Docstoc

Diabetic Ketoacidosis - PowerPoint

Document Sample
Diabetic Ketoacidosis - PowerPoint Powered By Docstoc
					www.medilectures.blogspot.com
DKA
 Medical Emergency
 Commonly seen in people with Type 1 DM
 Also seen in people with Type 2 DM
 Average mortality is 5 – 10 %
HHS
 Primarily seen in people with Type 2 DM
 In contrast to DKA acidosis and ketonemia are absent
  or mild
DKA- Clinical features
 Symptoms
    Nausea & Vomiting
    Abdominal Pain
    Thirst, Polyuria
    Shortness of breath
    Blurred Vision
    Leg cramp
    Weakness
 Signs
    Tachycardia
    Dry mucous membrane/ Reduced skin turgor
    Hypotension
    Kussmaul respiration & Fruity odor in breath
    Lethargy and CNS Depression
    Coma
Pathophysiology
 Three cardinal Biochemical features
   1. Hyperglycemia
   2. Hyperketonemia
   3. Metabolic Acidosis
                   INSULIN DEFICIENCY


GLUCONEOGENESIS    GLUCOSE        GLYCOLYTIC
                                                LYPOLYSIS
 GLYCOGENOLYSIS    UPTAKE          ENZYMES


                                               HEPATIC FFA
 HYPERGLYCEMIA



                                               KETOGENISIS
OSMOTIC DIURESIS
  DEHYDRATION
ELECTROLYTE LOSS
                                                ACIDOSIS
Precipitating Events
 Inadequate insulin administration
 Infection
 Infarction
 Drugs
 Pregnancy
Lab Investigations
 Blood Glucose (250-600 mg/dL)
 Urine analysis for ketones
 Serum electrolytes
         Na (125-135)
         K (Normal or increased)
   Serum Bicarbonate (<15meq/L)
   Arterial blood gas
   ECG
   Infection screening (CBC ESR, Blood &Urine culture,
    CRP, Chest X Ray)
Management
 Medical Emergency
 Should be treated in High Dependency unit
 Close Monitoring Essential
 Principal Components
   1) Administration of short acting insulin
   2) Fluid replacement
   3) Potassium replacement
   4) Administration of antibiotics if infection is present
Guidelines for management
Fluid Replacement
 0.9 % saline iv
     1 litre over 30 min
     1 litre over 1 hr
     1 litre over 2 hr
     1 litre over 3 hr
 When blood glucose < 250 mg/dl
      switch to 5% dextrose , 1 litre 8hrly with 8 U insulin
  added to it. Continue this till oral feeds are introduced
      if still dehydrated continue 0.9% saline & add 5%
  dextrose 1 litre per 12hrs
 Typical req is 6 liters in 1st 24 hrs
 Subsequent fluid requirement should be based on
  clinical response
Insulin Therapy
 Plain insulin 10U hourly till blood sugar is <200mg/dl
 Discontinued once blood sugar < 200mg/dl and start
  on 8 hrly s/c plain insulin ( Amount assessed based on
  previous requirements)
 Check RBS hourly
Potassium
 Anticipate hypokalemia
 Correction must be started once urine output is
  adequate and Serum K+ is documented
 To achieve 1 mEq rise in serum K, 100-200 mEq KCL is
  required
 Given in saline or dextrose as slow drip over 24 to 48
  hrs
 If initial K+ < 3.3meq/l, start insulin only after its
  correction
Bicarbonate
 Not routinely administered
 Indications:
      Severe acidosis
 300 ml 1.26 % over 30 mts into a large vein
Antibiotics
 If bacterial, fungal or any treatable infections
  suspected, start empirical broad spectrum antibiotics
Monitor
 Bp, pulse, mental status
 Hourly RBS
 4th hourly Serum electrolytes
 I/O chart
 In case of renal failure, continuous ECG monitoring
End point of treatment
 The end point of energetic treatment in DKA is
    Blood sugar below 200mg/dl & normal Ph
    Not the absence of ketone bodies
 KB continue to persist for few days
Additional Procedures
 Catheterization if no urine passes after 3 hrs
 Nasogastric tube to keep stomach empty in
  unconscious patient
 Central venous line if CVS compromised
 Plasma expander if systolic BP< 90mm Hg or does not
  rise with NS
Complications
 Cerebral edema
      - rapid reduction of blood glucose
      - use of hypotonic fluids & / or HCO3
 ARDS
 Thromboembolism
 DIC
 Acute circulatory failure
Hyperglycemic Hyperosmolar State
 Characterized by severe hyperglycemia (900mg/dl)
  without significant hyperketonemia or acidosis
 Affects elderly people. Mostly undiagnosed
 High mortality (40%)
Clinical findings
 Symptoms
    Polyurea
    Weight loss
    Diminished oral intake
 Signs
    Dehydration
    Hypotension
    Tachycardia
    Altered mental state
    Lethargy
    Coma
 Nausea
 Vomiting
                         ABSENT
 Abdominal Pain
 Kussmaul Respiration
Pathophysiology
   RELATIVE INSULIN                 DECREASED FLUID
      DEFICIENCY                        INTAKE




    HYPERGLYCEMIA




   OSMOTIC DIURESIS


                       INTRAVASCULAR
                      VOLUME DEPLETION
 Absence of Ketosis
    Relative insulin deficiency
    Lower level of counter regulatory hormones and FFA
    Liver is less capable of ketone body synthesis
    Insulin/Glucagon ratio is not favorable
Precipitating Factors
   Myocardial infarction
   Stroke
   Sepsis
   Pneumonia
   Debilitating conditions like dementia,
   Social factors compromising water intake
Laboratory Investigation
 Blood glucose (600 – 1200 mg/dl)
 Osmolarity (330 – 380 mOsm/ml)
 Serum Creatinine (Moderately increased)
 Serum Electrolytes
    Na (135-145)
    K (Normal)
 Urinary Ketone Bodies (Absent)
Management
 Stabilize hemodynamic status initially (1 to 3 L of 0.9%
  NS over 2 to 3 hrs)
 Rapid reversal of hyperosmolar state must be
  prevented
 If S. Na is > 150meq/l, 0.45% saline should be used
 When hemodynamic stability is achieved, IV fluids are
  given to reverse the water deficit over 1 to 2 days
 Potassium repletion
 Insulin – 10 U hourly with frequent monitoring
 Once Blood glucose approaches normal, 5% Dextrose
  infusion can be started with 8 units of insulin added to
  it or switch over to 8 hourly s/c insulin with oral/ ryles
  tube feed
 This should be continued till patient is able to eat
Prevention
 Patient Education
 To increase insulin during prodromal sick days
 Hydration
 Frequent RBS, Urine ketones
 Seek medical advise early
Thank You

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:1244
posted:3/19/2010
language:English
pages:34
Description: Diabetic Ketoacidosis