Endocrine

Question 1

Why ketones develop in DKA

Answer 1

In diabetic ketoacidosis (DKA), which is more common in patients with type 1 diabetes, no insulin is available to suppress lipolysis, resulting in ketone formation and acidosis.

Question 2

Antibodies in type 1 DM

Answer 2

Recognized auto-antibodies include glutamic acid decarboxylase (GAD), zinc transporter 8 (ZnT8)
and islet antigen 2 (IA-2)

Question 3

to confirm the diagnosis of diabetes 3

Answer 3

symptomatic
child by finding a markedly raised random blood glucose
(>11.1 mmol/L by the current WHO definition), glycosuria,
and ketosis. Where there is any doubt, a fasting blood
glucose (>7 mmol/L) or a raised glycosylated haemoglobin (HbA1c) are helpful

Question 4

factors that increase blood glucose levels 8

Answer 4

Insufficient insulin
Food (especially carbohydrates)
Illness
Menstruation (shortly before onset)
Growth hormone
Corticosteroids
Sex hormones at puberty
Stress

Question 5

Factors that decrease blood glucose 4

Answer 5

Exercise
Alcohol
Marked anxiety/ excitement
Hot weather

Question 6

Steps in management of DKA

Answer 6

• assess the severity
• Emergency measures
• fluids
• Insulin
• Monitor Electrolytes
• Normalization

Question 7

Step 1 assess the severity of DKA

Answer 7

*pH >7.2 or HCO3 10 – 18 mmol/L: Mild DKA
*pH 7.1 to 7.2 or HCO3 5 – 0 mmol/L: Moderate DKA
*pH <7.1 or HCO3 <5 mmol/L: Severe DKA

Question 8

Step 2 Emergency measures in DKA

Answer 8

-If shocked, give bolus of 20 ml/kg 0.9% NaCl
-Consider intravenous antibiotics, if suspecting sepsis as a trigger of DKA

Question 9

Step 3 fluids

Answer 9

• even If not in shock, give: Initial bolus
  +
• Rehydration fluids:
  pH < 7.1 or new onset DM= 9% dehydration;
  otherwise pH > 7.2 = 6% dehydration.
  Give rehydration fluid over
  48 hours
  +
  deficit fluids &Maintenance
  Start with 0.9%
  NaCl with 20mmol KCl
  per 500ml bag

Question 10

Step 4 Insulin in DKA

Answer 10

After one hour of rehydration
Start intravenous insulin infusion at 0.1 units/kg per hour

Question 11

symptoms of diabetic ketoacidosis 5

Answer 11

• smell of acetone on breath
• dehydration
• rapid breathing due to acidosis (Kussmaul
  breathing)
• hypovolaemic shock
• drowsiness and reduced level of consciousness

Question 12

Labs for DKA 8

Answer 12

-Serum glucose.
-Serum electrolytes (bicarbonate, Calcium, phosphorus magnesium)
creatinine, urea
-Venous (or arterial) pH and pCO2.
-Hemoglobin A1cΔ.
-Blood ketone
-Urinalysis +/- blood culture
-Cardiac monitor for T-wave changes of
hypokalaemia
- Weight (compare with recent clinic weight to ascertain level of dehydration)

Question 13

DKA is defined by the presence of all of the following in a patient with diabetes

Answer 13

*Hyperglycemia – Blood glucose ≥200 mg/dL (11 mmol/L).
*Metabolic acidosis – Venous pH <7.30 and/or serum bicarbonate <18 mEq/L.
*Ketosis – Elevated levels of ketones in urine or blood

Question 14

when to add dextrose to the fluids in DKA px

Answer 14

Add dextrose to the IV fluids when the blood glucose falls below approximately 300 mg/dL (17 mmol/L) to prevent hypoglycemia during treatment

Question 15

Step 5 Monitor electrolytes hourly 4

Answer 15

*hourly:
Vital signs.
Neurologic status.
Fluid intake (IV and oral) and losses.
Blood glucose hourly.

Question 16

Step 5 Monitor electrolytes after 1hr

Answer 16

• Electrolytes, VBG every 2 to 4 hours.
• Calcium, phosphorous, and magnesium every 4 to 6 hours.
  *More frequent monitoring may be necessary for patients with severe electrolyte derangements or rapid changes in these laboratory values.

Question 17

When to stop Insulin / Fluids depends on

Answer 17

Insulin depend on pH

Fluids depend on Sugar

Question 18

Step 6 normalization

Answer 18

When pH, glucose and blood ketones normal:
Give subcutaneous insulin and oral diet.
Stop intravenous insulin infusion 1 hour after giving subcutaneous insulin, as it takes time to be absorbed