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DIABETIC KETOACIDOSIS

DIABETIC KETOACIDOSIS. DIABETIC KETOACIDOS IS A MAJOR MADICAL EMERGENCY AND REMAINS A SERIOUS CAUSE OF MORBIDITY PRINCIPALLY IN PEOPLE WITH TYPE 1 DM. IT IS DEFINED AS

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DIABETIC KETOACIDOSIS

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  1. DIABETIC KETOACIDOSIS

  2. DIABETIC KETOACIDOS IS A MAJOR MADICAL EMERGENCY AND REMAINS A SERIOUS CAUSE OF MORBIDITY PRINCIPALLY IN PEOPLE WITH TYPE 1 DM. IT IS DEFINED AS “A MEDICAL EMERGENCY IN WHICH HYPERGLYCEMIA IS ASSOSIATED WITH A METABOLIC ACIDOSIS DUE TO GREATLY RAISED ( > 5 MMOL ) KETONE LEVELS”

  3. PRECIPITATING FATORS INFECTIONS SURGERY MI NON COMPLAINCE OR WRONG INSULIN DOSE

  4. PATHOGENESIS CARDINAL BICHEMICAL FEATURES OF DKA ARE HYPERGLYCEMIA HYPERKETONEMIA METABOLIC ACIDOSIS

  5. GLUCOSE HYPERGLYCEMIA GLYCOSURIA OSMOTIC DIURESIS FLUID & ELECTROLYTE DEFICIENCY RENAL HYPOPERFUSION DECREASED EXCRETION OF KETONES INCREASED H IONS KETONES ACIDOSIS VOMITING FLUID & ELECTROLYTE DEFICIENCY RENAL HYPOPERFUSION DECREASED EXCRETION OF KETONES INCREASED H IONS

  6. KETOGENESIS INSULIN DEFICIENCY INCREASED LIPOLYSIS INCREASE FREE FATTY ACID TAKE UP BY LIVER SUBSTRATE FOR KETONE FORMATION (ACETOACITIC ACID,ACETONE AND BETA HYDROXYBUTYRIC ACID ) PASS INTO BLOOD ACIDOSIS

  7. FLUID LOSS WATER 6 LITRE SODIUM 500 MMOL CHLORIDE 400 MMOL POTASSIUM 350 MMOL

  8. CLINICAL FEATURES SYMPTOMS IN FULMINATING CASES STRICKING FEATURES ARE THOSE OF SALT AND WATER DEPLETION POLYURIA THURST WT LOSS WEAKNESS NAUSEA VOMITING LEG CRAMPS BLURRED VISION ABDOMINAL PAIN

  9. SIGNS LOSS OF SKIN TURGER FURRED TONGUE CRACKED LIPS TACHYCARDIA SMELL OF ACETONE AIR HUNGER HYPOTHERMIA CONFUSION , DROWSINESS AND COMA

  10. DIAGNOSIS DIABETIC KETOACIDOSIS IS CONFIRMED BY HYPERGLYCEMIA METABOLIC ACIDOSIS KETONURIA,HYPERKETONEMIA

  11. INVESTIGATIONS BLOOD GLUCOSE & ELECTROLYTES URINARY KETONES URINE IS STRONGLU +VE FOR KETONE BODIES ABG’S BLOOD CP

  12. INVESTIGATIONS CXR TO LOOK FOR ANY INFECTION ECG K+ LEVELS UREA & CREATININE RENAL FUNCTION PLASMA OSMOLARITY 2[Na+]+[UREA]+[GLUCOSE] MMOL/L

  13. Diagnostic Criteria and Typical Total Body Deficits of Water and Electrolytes in Diabetic Ketoacidosis Diagnostic criteria* Blood glucose: >250 mg per dL (13.9 mmol per L) pH: <7.3 Serum bicarbonate: <15 mEq per L Urinary ketone: >=3+ Serum ketone: positive at 1:2 dilutions Serum osmolality: variable  Typical deficits Water: 6 L, or 100 mL per kg body weight Sodium: 7 to 10 mEq per kg body weight Potassium: 3 to 5 mEq per kg body weight Phosphate: ~1.0 mmol per kg body weight

  14. MANAGEMENT PRINCIPAL COMPONENTS OF TREATMENT ARE FLUID REPLACEMENT ADMINISTRATION OF SHORT ACTING (REGULAR) INSULIN K+ RERPLACEMENT ADMINISTRATION OF ANTIBIOTICS

  15. Protocol for management • Asses your ABC’s • Asses the consious levels, GCS • NG tube • Urinary cathetarization • Address the circulatory issues, CVP line & plasma expanders if BP not maintained • Antibiotics if obvious source of infection • Labs, Monitoring, ECGs

  16. 1. FLUID REPLACEMENT AVERAGE FLIUD LOSS IS 6 LITRES 3 LITERS FROM EXTRRACELLULAR COMPARTMENT 3 LITERS FROM INTRA CELLULAR COMPARTMENT

  17. SCHEME FOR FLUID REPLACEMENT FIRST WE REPLACE EXTRA CELLULAR FLUID BY 0.9% NaCl 1L 30MIN 1L 1HOUR 1L 2HOURS

  18. SCHEME FOR FLUID REPLACEMENT USE DEXTROSE SALINE OR 5% D/W WHEM BLOOD GLUCOSE IS < 15 mmol/L THOSE >65 YRS OLD OR WITH CCF NEEDS LESS SALINE MORE CAUTIOUSLY

  19. INSULIN START WITH I/V INSULIN INFUSION @ 5U/HRS ALTERNATIVELY 10 – 20 U I/M FOLLOWED BY 5 U/HR I/M BLOOD GLUCOSE CONCENTRATION SHOULD FALL BY 3 –6 mmol/L IF BLOOD GLUCOSE LEVELS DONOT FALL IN FIRST 2 HR THE DOSE OF INSULIN SHOULD BE DOUBLED

  20. WHEN LEVEL FALL TO 10 – 15 mmol/L DOSE OF INSULIN SHOULD BE DECREASED TO 1 – 4 mmol/L S/C ROUTE SHOULD BE AVOIDED BECAUSE S/C BLOOD FLOW IS REDUCED IN SHOCKED PT VERY RAPID BLOOD GLUCOSE FALL SHOULD BE AVOIDED BECAUSE IT CAN LEAD TO CEREBRAL OEDEMA

  21. POTASSIUM AS THE PLASMA K IS OFTEN HIGHER AT PRESENTATION TREATMENT WITH I/V KCL SHOULD BE STARTED CAUTIOSLY S K+ (mmol/L) AMOUNT OF KCL < 3 mmol/L 40 mmol/L <4 mmol/L 30 mmol/L <5 mmol/L 20 mmol/L

  22. SODIUM BICARBONATE IN PTS WHO ARE SEVERILY ACIDOTIC pH < 7.0 [H+] > 100mmol/L INFUSION OF NaHCO3 ( 300ml 1.26 % OVER 30 MIN )SHOULD BE CONSIDERED WITH SIMULTANEOUS ADMINISTRATION OF K

  23. ANTIBIOTICS INFECTION SHOULD BE CAREFULLY SOUGHT AND VIGOROSLY TREATED

  24. ADDITIONAL PROCEDURES CATHETERIZATION IF NO URINE OUTPUT FOR > 3 HRS N/G TUBE TO KEEP STOMACH EMPTY IN UNCONCIOUS CVP LINE IF CVS COMPROMISED PLASMA EXPANDER IF BP DOES NOT RISE WITH IV SALINE S/C HEPARIN 5000U/8 HR UNTIL MOBILE IN COMOTOSE , ELDERLY ,OBESE

  25. MONITORING BLOOD GLUCOSE & ELECTROLYTES HOURLY FOR 8 HRS VITAL MONITORING HOURLY URINE O/P KETONES ECG ABG’S

  26. SUBSEQUENT MANAGEMENT I/V DEXTROSE AND SALINE SHOULD BE CONTINUED UNTIL PT FEEL ABLE TO EAT AND KEEP FOOD DOWN A SIMILAR AMOUNT OF INSULIN IS GIVEN AS THERE INJECTION OF REGULAR INSULIN S/C INSULIN AT MEAL TIMES AND A DOSE OF INTERMEDIATE ACTING INSULIN AT NIGHT

  27. COMPLICATIONS HYPOTENTION CEREBRAL OEDEMA ARDS THROMBOEMBOLISM DIC ACUTE CIRCULATORY FAILURE

  28. O hour • Start iv insulin 5 u /hr alt give 10-15u i.m. followed by 5 u im thereafter • O.9 % NS 1 lt over 30 mins • Send urgent electrolytes • Urine and serum for ketone levels

  29. 30 mins • Cont. insulin 5 u/hr iv or im • O.9 % NS half lt in 30mins • If K levels >5.5 mmol/l no need for KCl, if 3.5-5.5 mmol/l give 20 mmol kcl • If K <3.5 mmol/l then give 40 mmol/l of infused levels • If pH <7.O , give 3OO ml sod bicarbonate over 3O mins

  30. Hour 1 • Cont. insulin 5 u/hr iv or im • O.5 lt NS in 1 hr • Recheck K levels • Recheck vitals every 15 mins

  31. Hour 2 • Cont. insulin 5 u/hr iv or im • O.5 lt NS in 2 hrs • Cont. observing vitals & biochemistry

  32. When RBS <15 mmol/l • Reduce rate of insulin to 1-4 U/hr • Change to 5 % dextrose inf 0.5 lt/2 hrs • Continue K replacement • Recheck every aspect hourly till pt. stable then 2 hrly

  33. PIT FALLS IN DKA PLASMA GLUCOSE IS USUALLY HIGH BUT NOT ALWAYS HIGH WCC MAY BE SEEN IN ABSENCE OF INFECTION INFECTION IN ABSENCE OF FEVER CREATININE SOME ESSAYS FOR CREATININE CROSS REACT WITH KETONE BODIES

  34. PIT FALLS IN DKA HYPONATREMIA DUE TO OSMOLAR COMPENSATION FOR HYPERGLYCEMIA SERUM AMYLASE RAISED UPTO 10 TIMES

  35. MCQS WHAT IS THE FIRST STEP IN THE MANAGEMENT OF PT WITH DKA GET AN IV ACCESS AND GIVE INSULIN ACCORDING TO SLIDING SCALE GET AN IV ACCESS AND GIVE IL OF 0.9% NaCl IN 30 MIN GET AN IV ACCESS AND GIVE 50 ML OF 50% DW

  36. AMOUNT OF KCL GIVEN IN DKA PT WITH SERUM K+ LEVEL OF <3 mmol/L 20 mmol/L 30 mmol/L 40 mmol/L

  37. CASE SCENARIO A 15 YEARS OLD BOY PRESENTED IN EMERGENCY DEPARTMENT WITH COMPLAINTS OF HIGH GRADE FEVER,PRODUCTIVE COUGH WITH YELLOWISH SPUTUM FOR LAST 5 DAYS.HE HAS PERSISTENT VOMITINF AND ABDOMINAL PAIN FOR 2 DAYS AND DROWSINESS FOR ONE DAY. WHAT IS YOUR CLINICAL IMPRESSION? WHAT CLINICAL SIGNS DO YOU SUSPECT IN THIS CASE?

  38. CASE SCENARIO BP 80/60mmHg PULSE 110/min, regular. TEMP 97 F R/R 26/min GCS 7/15 PUPILS HAS SLUGGISH REPONSE TO LIGHT,NORMAL SIZED. PLANTARS BILATERAL NON-SPECIFIC THERE IS BRONCHIAL BREATHING IN RIGHT BASAL LUNG THERE ARE SIGNS OF DEHYDRATION,REST OF EXAMINATION IS NORMAL. WHAT IS LIKELY DIAGNOSIS? HOW WILL YOU INVESTIGATE THIS CASE?

  39. CASE SCENARIO BSR SERUM KETONES URINARY KETONE SERUM ELECTROLYTES ABGS CP CXR

  40. CASE SCENARIO HOW WILL YOU MANAGE THIS PATIENT?

  41. THANK YOU

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