Endocrine Emergencies Flashcards
DKA PP? 3
- Body’s response to cellular starvation (NOT organism starvation)
- Relative insulin deficiency
- Counterregulatory excess (think glucagon)
DKA: Why does one become acidotic?
4
- Relative insulin deficiency (not enough
to drive glucose into cells)
leads to
- ellular starvation (cell requires
something other
than glucose for energy)
leads to
- Lipolysis with subsequent fatty
acid transport to hepatocytes
and formation of ketoacids
leads to
- Ketonuria, Anion gap metabolic acidosis with compensatory
tachypnea, and vomiting
DKA why does one become dehydrated?
4
- Relative insulin deficiency (not enough
to drive glucose into cells)
leads to
- Increased serum levels of glucose (hyperglycemia) increases osmotic load
and spills in urine (glycosuria)
leads to
- Water drawn out of cells (intracellular
dehydration) via oncotic pressure
leads to
- Impaired consciousness, shock
DKA
Why would we have hypotension if we are pulling fluid into the vascular compartment with the osmotic load?
Initially there is an increase in volume in vasculature compartment
Then, as glucose starts to spill into urine there is a massive osmotic diuresis (Carries water with it resulting in cellular dehydration and vasculature depletion!).
DKA presentation
3
- Hyperglycemia
- Acidosis from ketoacids
- Volume loss
How will the following present in DKA:
- Hyperglycemia? 2
- Acidosis from ketoacids? 2
- Volume loss? 3
- Hyperglycemia
- Polydipsia
- Polyuria - Acidosis from ketoacids
- Tachypnea (to diminish CO2 and restore pH)
- Fruity odor of breath - Volume loss
- Dehydration signs
- Dry membranes, poor skin turgor,
- delayed capillary refill, mental confusion.
DKA
What about abdominal pain
nausea, and vomiting: what is it due to?
Unclear, but thought to be
related to prostaglandin release
DKA: Approach to Management?
- Mainstay of therapy?
- Bedside labs? 3
- Other labs? 4
- ***Aggressive fluid therapy initiated if DKA suspected even prior to receiving laboratory results and Insulin
- Bedside
- glucose,
- urine dipstick,
- ECG - CBC,
- Electrolytes along with phosphate and magnesium
- Venous or arterial blood gas
- Blood cultures and other lab tests as indicated
DKA: Approach to Management:
Fundamentals of treatment include? 5
- Volume repletion
- Reversal of metabolic consequences of insulin insufficiency
- Correction of electrolyte and acid-base imbalances
- Treatment of precipitating cause (if applicable)
- Avoidance of complications
WHAT is the single most important initial step in the treatment of DKA?
***Rapid fluid administration
DKA
- Which fluid choice?
- Use of this prevents what?
- After initial resuscitation recommendation is then to?
- What will begin to fall after fluid administration and before implementation of any other therapeutic modality (rise in GFR allows for glucose and ketone body clearance)? 2
- What facilitates the action of insulin?
- Normal saline most frequently recommended fluid for initial volume repletion
- Use of NS prevents excessively rapid fall in extracellular osmolality (what could happen if we used a “free water” equivalent with regards to this?)
- After initial resuscitation, recommendation is then to alternate NS with 0.45%NS
- ***Blood glucose and ketone concentration
- Increased tissue perfusion facilitates the action of insulin
DKA Approach to Management: Insulin Therapy 1. Administered at what dose? 2. Ideal way of administering this? 3. Why? 2 4. What administration should be avoided? 2
- Administered at 0.1 units/kg per hour after initial fluid bolus
- “Ideal way” is by continuous intravenous infusion of small doses of regular insulin through an infusion pump
- Less complications
- Allows flexibility in adjusting dose
- Intramuscular and Subcutaneous administration should be avoided (absorption erratic in volume-depleted patient)
DKA: Approach to Management:
Potassium Therapy
1. What causes K deficiency? 3
2. Initial serum concentration usually normal or high due to the following? 3
3. Large amounts are necessary for replacement for first ____ hours?
- Combination of
- acidosis,
- osmotic diuresis, and
- vomiting causes potassium deficiency - Initial serum concentration usually normal or high due to the following
- Intracellular exchange of potassium for H+
- Total body fluid deficit
- Diminished renal function - 24-36
Both K+ and H+ do what? 2
- Both K+ and H+ are positively charged
- Both move freely between the intracellular and extracellular compartments
- When excess H+ ions are present in the extracellular fluid, they do what?
- ***Here’s the catch… when the H+ ion does this, another cation does what?
- move into the intracellular compartment for buffering (the bicarbonate system is not the only buffering system, just the one that can be highly regulated!!)
- K+ must leave the cell and move into the extracellular fluid