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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 8/21/2016 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. 8/21/2016 Predisposing Factors 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. 8/21/2016 Clinical Presentation 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) 8/21/2016 Signs and symptoms of DKA associated with possible intercurrent infection are as follows: Fever Coughing Chills Chest pain Dyspnea Arthralgia Urinary symptoms 8/21/2016 On examination Ill appearance Dry skin Labored respiration Dry mucous membranes Decreased skin turgor Decreased reflexes Characteristic acetone (ketotic) breath odor Tachycardia Hypotension Tachypnea 8/21/2016 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. 8/21/2016 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 8/21/2016 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 8/21/2016 Example how to arrange a chart to follow a DKA patient Time BP 3:00 PM 80/50 4:00 PM 8/21/2016 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. 8/21/2016 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. 8/21/2016 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 8/21/2016 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. 8/21/2016 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. 8/21/2016 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.) 8/21/2016 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. 8/21/2016 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. 8/21/2016 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) 8/21/2016 An electrocardiogram shows sinus tachycardia 120/min. Chest radiograph is normal. What is the most appropriate management? 8/21/2016