DKA Flashcards
How does DKA develop?
beta cells stop working–>insulin deficiency–>despite high serum glucose, intracellular glucose depletion–> increase in regulatory hormones to release more glucose into blood stream–>gluconeogenesis, breakdown of proteins and lipids–>even more hyperglycemia now with amino acids and fatty acids in blood stream–>derangement of fatty acids releases ketoacids into bloodstream–>
KETOACIDOSIS
HYPERGLYCEMIA (–>Glycosuria + OSMOTIC DIURESIS)
What does DKA do to the body?
KETOACIDOSIS
HYPERGLYCEMIA (with Glycosuria + osmotic diuresis)
clinical signs and symptoms: (4)
hyperglycemia (>180)
hypovolemia (5-10% fluid deficient w/ weight loss)
“fruity breath” (because acetoacetic acid turns to decarboxylate which turns to acetone)
hyperpnea with Kussmaul Breaths (as a פיצוי נשימתי לחמצת מטבולית)
(Abdomenal pain)
Management Priorities in order: (9)
- NEURO-RESP
- CIRCULATORY/PERFUSION/HEMODYNAMICS
- INSULIN admin
- SODIUM correction
- POTASSIUM and PHOSPHATE correction
- continued אומדנים
- Infection assessment
- chronic hyperglycemia assessment
- provide patient-family teaching (referals)
What אומדנים are done and what order?
NEURO-RESP CARDIO-VASC-URINE-WEIGHT+WEIGHT LOSS GLUCOSE+ELECTROLYTE LEVELS+ACID/BASE INFECTION MED HISTORY+SAMPLE
What is the אומדן נוירולוגי/נשימתי for DKA? what is important to suspect?
FUNCTION–הכרה, GCS,אישונים, רפלקסים קרניאלים, התפתחות תקינה, שמירה על נתיב אוויר, חימצון
IMPORTANT TO SUSPECT CEREBRAL EDEMA
What are the treatments of suspected Cerebral Edema in DKA? (2)
NACL 3% 10ML/KG over 30 min (PREFERRED cuz not diuretic)
MANNITOL 0.2-1gr/KG over 30-60 min
What does the אומדן הימודינמי entail in DKA?
דופק ל''ד מילוי קפילרי מתן שתן חום פריפרי צבע עור משקל נוכחי
What is the treatment for poor perfusion and hypovolemia in DKA?
הכנסת 2 עירויים עם עובי גדול
הכנסת AL
שוק: bolus NS 10-20ml/kg, can repeat, avoid>40ml/kg
ללא שוק: admin 5-20ml/kg over 1-2 hours
בשני מקרים: CALCULATE VOLUME DEFICIT and continue with maintinance+ [(deficit-minus previously given fluids) spread over 24-72 hrs]
at first give NS, when stable can move to 0.45%nacl
What does the insulin treatment in DKA entail?
infusion of 0.05-0.1 units/kg/hr
במקביל נוזלים עם סוכר
Should insulin be given in with העמסה?
לא, יגרום להיפוגליקמיה
When should insulin be moved to SC?
כאשר כבר אין קטואצידוזיס
(עדות: אין קטונים בשתן או חמצת בדם
When should insulin be reduced?
almost never–incrs glucose admin instead
What are the poss AE’s of correcting with insulin?
hypoglycemia
hypokalemia
How fast do we want the Glucose level to drop?
50-100 units/hr
When do we add D10% to NS and when add D5% to NS?
if glucose levels<200 give D5%
if glucose levels<300 give D10%
How often take מעקב סוכר?
כל שעה
What other electrolytes must be corrected in DKA?
נתרן, אשלגן, פוספאט
If we see Na<135, is it definitely hyponatremia? How do we calculate the true Na?
לא בהכרח
for every 100g/dL of glucose above 180, it “pushes” the Na 1.6meq/L below 135meq/L in the lab results (but is not really there). so must calculate the true Na value and correct according to that. if Na still below 135, correct with 2-4meq/kg of pt.
If we see K>3.5 before treatment, is the patient still at risk for hypokalemia? why yes/no?
yes, because of dehydration, the K concentration can still be high, but the absolute K is quite low so especially when we start giving fluids and insulin, it can plummet.
How do you correct potassium in DKA patient?
K<3.5 add 40meq/L in the NS
K תקין: add 30 meq/L in the NS
K>5.5: don’t give potassium addition
Do we correct PO4-? If so, how and when?
if phosphate<3, then give the potassium via potassium phosphate and not potassium gluconate
what are the risks in DKA regarding potassium levels?
cardiac arrythmias if hyperkalemia >7, if so give Calcium gluconate and weigh giving sodium bicarb
How often do we do מעקב כימיה?
כל שעתיים
What other tests must be performed in DKA patient?
אסטרופ עורקי ספירה HBA1C קטונים בכל שתן אומדני נוירו+נשימתי+קרדיווסק+ גלוקוז כל שעה IN-OUT כל שעה
