Diabetic ketoacidosis is as a result of ?
Severe insulin imsufficiency and occurs in type 1
Precipating factors for DKA are ?
Emotional stress
Infections
Insufficient or interrupted insulin therapy
Excessive alcohol intake
The main problem in DKA stems from?
acidosis with increased anion gap and debydration
Clinical findings of DKA
Polyuria , polydipsia , weakness
Nausea , vomiting , Abdominal pain , Anorexia
Kussmal respiration ( deep, sighing respiration
Fruity breath odor of acetone
Altered consciousness to coma
On physical exam
Fatal rhythm disorders
Signs of dehydration ( dry skin and mucous membrane , poor skin turgor)
Tachycardia
Hypothermia
The diagnosis of DKA can be made by
- finding elevated blood glucose,
- increased serum levels of acetoacetate, acetone, and hydroxybutyrate,
- metabolic acidosis (low serum bicarbonate and low blood pH),
- and increased anion gap (sodium – [bicarbonate + chloride]).
Lab findings of DKA
Hyperglycemia Ketonemia Metabolic acidosis with anion gap Electrolye changes Serum amylase and transaminase maybe increased Leukocytosis
Types of DKA
Abdominal Cardio Cerebral Renal Mixed
Abdominal type of DKA is characterized by ?
acute abdomen pain, dyspeptic signs with vomiting, leucocytosis and look like
acute appendicitis or peritonitis;
cardiovascular type
characterized by vascular collapse, tachycardia, cyanosis,
pain in the region of the heart, arterial fibrillation and is a result of decreased blood circulating volume due to the dehydration, in old patients with coronary arteries atherosclerosis
renal
develops in patients with diabetic nephropathy and is characterized by proteinuria, hematuria, azotemia
Treatment of DKA
Goals - Rehydration , correction of hyperglycemia , correction of electrolyte and acid base imbalance and investigating precipating factors
You give
- Fluids
- insulin
- Electrolyte imbalance
- treat complications
For rehydration treatment in DKA , you give
Pre hospital treatment of DKA
- Protect Airway and give oxygen
- 0,9% Nacl ( atleast 15mg/dl in first hour and in each of next 2 hours intervals )
- full monitoring
- hyperglycemia is initially treated by rehydration
Insulin treatment in DKA
Low dose insulin
- Regular insulin IV , maybe SC but never IM
- initial IV 8-10 units of short acting insulin in the first hour
- continous IV infusion of insulin 0.1unit/kg/hour in NACL infusion should be given after that
- when serum glucose conc reaches 11-13mmol/l insulin can be given SC ( if plasma and urine are “ - “ for ketones)
In the absence of effect for 2 - 3 hours. the insulin dose should be doubled and
the adequacy of hydration checked.
A reduction of 4 mmol/l or a blood glucose level of 15 mmol/l requires a dose reduction of half.
The rate of glycemic reduction could not be more than 4 mmol/l h. (danger of inverse osmotic gradient between intra - and extracellular space and cerebral edema); on the first day it is not necessary to reduce plasma glucose levels less than 13-15
mmol / l.
Rehydration treatment
- Rapid infusion fo sodium chloride
0,9% ( 1 l/h for the first 1-2 hrs and reduced to 0,5 when urine and BP stablizes )
Later it can be adjusted based on ….
- When serum glucose reaches 11-13 mmol/l ,give 5% glucose with insulin ( 1-2 units of insulin on each 100ml of 5% glucose sol)
Adding glucose helps in correction of tissue lipolysis and acidosis
Correction of electrolyte disorders
Correction of pottasium - pottasium infused in 3-5 hours , dont give until you know the renal function and serum K
Phosphate deficiency treated by pottssium phosphate
Magnesium def - MgSO4 6-8 ml every 3 hours
Correction of metabolic acidosis
It is as a result of insulin deficiency and rehydration so the ketone bodies will metabolize to bicarbonates when proper therapy starts ( fluids , electrolyes , insulin )
Exogenous administration of bicarbonate can overcorrect to ALkalosis
The use of bicarbonates to correct metabolic acidosis is recommended only in ?
Life threatening hyperkalemia
Whe Severe Lactic acidosis complicates DKA
Severe acidosis complicated with shock that is not responsive to fluid resuscitation
Bicarbonate dose will be
Infusion at a rate of 100-300ml of 2,5% sol
To prevent low pottasium , give iv infusion 50-75ml 2% pottasium chloride on each 100ml bicarbonate
Other treatmeny consideration for DKA
Check for infection and treat
Vascular thrombosis - heparin 5000 units. 4*/day
Vascular collapse - Mesatone 1-2ml
Cerebral edema - mannitol 1-2g/kg IV over 20 mins , dexametasone 0,25-0,50mg/kg/day every 4*/day
vascular thrombosis in DKA is due to
(it is secondary to severe dehydration, high serum viscosity, and low cardiac output
What is NKHHC ?
It is syndrome characterized by impaired consciousness, sometimes accompanied by seizures, extreme dehydration and extreme hyperglycemia that is not accompanied by ketoacidosis.
NKHHHC usually occurs in
patients with type 2 DM, who are treated with a diet or oral hypoglycemic agents, sometimes it is a complication of previously undiagnosed or medically neglected DM (type 2).
Predisposing factors to NKHHC
In 90 % of patients some degree of renal insufficiency seems to coexist.
- Infection (e.g., pneumonia, urinary tract infection, gram-negative sepsis)
- Use of certain drugs has been associated with this condition:
- steroids increase glucogenesis and antagonize the action of insulin;
- potassium-wasting diuretics (hypokalemia decreases insulin secretion), e.g.,
thiazides, furosemide;
- other drugs, e.g., propranolol, azathioprine, diazoxide. - Other medical conditions such as cerebrovascular accident, subdural hematoma,
acute pancreatitis, and severe burns have been associated with HNC. - Use of concentrated glucose solutions, such as used in peripheral
hyperalimentation or renal dialysis, has been associated with HNC. - HNC can be induced by peritoneal or hemodialysis, tube feeding.
- Endocrine disorders such as acromegaly, Cushing disease, and thyrotoxicosis
