Flashcards in FN: Diabetic Ketoacidosis Deck (19):
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Ketogenesis
1. Decreased insulin leads to increased stresss hormoes and raise dglucagon
2. reduced glucose utilisation and increased fat oxidation
3. raised free fatty acids and increased ATP and generation of ketone bodies
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Dehydration
1. Reduced insulin and decreased glucose utilisation and increased gluconeogenesis --> severe hyperglycaemia
2. osmotic diuresis leading to dehydration
3. Also, raised ketones and vomiting
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Acidosis
1. Dehydration --> renal perfusion
2. Hyperkalaemia
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Precipitants
1. Abdo pain + vomiting
2. Gradual drowsiness
3. Sighing "kussmaul" hyperventiation
4. Dehydration
5. Ketotic breath
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Diagnosis
1. Acidosis (raised AG): pH 11mM (or known DM)
3. Ketonaemia >3mM (>2+ on dipstix)
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Investigations
1. Urine: ketones and glucose, MCS
2. Cap glucose and ketones
3. VBG: acidosis + raised K
4. Bloods: U_E, FBC, glucose, cultures
5. CXR: evidence of infection
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Subtleties
1. Hyponatraemia is the norm
a. Osmolar compensation for hyperglycaemia
b. raised/normal Na indicates severe dehydration
2. Avoid rapid decrease in insulin once glucose normalised
a. glucose decreases faster than ketones and insulin is necessary to get rid of them.
3. Amylase is often raised (up to 10x)
4. Excretion of ketones --> loss of potential bicarbonate -- hyperchloraemic metabolic acidosis after treatment
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Complications
1. Cerebral oedema: excess fluid administration - commonest cause of mrotality
2. Aspiration pneumonia
3. Hypokalaemia
4. Hypophosphataemia --> resp and skeletal muscle weakness
5. Thromboembolism
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Management in HDU
Gastric aspiration
Rehydrate
Insulin infusion
Potassium replacement
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Management
1. Fluids
2. Insulin infusion
3. Assessment
4. Additional measures
5. Monitoring
6. Resolution
7. Transfer to SC insulin
8. Pt. Education
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Fluids used
2 bags
2nd bag of fluids with potassium replacement
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Insulin infusion
Actrarapid 0.u/kg/h IVI (6units if no wt. mas 15u)
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Assessment
Hx + full examination
Investigations: capillary, urine, blood,imaging
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Additional MEasures
1. Urinary catheter (aim:0.5ml/kg/hr)
2. HGT if vomiting or reduced GCS
3. Thromoprophylaxis with LMWH
4. Refer to specialist diabetes team
5. Find and treat precipitating factors
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Monitoring
1. Hrly capillary glucose and ketones
2. VBG @ 60min, 2h and then 2hrly
3. Plasma electrolytes 4 hrly
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Aims of management
reduced ketones by >0.5 M/h or raised HCO3 by >3mM/h
reduced plasma glucose by >3mM/h
Maintain K in normal range
Avoid hypoglycaemia
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Resolution
Ketones 7.3 (HCO3 >18mM)
Transfer to sliding scale if not eating
Transfer to SC insulin when eating and drinking
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Transfer to SC Insulin
1. When biochemically resolved and eating
2. Start long-acting insulin the night before
3. Give short-acting insulin before breakfast
4. Stop IVI 30min after short acting
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