Diabetic Ketoacidosis (DKA) - Pathophysiology, Deteriorating Patient, Treatment Strategies, Ethical and Legal Practice, Roles and Responsibilities, Quality Use of Medicines, Complementary Therapies

This presentation provides an in-depth understanding of Diabetic Ketoacidosis (DKA), including its pathophysiology, effects on the patient's health, treatment strategies, ethical and legal practices, roles and responsibilities of healthcare professionals, quality use of medicines, and complementary therapies.

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Diabetic Ketoacidosisis caused due to a deficiency of insulin in the body. As a result of the insulin
deficiency, the amino acids and triglycerides in the body are metabolized to release energy by the process
of lipolysis (Hoffman et al., 2017). This results in a rise in the levels of free fatty acids, glycerol and
Alanine in the serum. Also excess glucagon caused due to the deficiency of insulin causes the alanine and
glycerol act as substrates for hepatic gluconeogenesis and glugagon leads to the conversion of free fatty
acids into ketones in the mitochondria (Soto-Rivera et al., 2017). When there is sufficient insulin in the
body, the formation of ketone is restricted, but insulin deficiency leads to an increase in ketone levels in
the serum. The rise in ketones further causes production of beta-hydroxybutyric acid and acetoacetic acid
that causes metabolic acidosis (Sulimani et al. 2018). The pH of blood decreases due to this, making it
acidic (Adachi et al., 2017).
Pathophysiology
'Deteriorating patient'
Principles of ethical and legal practice and person centered care in
a critical care environment
References:
Adachi, J., Inaba, Y., & Maki, C. (2017). Euglycemic diabetic ketoacidosis with persistent diuresis treated with
canagliflozin. Internal Medicine, 56(2), 187-190.
Al-Ghamdi, A. H., Fureeh, A. A., Alghamdi, J. A., Alkuraimi, W. A., Alomar, F. F., Alzahrani, F. A., ... & Alghamdi, A.
M. (2017). High prevalence of vitamin D deficiency among Saudi children and adolescents with type 1 diabetes in
Albaha Region, Saudi Arabia. IOSR J. Pharm. Biol. Sci, 12, 5-10.
Burke, K. R., Schumacher, C. A., & Harpe, S. E. (2017). SGLT 2 Inhibitors: A Systematic Review of Diabetic
Ketoacidosis and Related Risk Factors in the Primary Literature. Pharmacotherapy: The Journal of Human
Pharmacology and Drug Therapy, 37(2), 187-194.
Cervera-Hernandez, M. E., & Reddy, N. (2017). Garcinia Cambogia, diabetic ketoacidosis, and pancreatitis. Rhode
Island Medical Journal, 100(10), 48.
Gilbert, J. D., & Byard, R. W. (2018). Fatal diabetic ketoacidosis—a potential complication of MDMA (ecstasy) use.
Journal of forensic sciences, 63(3), 939-941.
Health.gov.au. (2019). Department of Health | Policy. Retrieved from
http://www.health.gov.au/internet/main/publishing.nsf/Content/Policy-1
Health.gov.au. (2019). Department of Health | Quality Use of Medicines (QUM). Retrieved from
http://www.health.gov.au/internet/main/publishing.nsf/Content/nmp-quality.htm
Hoffman, W. H., Artlett, C. M., Boodhoo, D., Gilliland, M. G., Ortiz, L., Mulder, D., ... & Rus, H. (2017). Markers of
immune-mediated inflammation in the brains of young adults and adolescents with type 1 diabetes and fatal diabetic
ketoacidosis. Is there a difference?. Experimental and molecular pathology, 102(3), 505-514.
Jehle, D., Johnson, D., Martel, T., Molnar, J., Lark, M. C., Falkowitz, J., ... & Nambudiri, V. (2017). Severe diabetic
ketoacidosis presenting with negative serum ketones. The American journal of emergency medicine, 35(1), 196-e3.
Lien, A. S. Y., Jiang, Y. D., Mou, C. H., Sun, M. F., Gau, B. S., & Yen, H. R. (2016). Integrative traditional Chinese
medicine therapy reduces the risk of diabetic ketoacidosis in patients with type 1 diabetes mellitus. Journal of
ethnopharmacology, 191, 324-330.
Møller, N. (2017). Acute Metabolic Complications of Diabetes: Diabetic Ketoacidosis and the Hyperosmolar
Hyperglycemic State. Textbook of Diabetes, 534-539.
Moore, L. E. (2018). Diabetic Ketoacidosis. In Diabetes in Pregnancy (pp. 127-136). Springer, Cham.
Mousa, S. O., Sayed, S. Z., Moussa, M. M., & Hassan, A. H. (2017). Assessment of platelets morphological changes
and serum butyrylcholinesterase activity in children with diabetic ketoacidosis: a case control study. BMC endocrine
disorders, 17(1), 23.
DKA can significantly deteriorate the health condition of the patient and can be fatal is not treated timely
(Møller, 2017). According to Gilbert and Byard (2018), the acidification of the blood (or metabolic
acidosis) can lead to the production of excess hydrogen ions and insufficient production of bicarbonate
ion. This can cause several serious consequences such as respiratory acidosis, coma and even death.
Additionally, metabolic acidosis can also cause neurological problems (such as lethargy, stupor and
seizures) and cardiac problems (such as arrhythmia, trachycardia, reduced reaction to epinephrine and fall
in blood pressure). Other studies have shown that the condition can also cause retinal edema, ethylene
glycol poisoning and osteoporosis (Mousa et al., 2017). Thus the condition of the patient can rapidly
deteriorate due to the onset of one of several complications due to metabolic acidosis (Moore, 2018; Jehle
et al., 2017).
Student Name, Student Number
Diabetic Ketoacidosis (DKA)
Figure 1 (left-
pathophysiology of
DKA. Figure 2 (right)
symptoms of DKA.
Pharmacodynamics and pharmacokinetics of treatment strategies:
One of the most effective treatment strategy for DKA is the use of a combination of dapagliflozin and
insulin. Dapagliflozin is a selective inhibitor which is orally active which can inhibit renal SGLT2 (renal
sodium-glucose co-transporter type 2) and therefore used for the treatment of type 2 diabetes (or diabetes
mellitus) (Storgaard et al., 2016). The substance helps to improve the glycemic control for type 2 diabetes
patients by reducing the renal reabsorption of glucose that causes excretion of glucose in urine. The
extravascular distribution of dapagliflozin is extensive and is predominantly metabolized in the kidneys
and liver by uridine diphosphate-glucuronosyltransferase-1A9 to form dapagliflozin 3-O-glucuronide
which is a major metabolite of the process. Renal excretory process however is unable to remove
dapagliflozin and the half life of 10 mg of dapagliflozin is 12.9 hours. Multiple doses of dapagliflozin
lead to a reduction of the urinary excretion of glucose (Burke et al., 2017; Ogawa & Sakaguchi, 2016).
Roles and responsibilities of healthcare professionals when caring
for the deteriorating patient in acute care setting:
: This step involves coordinated activities such as provision of resources, training and educating the staff
and providing supporting to ongoing treatment.
The response arm of the rapid response system includes the medical emergency team, rapid response
team, critical care outreach, ICU liaison nurses as well as alternate systems of care delivery
(Safetyandquality.gov.au, 2019).
Calling criteria:
According to Australian healthcare policies, the following conditions can quality as a medical emergency
Airway obstruction Breathing problems: respiratory arrest, respiratory rate below 5 breaths per minute or
above 36 breaths per minute
Circulatory problems: cardiac arrest, pulse rate below 40 beats per minute or above 140 beats per minute,
systolic blood pressure below 90 mm Hg
Neurological problems: fall in level of consciousness (fall in Glasgow coma scale to less then 2 points,
repeated and extended seizures
(Safetyandquality.gov.au, 2019)
Ethical and legal principles of person centered care in a critical care environment include the following
aspects:
The Code of Ethics: The code of ethics was developed by the Nursing and Midwifery Board of Australia
for professional nurses and outlines the ethical responsibilities and duties of the nurse towards a patient,
including that of a critical care environment.
Rights based patient constitutions: These consititutions establishes a patient’s rights towards quality and
equity of care and against discrimination based on race, gender, ethnicity and socio economic status.
Confidentiality policies: The confidentiality policies implies that patient information should always be
kept confidential by healthcare workers and shared to relevant personnel only on a need to know basis in
order to promote confidentiality of patient health information and avoid its misuse.
Quality of care policies: These policies are aimed to maintain quality of care and ensure the maintenance
of evidence based practices and safe standards.
(Health.gov.au, 2019; Oecd.org, 2019; Nursingmidwiferyboard.gov.au, 2019)
Figure 3-Rapid response system in an acute care
setting. Source (Safetyandquality.gov.au, 2019
Quality use of medicines
The national medicines policy (NMP) of Australia outlines the following responsibilities of the healthcare
providers while administering medications to the patients:
Providing quality care that is responsive to the needs of the patients
Providing incentives for preventative health and cost effective care
Outlining the roles and responsibilities of the healthcare professionals in the administering of medication
Administering the medications on a timely basis.
Morover, the medications that are administered should qualify the following conditions:
Appropriateness: Selecting the medication that is most appropriate to the patient’s condition and
considering the potential risks, benefits, dosage, length of administration and costs of the treatment.
Judiciousness: The medications should be administered only if they are needed and after considering
alternative treatments
Safety: The medications should not be misused, overused or underused.
Effectiveness: The medications should be able to achieve the desired goals by causing beneficial changes
to the health and condition of the patient
(Health.gov.au, 2019; Oecd.org, 2019)
Complementary Therapies
Complementary therapies for DKA include:
Physical Intervention: Yoga, Message Therapy, Acupuncture, Medicinal Herbs
Dietary supplements: Chromium, Vanadium, Magnesium, Nicotinamide, Vitamin E
Miscellaneous approach: Aromatherapy, Biofeedback, Hydrotherapy, Chromotherapy
(Lien et al., 2016; Al-Ghamdi et al., 2017; Cervera-Hernandez & Reddy, 2017)
In situations where the patient’s condition is rapidly deteriorating, the healthcare professionals in charge
of the patient’s care have the the role of initiating a rapid response system for the patient in order to
quickly identify the condition and respond to it accordingly (Safetyandquality.gov.au, 2019). The rapid
response system involves the following steps:
Event recognition and triggering response: This step involves identifying the trigger that caused the
deterioration of patient’s condition and it includes activities such as recording vital signs, identifying
early warning scores, communicating the identified problem and develop understanding of the
abnormalities.
Crisis Response: This steps involves the provision of personnel and resources (like equipment and
medications) that can address the needs of the patient in a timely manner.
Process Improvement: This step involves collection of data and providing feedback to the healthcare
providers, planners as well as the patients and families and improve the care response that can prevent
future events.
Administration