DIABETIC DIABETIC KETOACIDOSISKETOACIDOSISBy, Dr. ASWIN ASOK CHERIYANBy, Dr. ASWIN ASOK CHERIYAN

Chair Person – Dr. JAYAMOHAN A.S. Chair Person – Dr. JAYAMOHAN A.S.

What is Diabetes?What is Diabetes?

Diabetes is a clinical syndrome characterized Diabetes is a clinical syndrome characterized by hyperglycemia due to absolute or relative by hyperglycemia due to absolute or relative deficiency of insulin which leads to multiple deficiency of insulin which leads to multiple organ dysfunction.organ dysfunction.

Types of DiabetesTypes of Diabetes

Type 1 Diabetes (I.D.D.M.)Type 1 Diabetes (I.D.D.M.) Type 2 Diabetes (N.I.D.D.M.)Type 2 Diabetes (N.I.D.D.M.) Other types like-Other types like- Gestational Diabetes mellitusGestational Diabetes mellitus DM due to genetic defects in insulin actionDM due to genetic defects in insulin action DM due to diseases of exocrine pancreasDM due to diseases of exocrine pancreas

Complications of DiabetesComplications of Diabetes

ACUTEACUTE

1.1. Diabetic KetoacidosisDiabetic Ketoacidosis

2.2. Hyperosmolar Non-ketotic Hyperosmolar Non-ketotic Diabetic ComaDiabetic Coma

3.3. HypoglycemiaHypoglycemia

4.4. Lactic acidosisLactic acidosis

CHRONICCHRONIC

1.1. MicrovasularMicrovasular--

Diabetic NeuropathyDiabetic Neuropathy

Diabetic RetinopathyDiabetic Retinopathy

Diabetic NephropathyDiabetic Nephropathy

2.2. MacrovasularMacrovasular--

Coronary Artery DiseaseCoronary Artery Disease

Peripheral Vascular DiseasePeripheral Vascular Disease

Cerebrovascular diseaseCerebrovascular disease

Diabetic Autonomic Neuropathies like Diabetic Autonomic Neuropathies like

Gastro paresisGastro paresis

Sexual DysfunctionSexual Dysfunction

Some Dermatological Complications are also Some Dermatological Complications are also presentpresent

DIABETIC KETOACIDOSIS or DIABETIC KETOACIDOSIS or DKADKA

A major medical emergencyA major medical emergency Usually seen in Type 1 Diabetic patientsUsually seen in Type 1 Diabetic patients The incidence is higher in elderly patientsThe incidence is higher in elderly patients

Mortality in developed countries - Mortality in developed countries - about 5-10% about 5-10%

Mortality in developing countries –Mortality in developing countries – about 30–40%about 30–40%

Precipitating FactorsPrecipitating Factors

Rapid decrease or no insulin intakeRapid decrease or no insulin intake

InfectionsInfections

Severe stress (physical and emotional) Severe stress (physical and emotional)

PathogenesisPathogenesis

DKA results fromDKA results from

Insulin deficiency andInsulin deficiency and

Glucagon excess Glucagon excess

The key features in DKA areThe key features in DKA are : :

HyperglycemiaHyperglycemia

Volume Depletion and DehydrationVolume Depletion and Dehydration

HyperketonemiaHyperketonemia

Metabolic AcidosisMetabolic Acidosis

Clinical Presentation in DKAClinical Presentation in DKA

Polyurea with signs of dehydrationPolyurea with signs of dehydration Nausea, VomitingNausea, Vomiting Abdominal painAbdominal pain Tachypnoea – Kussmauls BreathingTachypnoea – Kussmauls Breathing Weakness, ConfusionWeakness, Confusion Altered Consciousness or Frank comaAltered Consciousness or Frank coma

On Examination the patient may On Examination the patient may havehave::

HypothermiaHypothermia HypotensionHypotension Fruity odour of breath- Due to AcetoneFruity odour of breath- Due to Acetone

InvestigationsInvestigations:: Urine analysis- Presence of glucose and KetonesUrine analysis- Presence of glucose and Ketones Blood sugar analysis- Increase in plasma glucose levelsBlood sugar analysis- Increase in plasma glucose levels Plasma ketone levels are raisedPlasma ketone levels are raised Electrolyte levels Electrolyte levels Plasma PotassiumPlasma Potassium Plasma BicarbonatePlasma Bicarbonate Hydrogen ion concentration is raisedHydrogen ion concentration is raised Arterial pH is lowArterial pH is low Blood count and cultureBlood count and culture ECGECG Chest X-rayChest X-ray

Diagnostic Criteria for DKADiagnostic Criteria for DKA : :

Blood Glucose > 250 mg/dlBlood Glucose > 250 mg/dl Arterial pH < 7.3Arterial pH < 7.3 Moderate degree of ketonaemia and/or Moderate degree of ketonaemia and/or

ketonuriaketonuria

Management of DKAManagement of DKA : :

Insulin TherapyInsulin Therapy Fluid replacementFluid replacement Replacement of ElectrolytesReplacement of Electrolytes Correction of AcidosisCorrection of Acidosis AntibioticsAntibiotics

Insulin TherapyInsulin Therapy

Rapid acting insulin is usedRapid acting insulin is used Bolus- 10 units of insulin iv + 10 units s/cBolus- 10 units of insulin iv + 10 units s/c Followed by iv infusion of 50 units of plain insulin in Followed by iv infusion of 50 units of plain insulin in

500ml normal saline at the rate of 30 drops/min (10 500ml normal saline at the rate of 30 drops/min (10 units/hr) units/hr)

till RBS < 250 mgm%till RBS < 250 mgm% Once RBS < 250 mgm% , Stop iv insulin infusionOnce RBS < 250 mgm% , Stop iv insulin infusion Start s/c insulin 8Start s/c insulin 8thth hrly with iv DNS, ie. 2/3 hrly with iv DNS, ie. 2/3rdrd the the

dose of total insulin given so far.dose of total insulin given so far.

Points to be noted during insulin Points to be noted during insulin therapy :therapy :

If blood glucose does not fall within two hours If blood glucose does not fall within two hours of treatment- the dose of insulin should be of treatment- the dose of insulin should be doubleddoubled

A more rapid fall in glucose should be avoided A more rapid fall in glucose should be avoided as hypoglycemia can be precipitated and a as hypoglycemia can be precipitated and a serious complication of Cerebral Edema may serious complication of Cerebral Edema may developdevelop

Fluid ReplacementFluid Replacement : :

Early and rapid rehydration is essentialEarly and rapid rehydration is essential Usual regimen-Usual regimen- 2 pints of NS in the first half hour2 pints of NS in the first half hour ++ 2 pints of NS in the next hour2 pints of NS in the next hour ++ 2 pints of NS in the next 2 hours2 pints of NS in the next 2 hours An accurate record of fluid input and output must be An accurate record of fluid input and output must be

maintained.maintained.

Replacement of ElectrolytesReplacement of Electrolytes : :

Potassium ReplacementPotassium Replacement

Bicarbonate ReplacementBicarbonate Replacement

Additional ProceduresAdditional Procedures : :

Catheterization if no urine is passed after 3 Catheterization if no urine is passed after 3 hourshours

Nasogastric tube to keep Stomach empty in Nasogastric tube to keep Stomach empty in unconscious patientsunconscious patients

Antibiotics should be given to treat the Antibiotics should be given to treat the infectionsinfections

MonitoringMonitoring : :

Blood glucose and electrolytes hourly for 3 hrs Blood glucose and electrolytes hourly for 3 hrs and every 2-4 hrs thereafterand every 2-4 hrs thereafter

Temperature, Pulse, Respiration and BP Temperature, Pulse, Respiration and BP hourlyhourly

Urinary output and ketone levelsUrinary output and ketone levels ECGECG

Complications of DKAComplications of DKA : :

Cerebral EdemaCerebral Edema HypoglycemiaHypoglycemia Acute Respiratory Distress SyndromeAcute Respiratory Distress Syndrome ThromboembolismThromboembolism DICDIC Acute Circulatory FailureAcute Circulatory Failure Myocardial InfarctionMyocardial Infarction

PrognosisPrognosis : :

Poor prognostic signs at admission are Poor prognostic signs at admission are Hypotension, Azotemia, Deep Coma and Hypotension, Azotemia, Deep Coma and Associated illness. Associated illness.

PreventionPrevention : :

Prevention of DKA can be attained to a certain level –Prevention of DKA can be attained to a certain level – By making the patients aware of the importance of By making the patients aware of the importance of

insulin during an illness and the reasons never to insulin during an illness and the reasons never to discontinue insulin without consulting with the doctor discontinue insulin without consulting with the doctor first.first.

By making the patients aware of the importance of By making the patients aware of the importance of routine blood glucose evaluation and the use of routine blood glucose evaluation and the use of supplemental short or rapid acting insulin's.supplemental short or rapid acting insulin's.

The importance of treating an infection at the earliest.The importance of treating an infection at the earliest.

Last but not the Least…..Last but not the Least…..

THANK YOU FOR YOUR THANK YOU FOR YOUR PATIENT LISTENINGPATIENT LISTENING