7/31/2019 Ddf0Diabetic Ketoacidosis

1/18

Medical emergency

DIABETIC KETOACIDOSIS

7/31/2019 Ddf0Diabetic Ketoacidosis

2/18

contd medical emergency commonly in people with type 1 diabetes Mortality 10-15% in developed countriesPrecipitating factors

1. Infection2. Trauma3. Stress4. Missed or reduced insulin5. Myocardial infarction

7/31/2019 Ddf0Diabetic Ketoacidosis

3/18

Pathogenesis Insulin helps in Triglyceride and Fatty acid

synthesis and inhibits fatty acid oxidation andketone production.

In absence of insulin, ketone production

increases Ketones- acetoacetate, 3-hydroxybutyrate or

acetone

Normally produced in small amount andutilized.

In DKA, production exceeds utilization andpass into urine.

7/31/2019 Ddf0Diabetic Ketoacidosis

4/18

Cardinal features hyperglycaemia hyperketonaemia

metabolic acidosis

Osmotic diuresis leading to dehydration,hypotension & electrolyte loss, particularly ofsodium and potassium

metabolic acidosis forces hydrogen ions into cells,displacing potassium ions

7/31/2019 Ddf0Diabetic Ketoacidosis

5/18

AVERAGE LOSS OF FLUID AND

ELECTROLYTES

Water: 6 litres

Sodium: 500 mmol

Chloride: 400 mmol

Potassium: 350 mmol

3 litres extracellular -replace with saline

3 litres intracellular -replace with dextrose

7/31/2019 Ddf0Diabetic Ketoacidosis

6/18

CLINICAL FEATURES

(Symptoms)

Nausea, vomiting

Polyuria, thirst

Abdominal pain Weight loss

Weakness

Leg cramps Blurred vision

Note :- Abdominal pain is due to progression to

pancreatitis.

7/31/2019 Ddf0Diabetic Ketoacidosis

7/18

Signs

Tachycardia

Dehydration (dry mucous membrane, reduced skin turgor)

Hypotension (postural or supine)

Cold extremities/peripheral cyanosis

Tachypnea, Air hunger (Kussmaul breathing)

Smell of acetone

Hypothermia Confusion, drowsiness, coma (10%)

7/31/2019 Ddf0Diabetic Ketoacidosis

8/18

Precipitating Factors are

1. Inadequate insulin administration

2. Infection (Pneumonia/UTI/Sepsis/Gastroenteritis)

3. Infarction (Cerebral/coronory/mesentric/peripheral)

4. Drugs (cocaine)5. Pregnancy

7/31/2019 Ddf0Diabetic Ketoacidosis

9/18

Investigations

1. Blood glucose ( 13.9 33.3 mmol/l or 250- 600 mg/dl)

2. Arterial blood gases (PH 6.8 7.3)

3. Plasma Bicarbonate < 12 mmol/l = severe acidosis

4. Urine and plasma ketone = ++++5. RFT :- urea , creatinine & electrolytes,

6. Osmolality 300 320 mosm/l

7. Anion Gap = Increase

8. ECG9. Infection screen: FBC, blood and urine culture,

CRP, CXR

7/31/2019 Ddf0Diabetic Ketoacidosis

10/18

7/31/2019 Ddf0Diabetic Ketoacidosis

11/18

Monitoring In ketoacidosis

Serum Osmolality = [2 x (serum sodium + serumpotassium) + plasma glucose (mg/dL)/18 + BUN/2.8]

7/31/2019 Ddf0Diabetic Ketoacidosis

12/18

The principal components of

treatment

The administration of short-acting (soluble) insulin

Fluid replacement

Potassium replacementAntibiotics if infection is present

7/31/2019 Ddf0Diabetic Ketoacidosis

13/18

Fluid replacement 0.9% saline (NaCl) i.v.

1 litre over 30 minutes 1 litre over 1 hr 1 litre over 2 hrs 1 litre over next 4 hrs

When blood glucose < 15 mmol/l, Switch to 5% dextrose, 1 litre 8-hourly If still dehydrated, continue 0.9% saline and add 5%

dextrose 1 litre per 12 hrs

Typical requirement is 6 litres in first 24 hrsbut avoid fluid overload in elderly patients

7/31/2019 Ddf0Diabetic Ketoacidosis

14/18

Insulin

50 units soluble insulin in 50 ml 0.9% saline i.v. viainfusion pump

6 units/hr initially

3 units/hr when blood glucose < 15 mmol/l (270 mg/dl)

2 units/hr if blood glucose declines < 10 mmol/l (180mg/dl)

Check blood glucose hourly initially-if no reduction in firsthour, rate of insulin infusion should be increased

Aim for fall in blood glucose of 3-6 mmol/l (55-110 mg/dl)per hour

7/31/2019 Ddf0Diabetic Ketoacidosis

15/18

Potassium

If plasma potassium < 3.5 mmol/l, give 40 mmol addedpotassium

Avoid infusion rate of > 20 mmol/hr

If plasma potassium is 3.5-5.5 mmol/l, give 20 mmol addedpotassium

If plasma potassium is > 5.5 mmol/l, or patient is anuric,give no added potassium

Later, according to lab report. Note= If initial serum K+ < 3.3 mmol/l then stop insulin infusion

until K+ is corrected > 3.3mmol/l.

7/31/2019 Ddf0Diabetic Ketoacidosis

16/18

Others treatment

Continue Above until pt is stable and glucose goal is 150 250mg/dl & Acidosis is resolved then

Insulin infusion is /may decreased to 0.05 0.1 U/kg/hr.

Catheterisation if no urine passed after 3 hrs

Nasogastric tube to keep stomach empty in unconscious orsemiconscious patients.

Central venous line if cardiovascular system compromised.

Plasma expander if systolic BP is < 90 mmHg or does notrise with i.v. saline.

Antibiotic if infection demonstrated or suspected

ECG monitoring in severe cases

Monitoring Vitals (BP, pulse, RR, Temp)

7/31/2019 Ddf0Diabetic Ketoacidosis

17/18

Complication of DKA

7/31/2019 Ddf0Diabetic Ketoacidosis

18/18