamine
  • Precipitated by
    • infections
    • MI
    • drugs (steroids, thiazide diuretics)
    • noncompliance
    • pancreatitis
    • undiagnosed DM
Presentation
  • Symptoms
    • abdominal pain
    • vomiting
  • Physical exam
    • Kussmaul respiration
      • increased tidal volume and rate as a result of metabolic acidosis
    • fruity, acetone odor
    • severe hypovolemia
    • coma
Evaluation
  • Serology
    • blood glucose levels > 250 mg/dL
      • due to ↑ gluconeogenesis and glycogenolysis
      • tissues unable to use the high glucose as it is unable to enter cells
    • arterial pH < 7.3 
      • ↑ anion gap due to ketoacidosis, lactic acidosis
    • ↓ HCO3- 
      • consumed in an attempt to buffer the increased acid
    • hyponatremia 
      • dilutional hyponatremia
        • glucose acts as an osmotic agent and draws water from ICF to ECF
    • hyperkalemia 
      • acidosis results in ICF/ECF exchange of H+ for K+
      • depletion of total body potassium due to cellular shift and losses through urine 
    • moderate ketonuria and ketonemia
      • due to ↑ lipolysis
      • β-hydroxybutyrate > acetoacetate
        • β-hydroxybutyrate not detected with normal ketone body tests
    • hypertriglyceridemia
      • due to ↓ in capillary lipoprotein lipase activity
        • activated by insulin
    • leukocytosis
      • due to stress-induced cortisol release
    • H2PO4- is increased in urine, as it is titratable acid used to buffer the excess H+ that is being excreted 
Treatment
  • Fluids
  • Insulin with glucose 
    • must prevent resultant hypokalemia and hypophosphatemia 
    • labs may show pseudo-hyperkalemia prior to administartion of fluid and insulin
      • due to transcellular shift of potassium out of the cells to balance the H+ being transfered into the cells
      • Upon administration of insulin, potassium will shift intracellularly, possibly resulting in dangerous hypokalemia  
Prognosis, Prevention, and Complications
  •  5-10% mortality
  • Life-threatening mucormycosis
    • thrive in ketoacidotic state
  • Rhizopus infection
  • Cerebral edema
  • Cardiac arrhythmias
    • due to electrolyte imbalances
  • Heart failure
    • due to hypovolemia
 

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Questions (8)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.EC.38) A 14-year-old female with no past medical history presents to the emergency department with nausea and abdominal pain. On physical examination, her blood pressure is 78/65, her respiratory rate is 30, her breath has a fruity odor, and capillary refill is > 3 seconds. Serum glucose is 820 mg/dL. After starting IV fluids, what is the next best step in the management of this patient? Review Topic

QID: 100339
1

Intravenous regular insulin

75%

(254/337)

2

Subcutaneous insulin glargine

5%

(17/337)

3

Subcutaneous insulin lispro

13%

(44/337)

4

Intravenous Dextrose in water

3%

(10/337)

5

Intravenous glucagon

2%

(7/337)

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(M1.EC.101) A 20-year-old male is brought by ambulance to the emergency room in extremis. He is minimally conscious, hypotensive, and tachypneic, and his breath gives off a "fruity" odor. An arterial blood gas and metabolic panel show anion gap metabolic acidosis. This patient is most likely deficient in which of the following metabolic actions? Review Topic

QID: 100402
1

Formation of ketone bodies

19%

(5/27)

2

Glucose production

4%

(1/27)

3

Cortisol secretion

0%

(0/27)

4

Cellular uptake of glucose

74%

(20/27)

5

Glucagon production

4%

(1/27)

M1

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PREFERRED RESPONSE 4

(M1.EC.51) An 8-year-old boy is brought to the emergency department with severe dyspnea, fatigue, and vomiting. His mother reports that he has been lethargic for the last several days with an increase in urine output. She thinks he may even be losing weight, despite eating and drinking more than normal for the last couple weeks. Laboratory results are notable for glucose of 440, potassium of 5.8, pH of 7.14 and HCO3 of 17. After administrating IV fluids and insulin, which of the following would you expect? Review Topic

QID: 100567
1

Increase in serum glucose

0%

(0/7)

2

Increase in anion gap

0%

(0/7)

3

Decrease in serum potassium

100%

(7/7)

4

Decrease in pH

0%

(0/7)

5

Decrease in serum bicarbonate

0%

(0/7)

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(M1.EC.31) A 17-year-old male presents to your office complaining of polyuria, polydipsia, and unintentional weight loss of 12 pounds over the past 3 months. On physical examination, the patient is tachypneic with labored breathing. Which of the following electrolyte abnormalities would you most likely observe in this patient? Review Topic

QID: 100332
1

Alkalemia

4%

(1/26)

2

Hyperkalemia

62%

(16/26)

3

Hypoglycemia

19%

(5/26)

4

Hypermagnesemia

8%

(2/26)

5

Hyperphosphatemia

4%

(1/26)

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