DKA Flashcards
Describe Pathophysiology : Acidocétose diabétique (4)
- DKA results from an absolute or severe relative lack of insulin, leading to a starvation state at the cellular level.
- Gluconeogenesis is stimulated even as glucose utilization falls.
- Hyperglycemia and ketoacidosis cause profound osmotic diuresis and massive fluid shifts.
- The diuresis and acidosis cause severe electrolyte disturbances, with wasting of Na, K, Mg, and phosphate.
DKA results from an absolute or severe relative lack of Describe potassium in DKA
Acidosis, dehydration, hyperosmolality, and insulin deficiency can lead to** potassium shifts into the
extracellular space**, so patients may have significant serum hyperkalemia at presentation, even with massive total body deficits of potassium.
DKA happens more in DB1 or DB2?
DB1
Name DDX of DKA
Name signs and symptoms : DKA (4)
- polyaria
- polydipsia
- fatigue
- severe abdominal pain
Diagnosis of DKA is based on the triad of what?
- hyperglycemia
- ketosis
- anion-gap metabolic acidosis.
Describe tx of DKA (4)
- Fluid Resuscitation
- Insulin
- Potassium
- Bicarbonate (controversial)
Describe fluide resuscitation in DKA (6)
- The first step in treatment of DKA is infusion of crystalloid solution to correct hypovolemia and hyperosmolarity.
- Isotonic saline is the primary fluid recommended in current DKA clinical practice guidelines
- However, there is some evidence that using balanced crystalloid solutions such as lactated Ringers may lead to faster resolution of DKA.
- Shock is common and must be promptly treated with crystalloid infusion to prevent further organ damage.
- Adults with clinical shock should receive an initial 2 L bolus of crystalloid with frequent reassessment.
- In children, shock is treated with a bolus of 10-20 mL/kg of crystalloid.
Describe insuline usage in DKA (7)
- An insulin dose of 0.1 U/kg/h (5-10 U/h in the adult) is adequate for almost all clinical situations.
- Most guidelines still recommend an initial bolus of insulin, equal to a 1-hour infusion; however, this has not been shown to hasten recovery and may increase risk of a hypoglycemic events.
- Insulin boluses are not recommended in pediatric patients.
- Insulin does bind readily to common medical plastics, so IV tubing should be thoroughly flushed with the drip solution at the start of therapy.
- Regardless of the glucose level, insulin infusion should continue until the anion gap has returned to normal.
- Dextrose should be added to the IV infusion when the serum glucose falls to 200-300 mg/dL (11.1-16.7 mmol/L) to prevent hypoglycemia, a common complication of treatment.
- The combination of rehydration and insulin will usually lower the serum glucose much faster than the clearance of ketones.
What should be evaluated prior to insulin administration ? (1)
Potassium.
Potassium levels should be evaluated prior to insulin administration since insulin will drive potassium into cells and worsen hypokalemia, which can lead to life-threatening cardiac arrhythmias.
Describe potassium replacement in DKA (3)
- Potassium levels should be evaluated prior to insulin administration since insulin will drive potassium into cells and worsen hypokalemia, which can lead to life-threatening cardiac arrhythmias.
- If the potassium is elevated initially, the ECG should be evaluated for any hyperkalemic changes; the patient should be given fluids until the serum potassium reaches the normal range, and then potassium should be added to the IV infusion.
- If the initial serum potassium is normal or low, potassium replacement can be started immediately.
Describe bicarbonate replacement in DKA
- Sodium bicarbonate is not routinely administered in emergency treatment of DKA in adult or pediatric patients because multiple studies have failed to demonstrate its benefit, even in cases of extreme acidemia.
- Additionally, there are multiple theoretical and observed harmful complications from sodium bicarbonate administration, including hypernatremia, hypokalemia, paradoxical cerebrospinal fluid (CSF) acidosis, and residual systemic alkalosis.
- However, some clinicians still administer bicarbonate in cases of severe acidemia (typically pH less than 6.9) and/or cases of severe hyperkalemia.
Name complication : Cerebral edema (5)
- rare but devastating complication of DKA
- seen most often and most severely in patients younger than 25 years.
- It almost always occurs during the treatment phase of DKA and is a leading cause of morbidity and mortality in pediatric DKA.
- Patients with marked baseline hyperosmolarity (calculated serum osmolarity greater than 330 mOsm) are at higher risk.
- Among older adults, this is mostly an issue among patients with HHS rather than DKA; however, these conditions often overlap.
Name most common triggers for DKA (2)
- Infection
- Nonadherence to therapy
