!!!DKA!!! Flashcards
what precipitates DKA?
any stressors on the body can make you go to DKA myocardial infarction, stroke, trauma, and substance abuse,
common once are infection and
no compliance to medications
diagnosis of DKA?
PH is less than 7.3
or bicarbonate is less than 15
blood glucose more than 11 mmol/l
and the ketonemia more than 3
ketonuria urine dipstick shows 2 plus
DKA features ?
confused and drowsy
polyurea and polydipsia
abdominal pain
vomiting or nausea
weakness
weight loss
kussmaul breathing or high respiratory rate
investigation to order in DKA ?
bedside - ABG must
MSU /CSU
ECG
URINARY DISPSTICK FOR KETONES
bloods - POTASSIUM SODIUM
SERUM OSMOLALITY
fbc, ue, crp ,lft, bm
BLOOD CULTURE
radiology - cxr
managmnet to initiate
STart IV fluids
1L N saline in one hour then 2 hour, then 4 hours , 6 hourly
When Blood Glucose reaches <14, IV 10 percent dextrose is given concurrently with 0.9% saline
needs to be a positive fluid balance of 2-3L EVERY 6 HOURS if not increase the rate of infusion
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start empirical antibiotics
given oxygen supplementation
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if they meet the dka protocol
start fixed rate insulin infusion after checking the potassium
0.05units/kg/hr (0.1)
potassium is also given 40mmol/L if potassium is between 3.5-5.5
if below 3.5 - replace potassium before giving insulin
if blood glucose is not dropping by 5mmol/h and serum osmolarity is not decreasing by 3-8mosm/kg/hr the infusion is increased by 0.1 unit/kg/hour.
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hourly BM and ketone if intimal measurement >1.0
otherwise 4 hourly
4 hourly electrolyte and glucose monitoring
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long acting insulin can continue everything else must be stopped
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Thromboprophylaxis
when is DKA protocol stopped ?
ketones <0.6 mmol/L ,
venous pH >7.3 and
venous bicarbonate >15.
At this point if the patient is eating and drinking regularly, change to SC short acting insulin should be injected with the meal half an hour before the infusion stops
how to calculate serum osmolality ?
can be calculated by: 2 * Na+ glucose + urea
What features of the presentation would indicate early referral to ITU
**pH <7.1
Severe DKA by the following criteria: Ketones >6 mmol/L
or Bicarbonate <5 mmol/L
Hypokalaemia on admission (below 3.5)
GCS <12
Systolic BP <90 mmHg
Significant co-morbidity
Pregnant**
some of the complications of DKA?
Secondary to treatment:
=Hypokalaemia
=Hypophosphataemia – phosphate moves intra-cellularly in the same way as potassium
=Cerebral oedema. It may be precipitated by sudden shifts in plasma osmolality during treatment. Symptoms include drowsiness, severe headache and confusion. Mortality is around 70%.
=Hypoglycaemia – from overzealous insulin replacement
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Secondary to DKA
=Tissue hypoperfusion may result from dehydration
=Hypercoagulable state may result in thromboembolism
How will you manage this patient prior to discharge?
The most common is non-compliance with medication. Sometimes this may be accidental and sometimes it may be out of choice. I would also explain to the patient that she should seek early medical advice if she feels she is becoming unwell in the future, as early treatment of underlying infection may stop the progression to DKA.
I would make sure she has been seen by the hospital diabetic team to discuss her treatment and compliance. I would make sure I have written to the GP to arrange early follow up and I would also make she is under regular review for complications of diabetes.
what is HHS?
hyperglycaemia ((>30 mmol/L) ,
hyperosmolarity (> 320 mosmol/kg) a
nd dehydration, without significant ketoacidosis.
HHS most commonly presents in type 2 diabetics who have a concomitant illness that causes reduced fluid intake.
diagnostic criteria of HHS ?
There are no precise diagnostic criteria but the following are typically seen:
hypovolaemia
marked hyperglycaemia (>30 mmol/L)
significantly raised serum osmolarity (> 320 mosmol/kg)
can be calculated by: 2 * Na+ + glucose + urea
no significant hyperketonaemia (<3 mmol/L)
no significant acidosis (bicarbonate > 15 mmol/l or pH > 7.3 – acidosis can occur due to lactic acidosis or renal impairment)
does the management of HHS differ from DKA?
fuid losses in HHS are estimated to be between 100 - 220 ml/kg
IV 0.9% sodium chloride solution
typically given at 0.5 - 1 L/hour depending on clinical assessment
potassium levels should be monitored and added to fluids depending on the level
insulin should not be given unless blood glucose stops falling while giving IV fluids
venous thromboembolism prophylaxis
patients are at risk of thrombosis due to hyperviscosity
