What is diabetic ketoacidosis and what is the cause of DKA in this young woman What are the therapeutic targets and our immediate priority

DKA is characterized by the triad:

1. Plasma glucose >250mg/dl (13.9mmol/L)

2. Plasma ketone bodies (b-HB) > 3 mmol/L [or ketone bodies in plasma measured with Acetest strips > 2+])

3. Acidosis: pH < 7.3 or/and HCO— < 18mEq/L

Severity of DKA can be categorized as follows: Mild: pH: 7.25-7.30

HCO—: 15-18 mEq/L Anion gap: > 10 mmol/L Moderate: pH: 7.00-7.24

HCO—: 10-15 mEq/L Anion gap: > 12 mmol/L Severe: pH: < 7.00

(Note: Anion gap is calculated using the formula: [Na+] — [Cl — + HCO— and has a normal value of around 10 mmol/L. If this value is > 10 mmol/L, this implies the presence of non-measurable anions in the blood, such as ketone bodies or lactic acid. Apart from DKA, other causes of metabolic acidosis with a high anion gap are lactic acidosis, renal failure and drug poisoning with acids).

DKA is due to lack of insulin, which leads to excessive production of ketone bodies, resulting in acidosis (metabolic acidosis with large decrease of bicarbonate) and compensatory hypocapnia. Lack of insulin also leads to a large increase in blood glucose levels, causing osmotic diuresis-polyuria and consequently a large loss of water and electrolytes. The final result is dehydration, with the clinical signs of hypovolaemia and significant electrolyte disturbances. Increased concentrations of compensatory hormones (glucagon, cortisol, catecholamines and growth hormone) contribute to the development of DKA as well.

The causes of DKA are: initial manifestation of Type 1 DM (insulin-dependent), omission of an insulin dose (accidental or deliberate) in a person with insulin-dependent DM, serious infections in a diabetic person (this refers to both types of diabetes), whereas in a certain percentage of patients the cause remains unknown. In the woman in our case, DKA was the first manifestation of Type 1 DM, and the urine infection (fever, significant increase in WBCs and positive urinalysis) contributed to its onset.

Clouding of sensorium and coma are associated with an increase in plasma osmotic pressure (intracellular osmolality is also altered and is usually associated with severe intracellular dehydration). Osmotic pressure or tonicity (osmolality) is calculated from the formula:

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