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Diabetic Ketoacidosis (DKA) - Key Points

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1. Definition & Triad

• Hyperglycaemia - glucose ≥11.1 mmol/L (≥200 mg/dL), OR prior diabetes history
• Ketonaemia - beta-hydroxybutyrate (BOHB) ≥3 mmol/L, OR urine ketones 2+
• Metabolic acidosis - pH <7.3 and/or bicarbonate <18 mmol/L

Note: ~10% present with "euglycaemic DKA" (glucose <200 mg/dL), especially with SGLT2 inhibitor use, pregnancy, or starvation.

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2. Causes & Triggers

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3. Symptoms & Signs

• Hyperglycaemia symptoms: polyuria, polydipsia, polyphagia, weight loss, weakness
• Volume depletion signs: dry mucous membranes, poor skin turgor, tachycardia, hypotension, sunken eyes
• Acidosis signs: Kussmaul breathing (deep, rapid), acetone breath
• GI symptoms: nausea, vomiting, abdominal pain (>50% of patients)
• Neurological: altered mental status - alert in mild DKA, stupor/coma in severe DKA

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4. Severity Classification

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5. Key Investigations

• Plasma glucose - typically elevated
• Arterial/venous blood gas - metabolic acidosis (pH <7.3)
• Capillary/serum BOHB - ≥3 mmol/L is >90% sensitive and specific
• Electrolytes: serum K+ often normal/high despite total body deficit; Na+ usually low; Mg and Cl low
• Anion gap - typically >12 mmol/L (not recommended as sole resolution criterion)
• ECG - rule out MI, detect hypo/hyperkalaemia
• Urine/blood cultures - if infection suspected
• Potassium monitoring is critical before and during insulin therapy

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6. Treatment - The Pillars

A. Fluids (start immediately)

• Initial: 0.9% saline or balanced crystalloid at 500-1000 mL/hour for first 2-4 hours
• Severe dehydration (SBP <90 mmHg): 1 L/hour until resolved
• Correct deficit gradually over 24-48 hours to prevent cerebral oedema
• Add 5-10% glucose when blood glucose falls below 13.9 mmol/L (250 mg/dL)

B. Insulin

• Check potassium FIRST - do not start insulin if K+ <3.5 mmol/L
• Start IV infusion: 0.1 units/kg/hour of short-acting neutral insulin
• Once glucose <13.9 mmol/L: reduce to 0.05 units/kg/hour
• Target glucose: 8.3-11 mmol/L (150-200 mg/dL)
• Subcutaneous rapid-acting insulin (aspart/lispro) is an acceptable alternative for mild-moderate uncomplicated DKA

C. Potassium

• Most critical electrolyte in DKA management
• Replace when K+ <5 mmol/L: add 10-20 mmol per litre of IV fluid
• If K+ <3.5 mmol/L: replace at 10 mmol/hour and hold insulin until K+ >3.5
• Severe hypokalaemia (≤2.5 mmol/L) = threefold increase in mortality

D. Bicarbonate (controversial)

• Routine use is NOT recommended
• Only consider if arterial pH <7.0 (severe acidosis)
• If given: 100 mmol NaHCO3 in 400 mL sterile water every 2 hours until pH >7.0
• Always add potassium when giving bicarbonate

E. Phosphate

• Routine replacement is NOT recommended (no proven benefit)
• Only replace if phosphate <1 mmol/L with muscle weakness or respiratory/cardiac compromise

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7. Resolution Criteria

• Plasma/capillary ketones <0.6 mmol/L, AND
• Venous pH ≥7.3 OR bicarbonate ≥18 mmol/L
• Ideally glucose <11.1 mmol/L

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8. Complications of Treatment

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9. Monitoring During Treatment

• Blood glucose: every 1-2 hours
• Electrolytes, renal function, venous pH, BOHB: every 2-4 hours until stable
• Serum K+: check 2 hours after starting insulin, then every 4 hours

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10. Prevention

• Sick-day rules: never stop insulin, increase monitoring, seek help early
• CGM use reduces DKA hospitalisations by 47-53%
• Stop SGLT2 inhibitors 3-4 days before surgery or during acute illness
• Follow-up within 2-4 weeks post-discharge reduces readmissions (up to 22% readmit within 30 days)

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Quick Summary Table

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Describing Abdominal Pain

1. SOCRATES Framework (Standard Clinical Tool)

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2. Character (Quality of Pain)

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3. Location & What It Suggests

         RIGHT UPPER         |        LEFT UPPER
   Liver, gallbladder,       |    Stomach, spleen,
   biliary, hepatitis        |    pancreatitis, cardiac
   __________________________|__________________________
         RIGHT LOWER         |        LEFT LOWER
   Appendix, ovary (R),      |    Sigmoid colon, ovary (L),
   inguinal hernia, Crohn's  |    diverticulitis, constipation
   __________________________|__________________________
                   CENTRAL/UMBILICAL
              Small bowel, early appendicitis,
              aortic aneurysm, mesenteric ischemia
   __________________________|__________________________
                    SUPRAPUBIC
              Bladder, uterus, prostate

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4. Visceral vs. Somatic vs. Referred Pain

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5. Key Associated Features to Note

• Fever - suggests infection/inflammation (appendicitis, cholecystitis, PID)
• Vomiting - comes before pain in gastroenteritis; after pain in obstruction
• Jaundice - hepatobiliary cause
• Blood in stool - GI bleed, IBD, ischaemia
• Urinary symptoms - UTI, renal colic, pyelonephritis
• Menstrual history - ectopic pregnancy, endometriosis, ovarian cyst
• Last bowel movement - constipation, obstruction
• Anorexia/weight loss - malignancy

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6. Specific to DKA (from your document)

• Occurs in >50% of patients
• Is usually diffuse and generalised
• Correlates with the degree of acidosis - the more acidotic, the worse the pain
• Can mimic an acute surgical abdomen (guarding, tenderness)
• Resolves with treatment of DKA - if it doesn't, consider a true surgical cause
• Is thought to result from gastric paresis and electrolyte disturbances caused by the metabolic derangement

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7. Red Flag Features (Urgent/Emergency)

• Sudden, severe ("worst pain ever")
• Rigidity / board-like abdomen (peritonitis)
• Absent bowel sounds (obstruction/ileus)
• Haemodynamic instability (shock)
• Pain out of proportion to examination findings (mesenteric ischaemia)
• Pulsatile abdominal mass (aortic aneurysm)