Diabetic ketoacidosis Flashcards
Pathogenesis
Insulin deficiency Metabolism of TAG and AA Gycerol + FFA ++, alanine= +hepatic gluconeogenesis +Glucagon (not inhibited by insulin) Xblock of ketogenesis +Acetoacetic acid + bHB->metabolic acidosis Hyperglycemia->osmotic diuresis, +Na and K losses Serum K may rise in response to acidosis, but total depletion
Precipitating factors
Infection Initial presentation Infarction Intoxication Insulin missed
Symptoms
early symptoms: polyuria, polydipsia, malaise, nocturia, weight loss late signs and symptoms anorexia, nausea, vomiting, dyspnea (often due to acidosis), fatigue abdominal pain drowsiness, stupor, coma Kussmaul’s respiration fruity acetone breath Evidence of cause: infection, MI, intoxication
Examination
Level of consciousness Hydration status->tachyC, hypoT, poor perfusion, -ve skin turgor, dry mucus membranes May have fever Kussmauls breathing, acetone breath Evidence of infection
Investigations and findings
Plasma glucose ++ ABG->respiratory acidosis, low bicarbonate Urinalysis->+glucose, ketones, may have infection UEC: Urea->elevated Creatinine->elevated Sodium low Potassium elevated Chloride, Mg, Ca low Phosphate high Elevated anion gap Lactate ++ LFTs normal Amylase elevated Lipase normal Serum osmolarity variable FBC elevated WCC Consider: ECG, troponins CXR Blood, urine, sputum cultures if considering infection
Pediatric patients presenting with >11.1mml, next step
Serum ketones measured at bedside If +ve, assess for acidosis Urinalysis if ketones serum not available
Assessment of adolescents and children
- Level of dehydration 2. Level of consciousness (GCS) 3. Investigations -FBE -Blood glucose, UEC, CMP -Blood ketones at bedside -VBG -Urine -Ix for precipitant cause- if clinical signs of infection: septic workup
Level of deH % and findings
- Degree Of Dehydration (often over-estimated)
None/Mild (< 4%): no clinical signs
Moderate (4-7%): easily detectable dehydration eg. reduced skin turgor, poor capillary return
Severe(>7%): poor perfusion, rapid pulse, reduced blood pressure i.e. shock
Special care requirements re staff for children with DKA
Children and adolescents with DKA should be managed in a unit that has: Experienced nursing staff trained in the monitoring and management of DKA A paediatric endocrinologist, paediatrician or paediatric critical care specialist with training and expertise in the management of DKA. Where such expertise is not available on-site, telephone advice should be sought from the appropriate specialists Access to laboratories for frequent and timely evaluation of biochemical variables
Acute management DKA
- ABC 2. Supportive measures to considerif appropriate -Secure the airway and consider ng tube placement (to avoid aspiration) in the unconscious / severely obtunded patient -Insert a second peripheral IV catheter for convenient and painless repetitive blood sampling -Give oxygen to patients with severe circulatory impairment or shock. -Use a cardiac monitor for continuous electrocardiographic monitoring to assess for signs of hyperkalemia (peaked T-waves, widened QRS) or hypokalemia (flattened or inverted T waves, ST depression, wide PR interval). -Consider antibiotics for febrile patients after obtaining appropriate cultures -Catheterise the bladder if the patient is unconscious or unable to void on demand to allow for strict fluid balance (e.g. in infants and very ill young children). 3. Fluid -Bolus, Keep NBM until alert and stable, NGT if comatose, recurrent vomiting -Fluid replacement->NS and potassium for at least 6 hours. If glucose falls rapid or 12-15, change to NS + 5% dextrose + potassium 4. Glucose monitoring 5. Potassium replacement 6. Insulin 7. Ongoing monitoring -Strict fluid balance -Hourly observations-> pulse, BP, respiratory rate, level of consciousness (GCS), and neurological status (pupillary responses, assess for change eg restlessness, irritability, headache) -Hourly glucose and ketones -Re-check potassium -VBG + lab glucose 2/24 for 6/24, then 2-4/24 after -Monitor UEC 2-4/24 -Temperature 2-4/24 -Should be nursed heads up->avoid cerebral edema
Fluid bolus requirements
If hypoperfusion is present, give 0.9% saline at 10 ml/kg and reassess. If centralcapillary refill remains > 2 seconds, a further bolus of 10ml/kg 0.9% saline may be given In adults: BP NS 500ml IV over 10-15 minutes BP >90->NS 1L IV over 60 minutes
What happens to sodium as blood glucose levels fall
Remains stable of falls (corrected sodium)
Fluids beyond 6 hours- possible choice
Beyond the initial 6 hours, 0.45% NaCl with 5% dextrose and potassium may be used once the BGL is <12
What level to aim for blood glucose
Aim for 5-12mmol/L
What to do if BGL <5mmol/L
increase the dextrose concentration in the fluid to 10%. The insulin infusion rate should only be turned down if BGL continues to fall despite use of 10% dextrose