Diabetic Ketoacidosis (DKA) Case Study (45 min)

Diabetic Ketoacidosis – he is a Type I Diabetic with heavy breathing (Kussmaul Respirations) and fruity breath. These are classic signs. It’s important to recognize them and immediately begin anticipating the patient’s needs.

• Complete metabolic panel to check serum glucose, anion gap, potassium, etc.
• Arterial Blood Gas to assess for acidosis
• Urinalysis to look for ketones

• His glucose is extremely high and he is positive for ketones, which says that his body is having to break down fatty acids to make energy
• His anion gap is high, meaning there are other “ions” in the system besides the electrolytes – in this case, the extra acids are creating this ‘gap’
• He is in metabolic acidosis because of the ketoacids – this is what’s causing the Kussmaul respirations – his body is trying to breathe off CO2 to bring his pH up
• His potassium is high because the body will kick potassium out of the cells to compensate for an acidotic state. This way instead of having H+ (acids) in the blood stream, we have K+ – this protects many tissues, but puts our heart at risk
• His BUN/Cr are elevated because of the dehydration caused by osmotic diuresis (caused by hyperglycemia and hyperosmolarity)

• The #1 priority for DKA is to get the blood sugar down and get insulin into the system. Getting insulin into the system allows the gluconeogenesis to STOP (so that the body will STOP making ketoacids and start using the glucose it has).
• The #2 priority is fluid replacement due to severe dehydration from osmotic diuresis

Remind the provider that the only insulin that can be given IV is Regular Insulin and request that he change the order. Call the Pharmacist if you have to

• **Note – most facilities have a computerized ordering that prevents something like this from happening, but it’s important that you know this!!

• Frequent BMP’s are important to confirm the blood glucose when the POC meter is just reading MAX.  
• It’s also important to monitor the Anion Gap to see when it “closes” – indicating resolution of the acidosis
• We are also monitoring potassium levels. They will start elevated, but insulin drives potassium into the cells – causing it to decrease rapidly.

• The goal is to stop gluconeogenesis and reverse the acidosis. The glucose may fall rapidly while there are still ketoacids being made.
• By giving D5 ½ NS infusion with the insulin, we can continue to bring down the acidosis process while maintaining safe blood sugars.

• When you are ill, you should check your blood sugar more often as sometimes the body’s healing processes and stress response can make your sugar go higher than normal
• Notify your provider if you’re ill, they may recommend increasing your long-acting insulin
• Notify your provider or go to the ED at the FIRST indication of DKA – fruity breath, heavy breathing, feeling dry and hot, excessive urination, blurry vision, or a blood glucose over 400 mg/dL or over your meter MAX.  
• If you have an insulin pump, make sure it is working appropriately – if not, notify your provider or turn the pump OFF and switch to SubQ insulin until the pump can be fixed
• **Note – if a patient comes in with an insulin pump, it should always be turned OFF – we will manage their sugars with SubQ insulin and don’t want them to receive a double dose.