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Case discussion

Case discussion. 32 years old gentleman, underlying Type I Diabetes Mellitus, p/w: drowsinessx1/7 abdominal pain x 1/7 fever x 2/7 cough x 2/7 unable to tolerate orallyx1/7. Examination. Patient is confused, tachypneic , tongue coated.

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Case discussion

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  1. Case discussion • 32 years old gentleman, underlying Type I Diabetes Mellitus, • p/w: drowsinessx1/7 abdominal pain x 1/7 fever x 2/7 cough x 2/7 unable to tolerate orallyx1/7

  2. Examination • Patient is confused, tachypneic, tongue coated. • Vital signs: • Temp:39 ° C , Pulse rate:104 BP:100/70 RR:24 PS:6 • Lungs:Equal air entry, creps at right lower zone. • CVS:S1,S2 • P/A:Tender at epigastrium • What would you do?

  3. Airway , Breathing , Circulation, • DEFG! (Don’t ever Forget Glucose)

  4. Diabetic emergencies Dr Breithner Dr.WongCheaFann

  5. Definition of diabetic ketoacidosis • A complex disordered metabolic state characterised by hyperglycaemia, acidosis, and ketonaemia due to absolute or relative insulin deficiency.

  6. Diabetic ketoacidosis Diagnostic criteria: • Capillary blood glucose > 11mmol/L • Capillary ketones >3mmol/L or urine ketones ≥2+ • Venous pH <7.3 and/or bicarbonate <15 mmol/L.

  7. Severe diabetic ketoacidosis • Criteria: • Venous bicarbonate 6 mmol/L • Blood ketones >6 mmol/L • Venous pH <7.1 • Hypokalaemia on admission (<3.5mmol/L) • GCS<12 • Oxygen saturation <92% on air (ABG) • Systolic BP <90mm Hg • Pulse >100 or <60 bpm • Anion gap >16 (Anion gap=(Na+K)-(Cl+Hco3)

  8. FIRST HOUR OF Management • Start 0.9% saline drip. Systolic BP<90mmHg 1 pint 0.9% saline over 10-15 minutes If SBP>90mmHg BP still low 2pints 0.9% saline over next 60 minutes Consider colloids

  9. Start intravenous insulin infusion (0.1 unit/kg/hr based on estimate of weight). • Assess patient • BP • Pulse • Temperature • Respiratory rate • Oxygen saturation • Glasgow Coma Scale • Hydration status • Full clinical examination

  10. Investigations • Capillary and venous blood glucose • Arterial blood gases • Blood or urinary ketones • BUSE • FBC • Blood cultures • UFEME • ECG (if indicated) • CXR (if indicated)

  11. Monitoring • Hourly DXT • Vital signs and I/Ocharting hourly • Venous bicarbonate and potassium at 60 minutes, 4 hours and 6-hourly thereafter • 6-hourly BUSE and urine ketone • Continuous pulse oximetry (if indicated) • Continuous cardiac monitoring (if indicated)

  12. Look for precipitating causes and treat accordingly • Start broad-spectrum antibiotics if infection suspected

  13. Sodium bicarbonate is not indicated to correct acidosis!!!

  14. Aims of treatment in 2nd-6th hour of tx • Rate of fall of ketones of at least 0.5 mmol/L/hr, or • Bicarbonate rise 3 mmol/L/hr, and • Blood glucose fall 3 mmol/L/hr • Maintain serum potassium in normal range • Avoid hypoglycaemia

  15. Hourly Glucose • 4hourly blood/urine ketones • VBG(HCO3,pH, Potassium) at 60 minutes, 4-6 hourly(depending on severity) • If potassium is low, reassess potassium replacement and check potassium 1-2hourly depending on severity.

  16. Fluid replacement • 1L of 0.9% saline +Kcl over next 2hours • 1L of 0.9% saline+ Kcl over next 4 hours Cautious fluid replacement in young people aged < 18 years, elderly, pregnant, +heart/renal failure.

  17. Dxt<14 mmol/L: o Switch to D5 at 125 mL/hr and reduce insulin infusion rate to 0.05 units/kg/hour; or o Switch to D10 at 125 mL/hr with no change in insulin infusion rate.

  18. 6th-12 hrs of treatment • 1L of 0.9% saline +Kcl over next 4 hours • 1L of 0.9% saline +Kcl over next 8 hours VBG, HCO3,pH, Dxt, Blood ketone,Potassium at 6th hours Continue fluid replacement. Assess for complications (overload, cerebral edema) Avoid hypoglycaemia. Treat underlying cause.

  19. Resolution of dka criteria • Blood ketones <0.3 mmol/L, • Venous pH >7.3

  20. Dka myths • Myth #1: We should get ABGs instead of VBGs in DKA • Study : Ma OJ et al. Arterial Blood Gas Results Rarely Influence Emergency Physician Management of Patients with Suspected Diabetic Ketoacidosis. AcadEmerg Med Aug 2003; 10(8): 836 – 41. PMID: 12896883 Venous pH correlated well with arterial pH with difference of -0.015 +/- 0.006 pH units

  21. Myth #2: After Intravenous Fluids (IVF), Insulin is the Next Step Clinical Bottom Line: After starting IVF, the next step in DKA management is electrolyte replacement, NOT Insulin. Why?

  22. Myth #3: Once pH <7.1, Patients Need Bicarbonate Therapy • Study #1: Chua et al. Bicarbonate in Diabetic Ketoacidosis – A Systematic Review. Ann Intensive Care 2011; 1 (23). PMID: 21906367 • 44 studies of DKA patients reviewed which showed: • Transient improvement in metabolic acidosis • No improved glycemic control • Risk of cerebral edema in pediatric patients • No studies with pH <6.85 • Study #2:Duhon et al. Intravenous Sodium Bicarbonate Therapy in Severely Acidotic Diabetic Ketoacidosis. Ann Pharmacother 2013. 47(7 – 8): 970 – 5. PMID: 23737516 • Retrospective study of 86 patients with DKA which showed: • No difference in: Time to resolution of acidemia, time to hospital discharge, time on IV insulin, potassium requirement in 1st 24hrs • Subgroup Analysis of pH < 6.9 (n = 20) showed no statistical difference in time to resolution of academia

  23. Clinical Bottom Line: Intravenous bicarbonate therapy may transiently make acidemia better, but there is no improvement of glycemic control, time on insulin, time to hospital discharge, and in kids can worsen cerebral edema.

  24. Myth #4: We Should Bolus Insulin Before Starting the Infusion • Goyal et al. Utility of Initial Bolus Insulin in the Treatment of Diabetic Ketoacidosis. J Emerg Med 2010; 38(4): 422 – 7. PMID: 18514472 • Prospective, Observational Study of 157 patients with DKA: • Insulin bolus at the start of an insulin infusion IS EQUIVALENT to no insulin bolus at the start of an insulin infusion in several endpoints including: • Decrease normalization of glucose • Affect the rate of change of anion gap • Reduce ED or hospital length of stay • Insulin bolus at the start of an insulin infusion DOES: • Increase hypoglycemic events by 6 fold (6% vs 1%) [NOT Statistically Significant]

  25. Clinical Bottom Line: Insulin boluses increase hypoglycemic events without other clinical benefits in the treatment of DKA.

  26. Hyperglycaemic Hyperosmolar State DIAGNOSTIC CRITERIA: • Hypovolaemia • Marked hyperglycaemia (BG >30 mmol/L) • Osmolality >320 mosmol/kg

  27. Precipitating factors a) Infections and sepsis b) Thrombotic stroke c) Intracranial haemorrhage d) Silent myocardial infarction e) Pulmonary embolism

  28. GOALS OF TREATMENT • Normalise the osmolality • Replace fluid and electrolyte losses • Normalise blood glucose • Prevention of complications

  29. PRINCIPLES OF TREATMENT • Use 0.9% saline • Monitor Serum Osmolalilty regularly • Rate of rehydration- Assess severity & ptcomorbids! • Blood Glucose NOT >5mmol/Hour • Low dose IV insulin (0.05 units/kg/hr) • Prophylactic low molecular weight heparin (LMWH) • Correct Hyperkalaemia, hypokalaemia, hypophosphataemia and hypomagnesaemia if present. • Find out SOURCE of INFECTION if sepsis suspected.

  30. HYPOGLYCAEMIA • DEFINITION: a) Low plasma glucose level (<4.0 mmol/L).b) Development of autonomic or neuroglycopenic symptoms inpatients treated with insulin or OADs which are reversed by caloric intake.

  31. Symptoms

  32. severity

  33. severity

  34. HYPOGLYCAEMIA MILD-MODERATE, ALERT PT SEVERE& UNCONSCIOUS SEVERE+ CONSCIOUS • 20–50 mL of IV D50%over 1–3 minutes Take 20g honey, sugar or juice and repeat Dxt In 15 mins Take 15g honey, sugar or juice and repeat Dxt In 15 mins

  35. Case discussion • 32 years old gentleman, underlying Type I Diabetes Mellitus, • p/w: drowsinessx1/7 abdominal pain x 1/7 fever x 2/7 cough x 2/7 unable to tolerate orallyx1/7

  36. Examination • Patient is confused, tachypneic, tongue coated. • Vital signs: • Temp:39 ° C , Pulse rate:104 BP:100/70 RR:24 PS:6 • Lungs:Equal air entry, creps at right lower zone. • CVS:S1,S2 • P/A:Tender at epigastrium

  37. Investigations: • Dxt: 25mmol/L • FBC: Hb14 TWC:18 Plt 300 • Urea:10.2 Creat 123 Na:152 K:5.3 Chloride:110 • ABG: pH 6.9 pCO2:28 HCO3: 3.9 SaO2:98% • Serum Ketone: 7

  38. sources • Guidelines for Clinical Practice for the Management of Diabetes Mellitus, 2007 • Joint British Diabetes Societies Inpatient Care Group The Management of Diabetic Ketoacidosis in Adults March 2010 • https://www.diabetes.org.uk/resources-s3/2017-09/Management-of-DKA-241013.pdf

  39. Thank you.

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