Diabetic Ketoacidosis < DKA >

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Diabetic Ketoacidosis lt DKA gt

By Navinee Vongsupathai

• Hyperglycemic Hyperosmolar Nonketotic Syndrome
• lt HHNS gt

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Diabetic Ketoacidosislt DKA gt

• By Navinee Vongsupathai

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Contents

• Definition
• Etiology
• Pathophysiology
• Signs and Symptoms
• Diagnosis
• Lab
• Treatment
• Complications

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Definition

• Diabetic ketoacidosis ltDKAgt is near complete
  deficiency of insulin and elevated levels of
  stress hormones
• Glucagon
• Cathecolamine
• Cortisol
• Growth hormone
• DKA acute metabolic complication of diabetes
  characterized by
• Hyperglycemia
• Hyperketonemia
• Metabolic acidosis

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Definition

• DKA is a life-threatening complication in Pt.
  with untreated DM (chronic high blood sugar or
  hyperglycemia).
• DKA occurs mostly in type 1 DM
• DKA is less common in type 2 DM, but it may occur
  in situations of physiologic stress.
• Pts. with new undiagnosed Type 1 DM frequently
  present to hospitals with DKA

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Etiology

• Precipitates DKA -- gt 5I s
• Insulin deficiency c relative or absolute
  increase in glucagonltInadequate insulin
  administrationgt
• Infection or Inflammation lt pneumonia, UTI,
  gastroenteritis, sepsisgt
• Ischemia or Infarction lt cerebral, coronary,
  mesenteric, peripheralgt
• Intra-abdominal process ltpancreatitis,
  cholecystitisgt
• Iatrogenesis Drug lt glucocorticoids,cocainegt

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Pathophysiology

• 1. Hyperglycemia gluconeogenesis,
  glycogenolysis ,?glucose uptake into cell
  ltunderutilizationgt
• 2. Ketosis lipolysis, ketogenesis , ?
  Peripheral tissue uptake ketone -- gtketonemia
• 3. Hypertriglyceridemia ?free fatty acid
• 4. Osmotic diuresis hyperglycemia -- gt renal
  loss glucose, Na K -- gtelectrolyte imbalance
• 5. Volume depletion hyperglycemia, glucosuria
  osmotic diuresis -- gtdehydration

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Signs and Symptoms

• Initial symptoms of DKA
• Anorexia, nausea, vomiting, abdominal pain
• Polyuria, polydipsia
• Dehydration -- gt dry mucous membranes,
  tachycardia, hypotension
• Alterated mental function-- gt somnolence,
  stupor,coma
• Fever is not a sign of DKA -- gtsignifies
  underlying infection
• Classic signs of DKA
• Kussmaul s respirations ltdeepgt to compensate
  for metabolic acidosis with acetone odor on Pt.
  breath

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Lab

• ?????????????????????????????????
• 1. Glucose ketone in serum urine
• 2. Serum electrolyte, BUN, Cr, Ca, PO4
• 3. Blood gas capillary or arterial blood gas
• 4. EKG hypo/ hyperkalemia
• 5. CBC UA

• ???????????????? ????????????????
• 1. Hemoculture
• 2. Urine culture
• 3. Throat swab culture
• 4. CSF culture
• 5. Chest x-ray
• 6. Omission of insulin
• 7. Physical or emotional stress ???

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Diagnosis

1. Serum glucose gt 300 mg/dl
   
   lt euglycemic DKA-- gt
   pregnancy, alcolhol drinking, stravation gt
2. Acidosis serum HCO3 lt 15 mEq/ml or pH lt 7.25
   lt wide anion gap
   gt15 mEq/Lgt
   severity of DKA
   
   Mild HCO3 gt 15-18
   mq/L pH gt 7.3
   Moderate HCO3 10-15
   mq/L pH 7.1-7.3 Severe HCO3 lt 10
   mq/L pH lt 7.1
   
3. Ketone positive ketone in urine and / or serm

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Treatment

• Confirm Dx ? BS, positive serum ketone,
  metabolic acidosis
• Admit
• Assess
• Serum electrolyte K, Na, Mg, Cl, HCO3, PO4
• Acid-base status pH, H CO3, Pco2
• Renal function creatinine, urine output
• Replace fluid
• Administer regular insulin/ RI
• Assess patient
• What precipitated the episode
• Initial appropriate work up

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Treatment

• Measure capillary glucose every 1-2 hr/ Elyte,
  anion gap every 4 hr for first 24 hr
• Monitor BP, PR, respiration, mental status,
  fluid intake/output every 1-4 hr
• Replace K
• Continue above until Pt. stable
• Administer intermediate or long acting insulin
  as soon as Pt. eating
  
• / overlap in insulin infusion subcutaneous
  injection.

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Replace fluid

• DKA volume Na depletion
• 0.9NaCl or NSS -- gt 1 L/hr in 1-3 hr lt5-10
  mL/kg/hrgt then
• 0.45 NaCl or Nss/2-- gt 150-300 mL/hr
• Pt. Na gt150 mEq/L-- gt NSS/2
• Pt. euglycemic DKA -- gt 5 D/NSS/2
• Severe DKA volume depletion 5-6 L ,Na 500
  Cl 350 mEq
• When BS lt 300 -250 mg/dl change to 5DN/2
  80-100 ml/hr ltSevere dehydration add NSS/2 gt

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Replace fluid

• Adequate Fluid replace
• ?plasma volume
• ?urine output
• ?absorb/action insulin
• ?release counter-regulatory hormone
• Fluid replace 50 of volum in 6 hr 50 in 24
  hr
• Measure BP, PR, urine out put, E lyte,
  crepitation -- gt pulmonary edema

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Administer regular insulin

• RI -- gt ?blood sugar , inhibit ketone production
• low dose intramuscular insulin injection ( IMIII
  )
• low dose continuous intravenous insulin infusion
  ( CIII )

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Administer regular insulin

• low dose continuous intravenous insulin infusion
  
• RI 10 U (0.1 U/kg) iv-- gt RI 5-10 U/hr (0.1
  U/kg/hr) -- gt RI control BS decrease 75-100
  mg/dl/hr
• When BS 250-300 mg/dl change iv -- gt 5 or 10
  D/NSS/2 iv 80-100 ml/hr
• ???????????????? hypoglycemia
  ?????BS?????????????????? -- gt brain
  edema??????????????
• RI in NSS conc. 1 u/ml
• ???? drip RI ???????????RI ???????????????????????
  ???????????????? 100 ml ???????? RI
  ?????????????????????????????????
  ???????????????RI ?????????????????

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Administer regular insulin

• low dose continuous intravenous insulin infusion
  
• BS decrease to 250-300 mg/dl in 4-6 hr
• But acidosis improve ( HCO3 gt 18 mEq/L ,pH gt 7.3
  ) in 8-12 hr
• When BS 250-300 mg/dl -- gt continue drip RI 3-4
  hr 5 or10 D/NSS/2 for control acidosis
• HCO3 gt 18 mEq/L-- gt? RI 2-3 u/hr

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Administer regular insulin

• low dose continuous intravenous insulin infusion
  
• When can control BS, acidosis is resolve, Pt
  stable eating -- gt RI sc ac
• Pt. should have continue RI 24-48 hr until
  control BS , acidosis improve precipitate DKA--
  gtchange RI -- gtintermediate-acting insulin ( NPH
  )
• Rapid change RI to NPH -- gtrecurrence DKA

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Administer regular insulin

• low dose intramuscular insulin injection
• RI 10 U iv 5-10 U im -- gtthen RI 5-10 U im
  q 1 hr
• ?BS 75-100 mg/dl/hr or ?BS 50 in 4-6 hr
• BS lt 300 mg/dl -- gt RI 5-10 U sc q 4-6 hr
  5 or10 D/NSS/2
• ????????????????????????? ?????
  ??????????????????????????????????????????????????
  ?????
• ???????? ??? ???????????????????????????????
  ??????????????????????????????????????????????????
  ??????????????????

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Potassium Supplement

• Moderate to severe DKA loss K 300-1,000 mEq
  or 3-5 mEq/kg
• Rx RI ,iv fluid -- gt K shift in cell, loss K in
  urine-- gt hypokalemia lt cardiac arrhythmia
  ,muscle weakness gt
• K supplement -- gturine gt 40 ml/hr , klt 5.5 mEq/L,
  EKG normal
• K lt 3 KCl 30 mEq/hr
• K lt 3-4 KCl 20 mEq/hr
• K lt 4-5 KCl 15 mEq/hr
• K lt 5-6 KCl 10 mEq/hr
• K gt 6 not corrected K

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NaHCO3

• NaHCO3 for Rx acidosis not recommence
• Randomized trail-- gtNaHCO3 in Pt. DKA pH
  6.9-7.1 not benefit for change biochemistry in
  plasma CSF
• Because metabolic acidosis will improve when
  appropiate replace fluid RI
• S/E NaHCO3 -- gtmetabolic alkalosis,
  hypernatremia, hypokalemia ,paradoxical CSF
  acidosis

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NaHCO3

• Indication
• pH lt 7 mEq/L
• Shock
• Arrhythmia
• Dose 2 mEq/kg iv in 2 hr

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Monitor

• In first 6 hr
• BP, PR, RR, Mental status-- gt q 15 min 1 hr
• skin turgor, plasma ketone,BS q 1 hr
• Urine output, urine glucose, urine ketone -- gt q
  1 hr
• Elyte, BUN,Cr-- gt q 4 hr
• Long term F/U
• K supplement 7-10 day
• DM type 1 continue use insulin
• Advice control BS lt 300 mg/dl

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????????????????????????????? DKA

• ?????? iv fluid ?????????? -- gt BS
  ??????????????????
• ?????? insulin ???????????? ????????????????????
  BS ???????????????????????????????? -- gt
  BS??????????????metabolic acidosis???????????
• ?????????? insulin ?????????????? -- gt DKA
  ?????????????
• ?????????????? 5DN/2 ????? BS 250-300 mg/dl
  ????????? insulin -- gt hypoglycemia

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????????????????????????????? DKA

• ??????? insulin ????? BS lt 250 mg/dl -- gt
  hypoglycemia
• ?????? K / ????????????? --- gt hypokalemia,
  arrhythmia
• ?????? NaHCO3 ????????????????????????? -- gt
  ???????????????????????????????????????????????
• ?????????? RI ???? NPH ?????????? -- gtDKA
  ???????????
• ???????????????????precipitating cause-- gt
  ??????????????????????????????????????????????????
  ????????????????

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Complication

• Aspirate in Pt unconciouss-- gt retain NG
• Deep vein thrombosis ??????? hypercoagulability
• Disseminated intravascular clotting
• Rhabdomyolysis-- gt renal failure
• Adult respiratory distress syndrome/ ARDS-- gtpt lt
  50 yr
• Subclinical brain edema

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Hyperglycemic Hyperosmolar Nonketotic Syndrome

• ltHHNSgt

By Navinee Vongsupathai
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Hyperglycemic Hyperosmolar Nonketotic Syndrome

• Contents
• Definition
• Etiology
• Pathophysiology
• Signs and Symptoms
• Diagnosis
• Lab
• Treatment
• Complications

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Definition

• Extreme hyperglycemia lt without ketoacidosis gt
• Hyperosmolality
• Alteration of mental status

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Etiology Pathophysiology

• Etiology
• Insulin deficiency inadequate fluid intake
  ltdehydrationgt
• Precipitate same as DKA
• Pathophysiology
• Occur in type 2 DM
• Hyperglycemia-- gt osmotic diuresis-- gtprerenal
  azotemia-- gt?glucose

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Clinical manifastations

• Polyuria, thirst
• Altered mental state ltlethargy to comagt
• The prototypical pt
• midly diabetic, elderly with a several week hx of
  poluria, weight loss, deminished oral intake

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Diagnosis

• ?serum glucose gt 600 mg/dl
• ?serum osmolality gt 350 mOsm/L
• No ketoacidosis
• ?BUN ,Cr
• Na ?? depending on degree of hyperglycemia
  dehydration
• Pseudohyponatremia corrected Na -- gt add 1.6
  meq to measured Na for each 100 mg/dl rise in
  serum glucose

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Treatment

• Aggressive hydration
• 2-3 L of 0.9 NSS or 1/2NSS over first 1-3 hr
• Calculate free water deficit 8-10 L should be
  resolved over the next 1-2 day -- gt 0.45NS
  initially then 5DW
• K repletion is usually necessary
• BS may drop with hydration alone
• But Low-dose insulin is usually required
• RI 5-10 U iv -- gtthen 3-7 U/hr

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References

• Harrisons 15th Edition
• Pocket Medicine 2nd Edtion
• www.thaiendocrine.org/guidline
• www.chatlert.worldmedic.com

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THE END

• Thank for your attention.