Post on 04-Oct-2015
description
Diabetes 1
Diabetic Ketoacidosis (DKA)
1
Learning ObjectivesIdentify precipitating factors for the development of DKA
Outline steps needed to obtain accurate diagnosis of DKA
Implement strategies for the acute management of DKA
Explain methods that can be used to prevent recurrence of DKA2
Speaker Notes
2
DKA Progression3Insulin DeficiencyIncreased Lipolysis Increased KetogenesisKetoacidosis DKA
3
Overall Management Approach4
4
Regulation of Ketogenesis and Glucose Metabolism 5KetogenesisGluconeogenesisGlycogenolysisGlycolysisGlycogen SynthesisInsulinGlucagonCortisolGrowth HormoneCatecholamines
From Kreisberg R. Diabetic ketoacidosis. In: Rifkin H, Porte D, eds. Diabetes mellitus: theory and practice, 4th ed. New York: Elsevier Science, 1990:591603.
5
Precipitating Factors Inadequate insulin treatment
Infection (UTI, pneumonia, sepsis)
Myocardial infarction, stroke
Drugs
Pregnancy6
6
Signs and SymptomsPolyuria, polydipsiaEnuresis
Dehydration/Volume DepletionTachycardiaOrthostasisReduced skin turgorDry mucus membranes
Abdominal painNauseaVomitingFruity breathAcetone
Kussmaul breathing
Mental status changesSomnolentCombativeDrunk
Coma
7
7
Initial Evaluation of the Patient with Suspected DKAHistory of DM, hypoglycemic medication doses, and symptoms
History of DM-related complications
Medications
Social and medical history (including alcohol use)
Vomiting and ability to take fluids by mouth8
8
Initial Evaluation of the Patient with Suspected DKA (contd)Plasma glucose
Attempt to identify precipitating event (e.g. infection, omission of insulin, myocardial infarction)
Assess volume status and degree of dehydration
Assess presence of ketonemia and acid-base disturbance9
9
Laboratory Evaluation of the Patient with Suspected DKA (contd)Complete blood count (WBC often high; left shift suggests infection)
Serum glucose
Serum ketones
Calculate serum osmolality and anion gap
Measure osmolar gap if ingestion of osmotically active toxins suspected10
10
Laboratory Evaluation of the Patient with Suspected DKA (contd)Urinalysis and urine culture
Consider blood culture
Consider chest radiograph
Consider measuring HCG
Acid-base assessment
HbA1c11
11
Laboratory Values in DKADKAGlucose (mg/dL)250-600Sodium (meq/L)125-135Potassium (meq/L)Normal or increasedMagnesium Normal Chloride Normal Phosphate Decreased Creatinine (mg/dL)Increased
12
12
Laboratory Values in DKA (contd)DKASerum Osmolality (mOsm/kg)300-320Serum -hydroxybutirat acid (mmol/L)>0.6Serum Bicarbonate (meq/L)250>250>250Effective serum osmolality (mOsm/kg)[*]VariableVariableVariableUrine or serum ketones (NP reaction)PositivePositivePositiveArterial pH7.25-7.307.00-7.2412>12Typical mental statusAlertDrowsyStupor or coma
14Modified from Kitabchi AE, Umpierrez G, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care 2001;24:131153. *Effective serum osmolality (mOsm/kg) = 2 [measured serum sodium (mEq/L)] + [serum glucose (mg/dL)/18]. Normal range = 285 5 mOsm/kg. Urea nitrogen is an ineffective osmole (i.e. it diffuses freely across compartments) and is therefore purposely excluded from this equation.
*Effective serum osmolality (mOsm/kg) = 2 [measured serum sodium (mEq/L)] + [serum glucose (mg/dL)/18]. Normal range = 285 5 mOsm/kg. Urea nitrogen is an ineffective osmole (i.e. it diffuses freely across compartments) and is therefore purposely excluded from this equation.
14
Suggested Fluid ReplacementAdminister NS as indicated to maintain hemodynamic status, then follow general guidelines:NS for first 4 hoursConsider half NS thereafterChange to D5 half NS when blood glucose 250 mg/dL May need to adjust type and rate of fluid administration in the elderly and in patients with congestive heart failure or renal failure.
15HoursVolume0.5-11 L21 L3500 mL-1 L4500 mL-1 L5500 mL-1 LFirst 5 hours (total)3.5-5 L6-12200-500 mL/hour
NS, normal saline; D5, 5% dextrose in water
May need to adjust type and rate of fluid administration in the elderly and in patients with congestive heart failure or renal failure.
15
Average Electrolyte Losses16 Sodium 500 mEq Chloride 350 mEq Potassium 300-1000 mEq Calcium 50-100 mmol Phosphate 50-100 mmol Magnesium 25-50 mmol
16
Guidelines for Potassium ReplacementDo not administer potassium if serum potassium >5.5 mEq/L or if patient is anuric
Remember that normal or high serum potassium may mask total body depletion in setting of acidosis
Use KCI but alternate with KPO4 if there is severe phosphate depletion and patient is unable to take phosphate by mouth
Add IV potassium to each liter of fluid administered unless contraindicated17
17
Guidelines for Potassium Replacement18Serum K+ (mEq/L)Additional K+ Required5.5Stop K or dont start infusion
18
Guidelines for Insulin ManagementRegular insulin 0.15 U/kg IV (may not be needed)
Start regular insulin infusion 0.1 U/kg/hour or 5 U/hour
Increase insulin by 1 U/hour every 1-2 hours if 75 mg/dL/hour
Do not decrease insulin infusion to