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Diabetic ketoacidosis

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Diabatic ketoacidosis

Text of Diabetic ketoacidosis

  • 1. Muhammad Ramzan UL Rehman 1

2. Muhammad Ramzan ULRehmanMuhammad Ramzan UL Rehman 2 3. case scenario : 18 yrs old female.Problems1. Tiredness2. Weightloss3. Thisrsty4. Glycoseuria5. Drowsy6. B.P 96/60 mmHg7. Pulse rate 112 per min8. Cold extremities9. Kussmaule respiration10. Acetone BreathMuhammad Ramzan UL Rehman 3 4. Investigations1. Na 130 mmol/liter [ 142 momol/liter]2. K 5.8 mmol/liter [ 3.8-5 mmol/liter]3. Bicorbonate 5 mmol/liter [ 24 32 mmol/liter ]4. Urea 18 mmol/liter [2.5 10.7 mmol/liter]5. Creatinine 140 mol/liter [88.4 mol/liter ]6. Blood glucodse 32 mmol/liter [ 4-7 mmol/liter]Arterial Blood1. Hydrogen ion 89 mmol/liter PH ( 7.05) [ 7.5]2. Pco2 15 mmHg [ 40 mmhg]Muhammad Ramzan UL Rehman 4 5. case scenario :1. Tiredness2. Weightloss3. Thisrsty4. Glycoseuria5. Drowsy6. B.P 96/60 mmHg7. Pulse rate 112 per min8. Cold extremities9. Kussmaule respiration10. Acetone BreathMuhammad Ramzan UL Rehman 5 6. Investigations1. Na 130 mmol/liter [ 142 momol/liter]2. K 5.8 mmol/liter [ 3.8-5 mmol/liter]3. Bicorbonate 5 mmol/liter [ 24 32 mmol/liter ]4. Urea 18 mmol/liter [2.5 10.7 mmol/liter]5. Creatinine 140 mol/liter [88.4 mol/liter ]6. Blood glucodse 32 mmol/liter [ 4-7 mmol/liter]Arterial Blood1. Hydrogen ion 89 mmol/liter PH ( 7.05) [ 7.5]2. Pco2 15 mmHg [ 40 mmhg]Muhammad Ramzan UL Rehman 6 7. What Does The ABG Tells Us ?o pH 7.05 = therefore acidosis (severe).o pCO2 = 15 therefore not resp. acidosis.o HCO3 = 5 therefore metabolic acidosisMuhammad Ramzan UL Rehman 7 8. o Anion gap = Na + K (Cl-+ HCO3-)=130 + 5.8 (101+ 5)= 29.8 (>14)High anion gap metabolic acidosis with respiratorycompensationMuhammad Ramzan UL Rehman 8 9. DKAhyperglycemiaKetonemia/ketonuria MetabolicacidoisMuhammad Ramzan UL Rehman 9 10. Effects of hyperglycemia :o Hyperglycemia leads to hyperosmolarity that in turncause osmotic diuresis and loss of water and electrolytesin urine and although hyperosmolarity shifts water to ECF,hypervolemia doesnt occur dt concomitant osmoticdiuresis.Muhammad Ramzan UL Rehman 10 11. Mechanism of ketosis :1. Lack of insulin : stimulates lipolysis that deliver FFA usedfor ketogenesis.2. Excess glucagon : Citric acid (the product of krebs cycleI.e. glucose metabolism that Is inhibited by glucagon asdecribed before) is responsible for regulation of activity ofacetyl coA carboxylase. The later synthesize malony coA inthe liver which turn off carnitine acyl transferase 1 that is therate limitting enzyme in ketogenesis. ( so turn off the supplyof substrate into krebs cycle and ketogenesis is automaticallyturned on ).Muhammad Ramzan UL Rehman 11 12. Effects of ketosis :Metabolic acidosis increasing anion gapDraws out intracelluar cations a sodium and potasiumVomiting that aggravates dehydrationTotal body stores of K are depleted due to urinary loss however s.Kmaybe intially elevated due to acidosis pulling intacellular K out.It markedly decrease with insulin therapy that stimuate theinflux of K into the cells and with correction of acidosis.Muhammad Ramzan UL Rehman 12 13. DKA: PathophysiologyGlucoseInsulin + PFKPyruvateKetoacidsAcetyl-CoAKrebsCyclefat cellTGHSLFFALiver CellFattyAcyl-CoAInsulin+GlucagonInsulinVLDL (TG)++Muhammad Ramzan UL Rehman 13 14. Clinical manifestations of DKAPolyuria, Polydipsia, PolyphagiaDehydration + orthostasisVomiting (50-80%)Abdominal pain present in at least 30%.Kssmaul respiration if pH < 7.2Temperature usually normal or low, if elevated thinkinfection!Lethargy, deliriumMuhammad Ramzan UL Rehman 14 15. ManagementRehydration Insulin therapyElectrolyte repletionDKAManagement of complicationsand evaluation of therapyMuhammad Ramzan UL Rehman 15 16. Priority is given to correction of the state of hyperosmolarity anddehdration. rehydration should be done gradually to preventovershooting of s.NA levels. Insulin therapy is started only after support of heamodynamics toprevent latent shock of rehydration Potassium replacement is started even with normal levels as it isexpected to dramatically drop with insulin therapy. 100 % O2 is given to all cases of DKA even if the saturation is 100 %on RA.Muhammad Ramzan UL Rehman 16 17. RehydrationVolume! Volume! VolumeObjectives: 1- Restore intravascular volume. 2- Reduce blood glucose level. 3- Reduce counter regulatory hormones. (catecholamines,glucagon)Augment insulin sensitivity.Muhammad Ramzan UL Rehman 17 18. How much fluid will you give ? 15 20 ml/kg . (1-2 L ) in 1st hour 500 ml/h for next 2 hours or 1L /h if in shock 500-250 ml/h according to hydration status ( UOP & renalfunctions). maintainence fluids should be provided.Muhammad Ramzan UL Rehman 18 19. How much fluid will you give ? Subsequent choice for IV fluids depends on:1-Corrected serum Na (Nac)2- Effective serum osmolarity (E osm)o If E osm > 320 mOsm/L or Nac is normal/elevated 0.45% NaCl 4-14 ml/Kg/hro If E osm