Coupon Accepted Successfully!


Diabetic Ketoacidosis

Clinical features –

Symptoms – Nausea, vomiting, Abdominal pain Q Altered mental function. Shortness of breath

Signs –

  1. Tachycardia   
  2. Dry mucous membrane     
  3. Dehydration                       
  4. Hypotension        
  5. Kussmaul respiration Q                     
  6. Tachypnea     
  7. Abdominal tenderness       
  8. Fever. May be there    
  9. Fruity odour of the breath 

Medical diseases having severe pain abdomen (Acute abdomen)

  1. Acute intermittent Porphyria           
  2. Addisonian crises                 
  3. Sickle cell anemia
  4. Renal papillary necroses                 
  5. Basal pneumonia                 
  6. Inferior wall MI      
  7. DKA    
  8. Abdominal migraine         
  9. Abdominal epilepsy                  
  10. Tabetic crises 


FIGURE - Pathogenesis of diabetic ketoacidosis.



  1. Hyperglycemia – Blood sugar 400 – 600 mg%
  2. TLC – Leucocytosis. It is a feature of DKA. It does not indicate infection. Presence of fever indicate infection
  3. K+ - increase (shifting of K+ from intracellular to extracellular compartment due to decrease Insulin)
  4. Blood urea – increase (due to intravascular fluid depletion)
  5. S. Osmolality 300 – 320mosm/Kg 

MCQ: Blood pH is the single best test to know the prognosis of a case of DKA.

  1. Plasma ketones – Positive
  2. Metabolic acidosis - Low HCO-3 with increase anion gap.
  3. Hypertriglyceridemia – Hyperlipoproteinemia
  4. Hyperamylasemia        
  5. Pseudohyponatremia
    1. There is a reduction of (1.6 meq) of serum sodium for each 100 mg/dL rise in the serum glucose).

So when we treat a case of DKA, as the blood glucose level falls then measured serum sodium rises. (LQ 2012) (Ref. Hari.18th ed., Pg - 2978


Extra Edge:

Causes of pseudohyponatremia:

  1. Severe hyperglycemia (DKA, NKHOC)               
  2. Hyperlipidemia     
  3. Hyperproteinemia (Multiple myeloma) 


Complications of DKA–

  1. Cerebral edema (most dangerous complication, seen mostly in children)
  2. Venous thrombosis           
  3. ARDS           
  4. MI               
  5. Acute gastric dilatation 
Treatment –
  1. Fluids → 0.9% saline.
  2. Insulin →  Regular Insulin is given I/V in DKA. It is not given subcutaneous.
  3. Treat precipitating events →  Noncompliance, infection by antibiotics.
  4. K+ replacement →  Initially when patient comes, he is hyperkalemic, later on when patient is treated with insulin, serum potassium level goes down and may required potassium replacement. 
  5. Injection HCO3 I/V if Ph <7
Extra edge:

Serum osmolality is calculated as follows: (Ref. Hari.18th ed., pg-2977)


[2 x (serum Na + serum K) + plasma glucose (mg%)/18 + BUN (mg%) / 2.8)]


[2 X (135 + 5) + (90 / 18 + 14 / 2.8)]


=  (2 X 140) + (5 + 5)


= 290


Normal serum osmolality is 280 to 300 mosm/lit.

Non ketotic hyperosmolar coma (NKHOC)

Symptoms –Classically patient is

  1. Elderly
  2. H/O polyuria of several weeks with weight loss and decrease oral intake.
  3. Mentally confused
Signs –
  1. Tachycardia             
  2. Hypotension        
  3. Dehydration        
  4. Altered sensorium, coma

Important Points:


Nausea, Vomiting, Abdominal Pain, Kussmaul respiration & Ketosis are not the features of NKHOC.


Investigation –

  1. Blood sugar 900 – 1100 mg/dl
  2. Serum osmolality > 350mosm/kg
  3. Prerenal azotemia
  4. Pseudo hyponatremia
  5. pH normal i.e. no acidosis
  6. Ketonuria is absent. i.e. no ketosis

Note: (1), (2), (3) are most important Features.



  1. Fluid Total fluid deficit (9 – 10L) should be reversed over 1 –2 day
    Initially give normal saline to stabilize the patients hemodynamically (.(To bring systolic BP above 90mm Hg)
    After that Give 0.45% saline
  2. Regular Insulin to be given intravenous
  3. Subcutaneus heparin because these patients are prone to venous thrombosis

Lactic Acidosis

  1. Lactic acidosis is characterized by low pH in body tissues and blood. 
  2. Elevated lactate is indicative of tissue hypoxia, hypoperfusion and state of acute circulatory failure. 
  3. Lactic acidosis is characterized by lactate levels >5 mmol/L and serum pH <7.35. 
  4. It is very common in type 2 diabetic patient who are on metformin therapy.
  5. Signs:
    1. Deep and rapid breathing
    2. Vomiting
    3. Abdominal pain.

Recent Advances

The Cohen-Woods classification categorizes causes of lactic acidosis as follows: 
  1. Type A: Decreased perfusion or oxygenation (i.e in shock)
  2. Type B:
    1. B1: Underlying diseases (Sometimes causing type A)
    2. B2: Medication or intoxication
    3. B3: Inborn error of metabolism


  1. Lactic acidosis is typically associated with tissue hypoperfusion. Appropriate measures include treatment of shock, restoration of circulating fluid volume, improved cardiac function, identification of sepsis source and appropriate therapy, and resection of any potential ischemic regions.
  2. Sodium bicarbonate is given I/V
  3. Thiamine
    Thiamine deficiency may be associated with cardiovascular compromise and lactic acidosis. The response to thiamine repletion may be dramatic and potentially lifesaving. (Ref. Hari.18th ed. , Pg- 597)

Test Your Skills Now!
Take a Quiz now
Reviewer Name