University of Toronto - Faculty of Medicine

 

Author
The revision of this chapter was prepared by Carolyn Lawton, RN, MScN, CDE

 

• Diabetic Ketoacidosis (DKA) is an acute-life threatening complication.
• Insulin deficiency is the main underlying abnormality
• Risk factors for DKA include new diagnosis of diabetes, insulin omission, infection, myocardial infarction, abdominal crisis, trauma and possibly treatment with insulin infusion pumps.
• Intercurrent illness can disrupt metabolic balance and result in the release of counterregulatory hormones, epinephrine/norepinephrine, glucagon, cortisol and growth hormone
• Failure to administer adequate supplemental insulin may lead to DKA
• The risk for DKA with concurrent illness is a result of insufficient insulin to regulate ketone production, as seen in Figure 14.1, and can result in life threatening consequences
• Sufficient insulin must be administered to reestablish glucose and lipid homeostasis
• In mild illness without substantial counter-regulatory responses and if caloric intake is reduced by nausea, vomiting, diarrhea etc., insulin requirements may decline if the blood glucose level is falling
• Individuals with type 1 diabetes should learn how to prevent DKA during illness

 

Hyperglycemia and ketonuria during illness results from activation of counterregulatory (stress) hormones leading to relative insulin deficiency resulting in the following metabolic derangement: See Figure 14.1.

 

 

There are no definitive criteria for the diagnosis of DKA, however, we suggest the following:

• Suspect DKA with significant hyperglycemia, especially when ill or symptomatic
• Symptoms include: shortness of breath, rapid breathing, acetone-breath, dehydration, nausea, vomiting, abdominal pain, alteration in mental status and ultimately coma
• Serum glucose > 14, arterial ph < 7.3, serum bicarbonate < 18 mEq/l , anion gap >12, moderate ketonuria or ketonemia.

 

Blood ketone testing is an essential skill for all patients with type 1 diabetes during periods of intercurrent illness. It is the preferred method over urine ketone testing as it quantifies beta-hydroxybutyric acid the predominant ketone body.

Most illness can be managed by following the following principles:

• Check blood glucose and blood ketones at least every 4 hours around the clock.
• Do not omit insulin, insulin requirements will be much larger than normal when ketones are present (see Table 14.1).
• Correct dehydration encourage consumption of as much water and sugar-free beverages as possible
• Any underlying illness must be treated.
• Rapid acting or fast acting insulin should be available for supplementation during illness.
• Pump users should inject insulin using syringe or pen to treat hyperglycemia and check for pump malfunction.
• If the patient is unable to tolerate a regular diet then sugar-containing fluids should be substituted (see Table 14.2 for suggested replacement) .
• The physician/health care team should be consulted during illness.
• Fever generally increases insulin requirement and should be investigated for the presence of a bacterial illness.
• Emergency department assessment is indicated if the person is unable or refuses to take fluid supplements or vomits twice or more in 8 - 12 hour time span, if ketones persist despite taking supplemental insulin.
• See Table 14.1 for insulin dosage adjustment for intercurrent illness

TABLE 14.1 Adult Patient Guidelines for Sick Day Management
Guidelines for insulin dose adjustments when sick with flu or a fever but tolerating fluids or food (adults only): Test BG and blood ketones every 4 hours, all day and night. If blood ketones >3.0 mmol/L at any time, go to the ER immediately; you need IV insulin and fluids. If you are not able to drink fluids without vomiting, go to the ER. You may require IV insulin and fluids. The TDD formula is used to help determine how much extra rapid or fast insulin is needed. 1. Add up the number of units of insulin (all kinds) you usually take each day (use baseline or usual doses). Your TDD =______ units 2. Calculate 10% = ____ , 15% = _____ , and 20% =____ of your TDD 3. Follow the chart to decide how much extra rapid or fast insulin to take every 3 to 4 hours, in addition to your usual baseline insulin doses. If you are not eating as usual, replace the usual carbohydrate with sugar-containing fluids.
BG (mmol/L)	Blood ketone (mmol/L)	Action required * *Note: Person is able to take fluids	Extra insulin dose
<3.9	--	No extra insulin required Decrease dose of premeal insulin as directed Contact care team if vomiting occurs
4.0-16.0	<0.6	Use same insulin dose (and scale) as for non-sick days
4.0-16.0	>0.6	Take a 10% supplement of fast or rapid insulin every 4 h, as needed, all day and night, in addition to normal baseline insulin doses
>16.0	<0.6	Take a 10% supplement of fast or rapid insulin every 4 h, as needed, all day and night, in addition to normal baseline insulin doses
>16.0	>0.6-1.4	Take a 15% supplement of fast or rapid insulin every 4 h, as needed, all day and night, in addition to normal baseline insulin doses
>16.0	>1.5-3.0	Take a 20% supplement of fast or rapid insulin every 4 h, as needed, all day and night, in addition to normal baseline insulin doses Contact your care team as soon as possible

Patients should be encouraged to have on hand sick day supplies, which include:

• Blood glucose meter and glucose and ketone test strips
• Rapid acting or Fast acting insulin
• Thermometer
• Acetaminophen (if no contraindication, for treating fever)
• Sugar-free cough drops and syrup
• Emergency medical contact phone number
• Local 24 hour pharmacy phone number

 

• Many cases of DKA can be prevented by better access to medical care, proper education and effective with health care providers.
• In adults with diabetes consideration should be given to influenza vaccination and immunization against pneumococcus..

TABLE 14.2 Sugar Containing Fluid Diet
The following each contain 15g of carbohydrate:
3/4 cup orange juice 1/3 cup grape juice 3/4 cup regular soft drink/pop 1/4 cup regular Jello 1½ Popsicles (3 sticks) 1/2 cup sugar sweetened Kool-Aid	6 soda crackers 1 slice toast 2 digestive cookies 3/4 cup applesauce 1/3 cup sherbet 1/2 cup vanilla ice cream

References

1. Booth, GL Fang, J. Acute complications of diabetes. In: Hux JE, Booth GL, Slaughter PM, et al, eds. Diabetes in Ontario: An ICES Practice Atlas. Toronto: Institute for Clinical Evaluative Sciences; 2003:2.19-2.50..
2. Kitabchi, AE, Umpierrez, GE, Murphy, EJ, Kreisberg, RA, . Hyperglycemic crises in adult patients with diabetes. A consensus statement from the American Diabetes Association Diabetes Care 2006; 29(12): 2739-2748..
3. American Diabetes Association. Hyperglycemic Crises in Patients with Diabetes Mellitus. Diabetes Care 2003; 26(suppl 1): S109-117.
4. Booth, G. Short-Term Clinical Consequences of Diabetes In Adults. Chpt 7p 68-106, In Gerstein H., Haynes R.B (eds). In Evidence-based Diabetes Care (2001).. Hamilton: BC Decker Inc.
5. Umpierrez, G. E., Murphy, M. B., & Kitabchi, A. E.Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome. Diabetes Spectrum 2002; 15(1): 28-36.
6. Canadian Diabetes Association. Building competency in diabetes education: Advancing practice 2003. Chapter 2: 60-62.
7. Daneman D., Frank M. Managing intercurrent illness in the child with diabetes. Clin Diab 1984;2(1):1-7.
8. American Diabetes Association. Hyperglycemic crises in patients with diabetes mellitus. Diabetes Care 2002 25: S100-S108.
9. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2008;27(suppl 1): S1-S201.
10. Registered Nurses Association of Ontario. Best Practice Guideline for the Subcutaneous Administration of Insulin in Adults with Type 2 Diabetes 2004
11. Chiasson JL, Aris-Jilwan N, Belanger R, et al. Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state. CMAJ. 2003; 168:859-866