Download Diabetic ketoacidosis

Diabetic ketoacidosis
Mosul Medical College
Department of Medicine
Presented by:
Dr. Salam Fareed
8/21/2016
INTRODUCTION
Diabetic ketoacidosis (DKA) is an acute, major, lifethreatening complication of diabetes that mainly
occurs in patients with type 1 diabetes, but it is not
uncommon in some patients with type 2 diabetes.
This condition is a complex disordered metabolic
state characterized by:
hyperglycemia: blood glucose level > 200 mg/ dl
Ketoacidosis: ketonuria > ++ on standard urine
sample.
 Metabolic acidosis: PH < 7.3, s. bicarbonate < 15
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Pathophysiology
DKA typically occurs in the setting of
hyperglycemia with relative or absolute insulin
deficiency and an increase in counterregulatory
hormones.
Sufficient amounts of insulin are not present
to suppress lipolysis and oxidation of free fatty
acids, which results in ketone body production
and subsequent metabolic acidosis.
DKA occurs more frequently with type 1
diabetes, although 10% to 30% of cases occur in
patients with type 2 diabetes.
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Predisposing Factors
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Several risk factors can precipitate the development
of extreme hyperglycemia:
infection.
intentional or inadvertent insulin therapy.
myocardial infarction.
Stress.
trauma.
confounding medications, such as glucocorticoids or
atypical antipsychotic agents.
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Clinical Presentation
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The most common early symptoms of DKA are the
insidious increase in polydipsia and polyuria. The following
are other signs and symptoms of DKA:
Malaise, generalized weakness, and fatigability
Nausea and vomiting; may be associated with diffuse
abdominal pain, decreased appetite, and anorexia
Rapid weight loss in patients newly diagnosed with type 1
diabetes
History of failure to comply with insulin therapy or missed
insulin injections due to vomiting or psychological reasons
or history of mechanical failure of insulin infusion pump
Decreased perspiration
Altered consciousness (eg, mild disorientation, confusion)
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Signs and symptoms of DKA associated with
possible intercurrent infection are as follows:
 Fever
 Coughing
 Chills
 Chest pain
 Dyspnea
 Arthralgia
 Urinary symptoms
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On examination
 Ill appearance
 Dry skin
 Labored respiration
 Dry mucous membranes
 Decreased skin turgor
 Decreased reflexes
 Characteristic acetone (ketotic) breath odor
 Tachycardia
 Hypotension
 Tachypnea
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Investigations:
•Serum glucose levels
•Serum electrolyte levels
•Amylase and lipase levels
•Urine dipstick
•Ketone levels
•ABG measurements
•CBC count
•BUN and creatinine levels
•C-RP
•Urine and blood cultures if intercurrent infection is suspected
•ECG
•Chest radiography: to rule out pulmonary infection
•Head CT scanning: to detect early cerebral edema.
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Management:
Managing diabetic ketoacidosis (DKA) in an
intensive care unit during the first 24-48 hours
always is advisable.
Plan for therapy:
When treating patients with DKA, the following
points must be considered and closely monitored:
 Correction of fluid loss with intravenous fluids
 Correction of hyperglycemia with insulin
 Correction of electrolyte disturbances, particularly
potassium loss
 Correction of acid-base balance
 Treatment of concurrent infection, if present
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Laboratory studies for diabetic ketoacidosis (DKA)
should be scheduled as follows:
 Blood tests for glucose every 1-2 h until patient
is stable, then every 4-6 h
 Serum electrolyte determinations every 1-2 h
until patient is stable, then every 4-6 h
 Initial blood urea
 Initial arterial blood gas (ABG) measurements,
followed with bicarbonate as necessary
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Example how to arrange a chart to follow a
DKA patient
Time
BP
3:00 PM 80/50
4:00 PM
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Input
Insulin
fluid
Output RBS
S. k
20 units
2 L/NS
IM
Nil
6.2
410
Insulin Therapy:
Using soluble (Short acting) insulin administered
either:
 I.V infusion(prefered method):
o Bolus: 0.1 unit/ kg. I.V direct
o then maintain contiueous iv infusion of 0.1 unit/ kg./
hr. using syringe pump.
 I.M:
o Bolus: 10-20 units
o Followed by 5 units hourly.
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Target blood sugar:
Falling 55-110 mg/ dl per hr.
(3-6 mmol/l)
 Rapid decline → cerebral edema
 Failure to reach the target → require
reassessment of insulin therapy.
Shift to subcutaneous insulin regimen
when the patient vomiting stopped and
become biochemically stable.
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Fluid Replacement:
Average of 6 litres fluid deficit exist
 3 L are extracellular replaced by 0.9% isotonic saline.
 3 L are intracellular replaced by dextrose
Set 2 wide bore IV line initially
Timing and amount as following:
 1st hr: using normal (isotonic) saline
 systolic BP > 90 mmHg → 1 L
 systolic BP < 90 mmHg → 2 L
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 Then as :
 1 L OVER 2 hrs
 1 L OVER 2 hrs
 1 L EVERY 6 hrs
Shift to 10% dextrose fluid whenever blood sugar level
become < 250 mg/dl (14mmol/l).
Note: be cautious with elderly, pregnant, those with
heart or renal failure.
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Potassium Replacememt
According to serum potassium level as:
 > 5.5 mmol/l → non to be given
 3.5 – 5.5 (mmol/l) → 40 meq/l
be cautious in replacing K usually hyperkalemia
occurs initially due to prerenal failure secondary to
dehydration for that reason K is not recommended to
be given in the first hour of therapy.
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Other
 Acidosis: is usually corrected with the time by
adequate fluid and insulin replacement. Bicarbonate
therapy is not recommended as it can induce cerebral
edema
 Infection: should be treated by antibiotcs
accordingly
 Brain edema: is the leading cause of death in DKA, it
can exist in spite of metabolic stablisation. It should be
treated by mannitol solution 20%
(7 ml/ kg.)
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Case Scenario
A 20-year-old woman is evaluated in the
emergency department for polyuria,
polydipsia, polyphagia, and an
unintentional 5.4-kg (11.9-lb) weight loss
over the past month. She has had increasing
lethargy over the last 24 hours. Her medical
history and family history are unremarkable.
She takes no medications.
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On physical examination,
temperature is 37.5 °C , blood pressure is
98/52 mm Hg, pulse rate is 120/min, and
respiration rate is 30/min. BMI is 17.
She is lethargic with dry mucous
membranes, tachypnea, and tachycardia.
Chest auscultation is clear. Abdominal
examination shows diffuse mild tenderness
and normal bowel sounds. There is no
rebound tenderness or guarding with
palpation.
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Laboratory studies:
 Hemoglobin= 17 g/dL (170 g/L)
 Leukocyte count= 14,200/µL (14.2 × 109/L)
 Blood gases, arterial::
 pH= 7.25
 PCO2= 21 mm Hg
 Creatinine= 1.3 mg/dL
 Electrolytes
 Sodium= 130 mEq/L
 Potassium= 3.0 mEq/L
 Chloride= 99 mEq/L
 Bicarbonate= 9 mEq/L
 Glucose= 620 mg/dL (34.4 mmol/L)
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An electrocardiogram shows sinus tachycardia 120/min.
Chest radiograph is normal.
What is the most appropriate management?
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