Ddf0Diabetic Ketoacidosis

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    Medical emergency

    DIABETIC KETOACIDOSIS

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    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

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    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.

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    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

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    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

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    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.

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    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%)

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    Precipitating Factors are

    1. Inadequate insulin administration

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

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

    4. Drugs (cocaine)5. Pregnancy

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    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

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    Monitoring In ketoacidosis

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

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    The principal components of

    treatment

    The administration of short-acting (soluble) insulin

    Fluid replacement

    Potassium replacementAntibiotics if infection is present

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    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

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    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

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    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.

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    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)

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    Complication of DKA

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