• Clinical Manifestations of Ketoacidosis
  • Stages:
    1. anorexia, nausea, vomiting
    2. increased urine formation; abdominal pain
    3. Kussmaul respiration (air hunger); signs of volume depletion; leukocytosis
    4. later stages: altered consciousness/coma;
  • Hypertriglyceridemia
  • Prerenal azotemia
  • Pancreatitis

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• Diagnosis of ketoacidosis (in a patient with insulin-dependent diabetes):
  • positive urine test for glucose and ketones
  • strong plasma reaction using ketone reagent strips following dilution exceeding 1:1 (a positive test without dilution may indicate starvation as a cause)
  • Note, the other common ketoacidotic state (other than diabetes) is alcoholic ketoacidosis

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• Treatment:
  • Diabetic ketoacidosis reversal requires insulin, probably using a higher dose schedule which insures receptor saturation
    • Insulin at high concentration may accelerate ketoacidosis reversal by acting through the IGF-1 receptor
  • Intravenous fluids are also required (usual fluid deficit: 3 -- 5 L.)
  • Potassium replacement always necessary.
  • Bicarbonate treatment in severely acidotic patients (pH = 7.0 or less)

• Treatment Response:
  • plasma glucose levels fall more rapidly than plasma ketone levels (insulin should treatment should continue until ketosis has cleared)
  • Plasma ketone values: may not be helpful in assessing clinical response. {Testing materials manager acetone and acetoacetate, but not beta-hydroxybutyrate}
    • Clinical state may be more accurately assessed by pH and calculated anion gap.

• Outcome:
  •  mortality rate: about 10%
  •  Major causes of mortality:
    • myocardial infarction
    • infection, especially pneumonia
  •  Poor prognostic signs (on admission):
    • hypotension
    • azotemia
    • deep coma
    • Cerebral edema (in children)

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