Diabetic Emergencies!!!!!!!!! Flashcards
DKA requires immediate attention bc…
It’s a life threatening dz w/ 5% mortality in < 40 y.o. And 20% mortality in elderly
DKA can be diagnosed with these 3 criteria:
1- hyperglycemia >250
2- ketosis: ketones in serum of blood
3- acidosis: pH <7.3 or serum bicarb <15
Etiologies of DKA (7)
1- poor glucose control
2- pt. Newly dxed T1DM
3- infx: usually UTI or PNA
4- insulin pump failure or insulin leakage
5- SE of SLGT-2 usage
6- severe stress w/ T2DM: sepsis or trauma
7- setting w/ illness: MI, surgery, trauma, or pancreatitis
Symptoms of DKA and onset:
Onset of s/s: 24-48 hrs
- -> can progress rapidly
- n/v/anorexia
- weakness and fatigue
- tachypnea (to blow of CO2)
- polydipsia/polyuria
- abdominal pain
- mental stupor–> coma
Clinical signs of DKA:
- abdominal pain
- evidence of dehydration
- rapid deep breathing (kussmaul breathing)
- fruity breath odor
- worsening mental status changes
- hypotension/tachycardia
DKA Lab findings: (8)
1- elevated blood glucose (250-600)
2- serum electrolytes: serum sodium-(serum bicarb+ serum Cl): shows AKI, mild hyponatremia, and low bicarb; anion gap elevated and >20
3- CBC w/diff: hemoconcentration (from dehydration) and leukocytosis (from stressor)
4- elevated plasma osmolality (increased salt)
5- UA and urine ketones: concentrated urine with high amounts of glucose and ketones
6- serum ketones: acetone, acetoacetic acid, & beta-hydroxybutyric acid (preferred)
7- ABG: likely not used if mild DKA; reveals degree of acidosis
8- ECG (stress on CV)
What three factors contribute to the rapidity of DKA onset and severity?
1- hyperglycemia
2- ketoacidemia
3- fluid and electrolyte depletion
Etiology behind hyperglycemia
- reduced or diminished insulin output–> so no glucose reuptake by cells
- IV starvation and glucagon predominates–> hepatic glycogenolysis leading to even higher glucose levels and FA breakdown–> ketone production and even more glucose in blood
(Problem at the cellular level for glucose getting into cells)
Etiology of ketoacidemia
Glucagon predominates and lipolysis and hepatic ketogenesis (starvation mode)
etiology of fluid and electrolyte depletion
High ketones and blood glucose–> osmotic diuresis and excretion of fluid by kidney
Average fluid loss in DKA
5 L
Prevention of DKA:
- Most important to have pt. come in early
- patient education for early s/s
- ->+ for replenishing fluids and electrolytes
- at home ketone detection kit (of urine)
- additional insulin on sliding scale
If persistent ketonuria exists x2 tests, patient should..
- List 2 worsening s/s:
Contact their MD!! Likely ED/hospitalization
+ vomiting; resistant to insulin increases
Emergent Initial Tx of DKA includes..
1- thorough h&p (etiology)
2- pt. On tele and large IV NS wide open (Rq lots of fluid)
3- CBC, lytes, +/- cultures, ABG if critically ill; EKG and UA
4- serum K
Begin insulin gtt only w/ serum K levels of:
> 5.3 mEq
Begin both insulin gtt and K replacement w/ serum levels:
3.4-5.3 mEq/L
Begin K replacement only w/ serum K levels of:
3.3 mEq/L or less
Hospital tx of DKA involves:
1- insulin replacement
2- fluid replacement
3- K replacement
Insulin replacement tx:
Initial bonus to prime insulin receptors–> IV insulin infusion drip
Initially 0.9% or 0.45% NS & convert to D5 with BG<250 (solution dependent on volume needs)
Insulin replacement physiology:
1- corrects acidosis
2- reduces hyperosmolality
3- reduces hyperglucagonemia
Fluid replacement specifics:
Most commonly w/ 4-5L
Hypovolemia ass. W/ adverse outcomes (at least 3-4L in 8 hr)
Hypervolemia–> ARDs and cerebral edema
Potassium replacement tx:
- K loss w/ polyuria and vomiting
- Acidosis shifts k into extracellular space, so initial measurements higher on avg.
- correction of acidosis–> k shift intracellularly so replacement rq. In 2nd and 3rd hrs of tx (20-30 mEq/hr)
C/I of potassium supplementation:
- anuria; persistent K>5; uremic (waste products in blood)
other replacement metabolites in tx w/ DKA:
- phosphate (may be needed; replaced slowly)
- hypercholeremia: self-limiting in 12-24h
- sodium bicarb: controversial; only w/ severe acidosis (<7.0)
Additional hospital management or considerations in DKA:
- NG tube: to decompress stomach
- strict I/O
- no narcotics/sedatives
- tx ass. Infx
- strict documentation and familial communication
- re-educate; check meds and discuss compliance; indicate severity of situation