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DIABETIC KETOACIDOSIS

DIABETIC KETOACIDOSIS. By, Dr. ASWIN ASOK CHERIYAN Chair Person – Dr. JAYAMOHAN A.S. What is Diabetes?. Diabetes is a clinical syndrome characterized by hyperglycemia due to absolute or relative deficiency of insulin which leads to multiple organ dysfunction. Types of Diabetes.

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DIABETIC KETOACIDOSIS

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  1. DIABETIC KETOACIDOSIS By, Dr. ASWIN ASOK CHERIYAN Chair Person – Dr. JAYAMOHAN A.S.

  2. What is Diabetes? • Diabetes is a clinical syndrome characterized by hyperglycemia due to absolute or relative deficiency of insulin which leads to multiple organ dysfunction.

  3. Types of Diabetes • Type 1 Diabetes (I.D.D.M.) • Type 2 Diabetes (N.I.D.D.M.) • Other types like- • Gestational Diabetes mellitus • DM due to genetic defects in insulin action • DM due to diseases of exocrine pancreas

  4. ACUTE Diabetic Ketoacidosis Hyperosmolar Non-ketotic Diabetic Coma Hypoglycemia Lactic acidosis CHRONIC Microvasular- Diabetic Neuropathy Diabetic Retinopathy Diabetic Nephropathy Macrovasular- Coronary Artery Disease Peripheral Vascular Disease Cerebrovascular disease Complications of Diabetes

  5. Diabetic Autonomic Neuropathies like Gastro paresis Sexual Dysfunction • Some Dermatological Complications are also present

  6. DIABETIC KETOACIDOSIS or DKA • A major medical emergency • Usually seen in Type 1 Diabetic patients • The incidence is higher in elderly patients • Mortality in developed countries - about 5-10% • Mortality in developing countries – about 30–40%

  7. Precipitating Factors • Rapid decrease or no insulin intake • Infections • Severe stress (physical and emotional)

  8. Pathogenesis • DKA results from Insulin deficiency and Glucagon excess

  9. The key features in DKA are : • Hyperglycemia • Volume Depletion and Dehydration • Hyperketonemia • Metabolic Acidosis

  10. Clinical Presentation in DKA • Polyurea with signs of dehydration • Nausea, Vomiting • Abdominal pain • Tachypnoea – Kussmauls Breathing • Weakness, Confusion • Altered Consciousness or Frank coma

  11. On Examination the patient may have: • Hypothermia • Hypotension • Fruity odour of breath- Due to Acetone

  12. Investigations: • Urine analysis- Presence of glucose and Ketones • Blood sugar analysis- Increase in plasma glucose levels • Plasma ketone levels are raised • Electrolyte levels Plasma Potassium Plasma Bicarbonate • Hydrogen ion concentration is raised • Arterial pH is low • Blood count and culture • ECG • Chest X-ray

  13. Diagnostic Criteria for DKA : • Blood Glucose > 250 mg/dl • Arterial pH < 7.3 • Moderate degree of ketonaemia and/or ketonuria

  14. Management of DKA : • Insulin Therapy • Fluid replacement • Replacement of Electrolytes • Correction of Acidosis • Antibiotics

  15. Insulin Therapy • Rapid acting insulin is used • Bolus- 10 units of insulin iv + 10 units s/c • Followed by iv infusion of 50 units of plain insulin in 500ml normal saline at the rate of 30 drops/min (10 units/hr) till RBS < 250 mgm% • Once RBS < 250 mgm% , Stop iv insulin infusion • Start s/c insulin 8th hrly with iv DNS, ie. 2/3rd the dose of total insulin given so far.

  16. Points to be noted during insulin therapy : • If blood glucose does not fall within two hours of treatment- the dose of insulin should be doubled • A more rapid fall in glucose should be avoided as hypoglycemia can be precipitated and a serious complication of Cerebral Edema may develop

  17. Fluid Replacement : • Early and rapid rehydration is essential • Usual regimen- 2 pints of NS in the first half hour + 2 pints of NS in the next hour + 2 pints of NS in the next 2 hours • An accurate record of fluid input and output must be maintained.

  18. Replacement of Electrolytes : • Potassium Replacement • Bicarbonate Replacement

  19. Additional Procedures : • Catheterization if no urine is passed after 3 hours • Nasogastric tube to keep Stomach empty in unconscious patients • Antibiotics should be given to treat the infections

  20. Monitoring : • Blood glucose and electrolytes hourly for 3 hrs and every 2-4 hrs thereafter • Temperature, Pulse, Respiration and BP hourly • Urinary output and ketone levels • ECG

  21. Complications of DKA : • Cerebral Edema • Hypoglycemia • Acute Respiratory Distress Syndrome • Thromboembolism • DIC • Acute Circulatory Failure • Myocardial Infarction

  22. Prognosis : • Poor prognostic signs at admission are Hypotension, Azotemia, Deep Coma and Associated illness.

  23. Prevention : Prevention of DKA can be attained to a certain level – • By making the patients aware of the importance of insulin during an illness and the reasons never to discontinue insulin without consulting with the doctor first. • By making the patients aware of the importance of routine blood glucose evaluation and the use of supplemental short or rapid acting insulin's. • The importance of treating an infection at the earliest.

  24. Last but not the Least…..

  25. THANK YOU FOR YOUR PATIENT LISTENING

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