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Diabetic ketoacidosis Dr. Ibrahim Showaihi Consultant emergency medicine Security forces hospital
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Diabetic ketoacidosis Definition ?
•  acute, life-­‐threatening complication of DM •  a syndrome in which insulin deficiency and glucagon excess combine to produce a hyperglycemic, dehydrated, acidotic patient with profound electrolyte imbalance Diabetic ketoacidosis Diabetic ketoacidosis Counter-­‐regulatory hormones ?
1.  glucagon the principal 2.  catecholamines, 3.  cortisol, and 4.  growth hormone
Diabetic ketoacidosis 1.  Occur in Type 1 2.  Very rarely in type 2 3.  25% new onset DM
Diabetic ketoacidosis What mechanism cause complete or relative insulin deficiency ?
1.  Non compliance 2.  Stressors ( physical or emotional )
Diabetic ketoacidosis Important Causes of Diabetic Ketoacidosis
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Omission or reduced daily insulin injections Dislodgement/occlusion of insulin pump catheter Infection Pregnancy Hyperthyroidism Substance abuse (cocaine) Medications: steroids, thiazides, antipsychotics, sympathomimetics Heat-­‐related illness Cerebrovascular accident GI hemorrhage Myocardial infarction Pulmonary embolism Pancreatitis Major trauma Surgery
Diabetic ketoacidosis What is kussmaul breathing ?
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Kussmaul respirations, increased rate and depth of breathing, may be observed The acidotic patient attempts to increase lung ventilation and rid the body of excess acid with Kussmaul’s respiration
Diabetic ketoacidosis Diabetic ketoacidosis Diabetic ketoacidosis Lower glucose level 1.  present just after receiving insulin or who have impaired gluconeogenesis (alcohol abuse or liver failure) may have lower initial serum glucose levels.
Diabetic ketoacidosis Negative ketone in urine or blood 1.  The nitroprusside reagent normally used to detect urine and serum ketones only detects AcAc; acetone is only weakly reactive and HB not at all
Diabetic ketoacidosis Increased ketones level with treatment 1.  Paradoxically, as the patient is being treated and clinically improves, measured ketone levels will increase as the body converts the more acidic HB to AcAc
Diabetic ketoacidosis Blood gases
•  Venous vs arterial pH •  Venous ph not significantly different from arterial pH, just as good •  Difference is ~ 0.03
Diabetic ketoacidosis What can exclude presence of DKA
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PH Ketones Normal Blood suger level Normal anion gap Normal bicarb Diabetic ketoacidosis Potassium 1.  Hyperkalemia 2.  Hypokalemia 3.  Normal Diabetic ketoacidosis Management outlines •  ABC •  Rehydration •  Restore insulin •  Restore electrolyte balance •  Treat underlying cause
Diabetic ketoacidosis Fluid 1. 
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The average adult patient has a water deficit of 100 mL/kg (5 to 10 L) NS is the recommended for initial boluses Then either NS or ½ NS folllow In general, the first 2 L are administered rapidly over 0 to 2 hours, the next 2 L over 2 to 6 hours, and then 2 L more over 6 to 12 hours. 5.  When the blood glucose level is approximately 250 milligrams/dL, change to 5% dextrose in 0.45 NS 6.  CVP should be considered during fluid replacement in elderly patients or in those with heart disease 7.  Excess fluid may contribute to the development of adult respiratory distress syndrome and cerebral edema Diabetic ketoacidosis Insulin 1.  NO bolus 2.  0.1 U/kg/hr up to 5 to 10 U/kg/hr 3.  Insulin binds to plastic tubing, so thae first 20 mL of a prepared insulin solution should be discarded 4.  Drop suger 50-­‐70 mg/dl /hr if failed double the dose 5.  The insulin infusion should continue until ketonemia has cleared and the anion gap has normalized 6.  transition from the IV insulin infusion to SQ insulin is necessary to avoid relapse to hyperglycemia or DKA when the insulin infusion is stopped Diabetic ketoacidosis Potassium 1.  Always needed in DKA 2.  Initial level is often normal or high despite a large deficit because of severe acidosis 3.  If hypokalemia may become life-­‐threatening when insulin therapy is administered 4.  < 3.3 hold insulin drip for 30 min start kcl 60 meq/ l at 250 /hr until potassium > 3.3 then start insulin infusion 5.  > 3.3 < 5.3 urine out put , 40 meq kcl 6.  > 5.3 start insulin infusion no kcl Diabetic ketoacidosis Bicarbonate 1.  Acidotic patients routinely recover from DKA without alkali therapy 2.  Routine use of supplemental bicarbonate in the treatment of DKA is not recommended Diabetic ketoacidosis Possible disadvantages of bicarbonate administration in DKA
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severe and worsening hypokalemia paradoxical central nervous system acidosis worsening intracellular acidosis impaired (shift to left) oxyhemoglobin dissociation hypertonicity and sodium overload delayed recovery from ketosis elevation of lactate levels Rebound alkalosis and possible precipitation of cerebral edema Diabetic ketoacidosis Disposition •  Usually ICU admission •  Patients presenting early in the course of their illness who can tolerate oral liquids may be managed safely in the ED or observation unit and discharged after 4 to 6 hours of therapy. The anion gap on discharge should be <20.
Diabetic ketoacidosis Disposition !May discharge home if: ! Initial ph > 7.35 ! HCO3 > 20 meq/l ! Resolution of clinical findings ! Tolerating po fluids ! Reliable caretaker ! No underlying etiology requiring hospitalization ! Close followup
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