diabetic ketoacidosis Flashcards
what values define a diabetic ketoacidosis 3
hyperglycaemial acidosis , ketonuria
glucose >11 or known diabetic
SERUM ketones >3mmol/l
pH <7.3 or HCO3 <15
who can present with diabetic ketoacidosis
any diabetic patient that is unwell
-normally T1DM
*-can be first presentation of T1DM
how long does a DKA take to develop
usually over 24hrs
symptoms of diabetic ketoacidosis 5
abdo pain
vomiting
fatiuge
dehydration
polyuria
precipitatoins of diabetic ketoacidosis 4
4 āiās
infection
infarction-silent MIs, common in diabetic patients
incurrent illness-trauma, recent surg, PE
insufficient insulin-poor compliance
common precipitant of DKA in young patients 1
vomiting due to alochol excess
clinical signs of DKA 4
generally look unwell
dehydrated
pear drop breath
kussmaul breathing
give examples of signs of dehydration in a patinet 5
dry mucous membranes
sunken eyes
slow CRT
tachycardia
hypotensive
management of DKA in 0-60 mins 2
1l NaCl 0.9% over 1 hr
IV solubule insulin 6U/hour
children 10ml/kg
interventions to consider in a DKA presentation 8
ECG
GC
iinsert catheter if oliguric
MSSU
blood culures
central line
CXR
DVT prophylaxis
management of DKA 60-120 minutes 2
1l NaCL 0.9% over 1hr
continue insulin 6u/hr
management of DKA hours 3 and 4
500ml NaCL 0.9% per hour
how should potassium be introduced in DKA managmenet 1
after first hour or when serum K+ is back
-prescribe KCL in 500ml NaCL bag as
how much potassium should be given dependent on the serum postassium level (3 options)
if anuric or K+>5mmol/l - none
if K+ 3.5-5mmol/l- 10mmol/l
if K+ <3.5mmol/l - 20mmol/l -NEED CARDIAC MONITORING
how often should finger prick glucose and lab glucose be checked in DKA
finger - every hour for first 4 hrs
lab -2hrs and 4hrs
when should dextrose be added to DKA management and how much
if blood glucose falls to <14mmol/l in first 6 hours
commence dextrose 10% 500mls 100ml/hr
*CONTINUE 0.9%NACL at 400ml/hr (potassium goes in with this)
IF BM <14 OCCURS AFTER 6HRS:
-change fluid to 0.45%NaCl/5% Dextrose(paeds)
when should insulin be reduced
after first 4 hours when blood glucose falls below <14mmol/l
-ONLY AFTER FIRST 4 HOURS
what is the target glucose range in DKA managemnt
between 9-14mmol/l
adjust insulin rate as necessary
what should be continued whilst on DKA pathway
always continue long acting insulin
what should be measured 4hrly for DKA management 2
UnEs
HCO3
other aspects of DKA management 3
LMWH due to thrombosis risk
catherised for monitoring fluid balance
symptom mangement ie -antiemetics
how is plasma osmolaitily calculated
-what value should it be
-what is it useful for
2 (Na +K) + urea and glucose
-should be higher than 290
-can be used to differentiate between HHS and DKA
-HHS osmolaity is usually higher
-ketones also less signficant part of presentation
complications of DKA 6
hypo/hyperkalaemia
hypoglycaemia
cerebral oedema (due to fluid shifts)
pulmonary oedema- ARDS
-arrhythmias due to electrolyte distrubances
AKI
describe kussmauls breathing
deep laboured breathing
-associated with severe metabolic acidosis
-form of hyperventilation - creates respiratiory comppensation (alkalosis) in severe acidosis
triad of HHS
severe hyperglycaemia
dehydration and renal failure
mild/absent ketonuria
sympomts of HHS 5
lethargy
decreased appetite
confused or drowsy
hypotensive
tachycardic
-insidious onset
-not as common as DKA but mortality is higher (50%)
how can clinical features of HHS be classififed 4
general
neuro
haematologyical
cardiovascular
general syx of HHS 3
fatigue
lethargy
N+V
neuro syx of HHS4
altered level of consciousness
headaches
papilloedema
weakness
haematological syx of HHS 1
-what can this result in 3
hyperviscosity
-can result in MI, stroke , peropheral arterial thrombosis
cardiovascular syx of HHS 3
dehydration
hypotension
tachycardia
diagnosis of HHS 5
hypovolaemia
very high BM >30mmol/l
serum osmolality >320mOsmol/l
bicarb usally >15momol
abscence of ketones
-ketoacidosis not present
mdanagement of HHS 4
IV fluids
-slow and steady
IV insulin
IV potassium
-much less pronunced than DKA so less agressive replacement is required
anticoag drugs- due to HHS ptx often being hypercoagulable
comparing DKA and HHS
degree of insulin deficiney
DKA- absolute insulin deficiency
HHS- relative insulin deficiency
comparing DKA and HHS
BMs
DKA- generally lower BMs
HHS- BMs often v high
comparing DKA and HHS
lipolysis and ketogenesis
DKA- yes
HHS- often absent
comparing DKA and HHS
plasma sodium levels
DKA-usualy normal
HHS
- high
comparing DKA and HHS
age of patients
DKA- younger
HHS- older
