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Case Study – Diabetic Ketoacidosis

David is a 23 year old male who has type 1 diabetes mellitus (T1DM)
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The
doctor has prescribed 2 litres of fluid (0
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DKA is a potentially fatal metabolic condition associated with the accumulation of
ketone bodies and hyperglycaemic crisis (Gosmanov et al, 2014) characterised by
hyperglycaemia, and ketosis leading to a state of metabolic acidosis and osmotic
diuresis (Braun and Anderson, 2011)
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An individual with DKA has a
characteristic ‘pear drop’ smell to the breath produced by excess ketones in blood
(Porth
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Aetiology and risk factors
DKA is commonly caused by infections, in critically ill patient it can be caused by
myocardial infarctions, pancreatitis and surgery (Creed and Spiers, 2010)
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Pathogenesis
DKA is caused when the insulin level is inadequate, usually >33
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Porth (2015) states ketoacidosis can occur due to
omission or inadequate use of insulin
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When insulin is absent or deficient in T1DM blood glucose remains high following
meals at times of illness or stress (Wallymahamed, 2007)
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The increasing hormone levels cause glycogenolysis which involves the liver
converting stored glycogen back to glucose when blood glucose levels fall below
normal (Porth, 2015), generating hyperglycaemia, lipolysis and gluconeogenesis
(Marieb and Hoehn, 2010)
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During which fatty acids develop rapidly and are converted
into ketones (Cutler and Cutler, 2010)
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Hyperglycaemia causes fluid and electrolytes to shift from the intracellular to the
extracellular space; resulting in cellular dehydration and electrolyte imbalance
(Noble-Bell and Cox, 2014)
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Fluid depletion and
electrolyte imbalances commonly result from vomiting due to DKA (Joint British
Diabetes Soceities, (JBDS) 2013)
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Another common symptoms is a sweet, fruity breath caused by acetone being
released due to the build-up of ketones
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Hyperglycaemia can cause polyuria due to water reabsorption in the kidneys
becoming inhibited due to the kidneys filtering out larger volumes of urine in order to
remove the excess glucose (Dougherty and Lister, 2011)
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9%
sodium chloride for fluid resuscitation, however, if the patient has renal failure it may
be more appropriate to use 0
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Patient with DKA are usually
dehydrated therefore, fluid replacement is an important intervention (Noble-Bell and
Cox, 2014)
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Both intravascular and extravascular fluid resuscitation decreases hyperglycaemia
by stimulating osmotic diuresis enhancing the peripheral action of insulin (Gosmanov
et al, 2014)
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New interventions / treatment
Insulin treatment is crucial as it increases glucose utilisation in peripheral tissues,
decreasing glucose production by the liver
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There is no generic diet for diabetics, however, an individualised dietary plan based
on metabolic parameters can be advised by a dietician (Porth, 2015)
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Conclusion
DKA is a serious and life threatening condition, awareness and prompt recognition
will promote better outcomes for the patients
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Prompt fluid resuscitation using 0
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45% saline in a patient with renal
failure and intravenous insulin is crucial
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and Caico, C
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Pathophysiology of nursing demystified
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and Anderson, C
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Pathophysiology: A clinical approach
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Philadelphia: Lippincott Williams and Wilkins
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and Spiers, C
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Care of the acutely ill adult: An essential guide for
nurses
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and Lister, S
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The Royal Marsden Hospital Manual of Clinical
Nursing Procedures
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Chichester: Wiley-Blackwell
Gosmanov, A
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and Dillard-Cannon, E
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‘Management of adult
diabetic ketoacidosis’
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7 (2)
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255-265
Joint British Diabetes Societies
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The Management of Diabetic Ketoacidosis in
Adults
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Joint British Diabetes Societies
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The Management of Diabetic Ketoacidosis in
Adults
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Noble-Bell, G
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(2014)
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Nursing Times
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PP
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and Dutton, H
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Acute Nursing Care: Recognising and Responding
to Medical Emergencies
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Porth, C
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Essentials of pathophysiology
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Philadelphia: Wolters
Kluwer
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R
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‘Diagnosis and management of diabetic ketoacidosis in adults’
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35 (3)
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21-26



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