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Flashcards in High Glucose States Deck (19):
1

Diabetic Ketoacidosis

Diabetic Ketoacidosis (DKA) is a disordered metabolic state that usually occurs in the context of an absolute or relative insulin deficiency accompanied by an increase in the counter-regulatory hormones i.e. glucagon, adrenaline, cortisol and growth hormone

2

Why do people die from diabetic ketoacidosis?

Adults:
Hypokalaemia, Aspiration Pneumonia, ARDS,
Co-morbidities
Children:
Cerebral oedema

3

Common precipitants of DKA

infections (20 to 25%) – may be an over-estimate
Illicit drugs and alcohol (10 to 15%)
non-compliance with treatment (45 to 50%) – may be under-estimate
newly diagnosed diabetes (25% and falling?)

4

Diabetic Ketoacidosis Diagnosis

Ketonaemia > 3mmol /L, or significant ketonuria (>2+ on standard urine stick)

Blood glucose > 11.0 mmol /L or known diabetes (NB euglycaemic DKA)

Bicarbonate < 15 mmol /L or venous pH < 7.3

5

Classical biochemistry DKA

Glucose
-Median level around 40 mmol/L
-From 10 [‘euglycaemic ketosis’] to 100 mmol/L
Potassium
-Usually raised above 5.5 mmol/L
-Beware the low normal
Creatinine: often raised
Sodium: often reduced
Raised lactate is very common

6

Management of DKA

Replace losses
Fluid
Initially with 0.9% sodium chloride
Glucose falls to about 15, switch to dextrose
Insulin
Potassium
Phosphate [rarely] and Bicarbonate [almost never] replaced
Address risks
? is a naso-gastric tube required?
Monitor K+
Prescribe prophylactic LMWH
Source sepsis: CXR, Blood Culture, MSSU +/- viral titres, etc

7

Urine ketone testing

Measures acetoacetate
Indicates levels of ketones 2-4 hours previously
Ketonuria persists after clinical improvement due to mobilisation of ketones from fat tissue

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Blood ketone testing

Optium meter
Measures beta-hydroxybutyrate
Meter range 0 - 8mmol/L
< 0.6 mmol/L normal

9

When should you admit someone to hospital for DKA

Unable to tolerate oral fluids
Persistent vomiting
Persistent hyperglycaemia
Persistent positive/increasing levels of ketones
Abdominal pain / breathlessness

10

Clearance of lactate?

Clearance requires hepatic uptake and aerobic conversion to pyruvate then glucose

11

Where does lactate come from?

Lactate comes from red cells, skeletal muscle, brain and renal medulla

12

Type A lactic acidosis

Associated with tissue hypoxaemia
Infarcted tissue, eg ischaemic bowel
Cardiogenic shock
Hypovolaemic shock
Sepsis [endotoxic shock]
Haemorrhage

13

Type B lactic acidosis

May occur in Liver disease
Associated with drug therapy, eg Metformin
Associated with Diabetes
10% of cases of DKA associated with lactate >5 mmol/L.
With Metformin usually in severe illness states or renal failure
Also consider rare inherited metabolic conditions if well and non-diabetic

14

Which type of lactic acidosis is associated with diabetes?

Type B lactic acidosis
(also associated with metformin)

15

Normal range of lactate

0.6 - 1.2. is normal range for lactate

16

Lactic acidosis presentation

Hyperventilation
Mental confusion
Stupor or coma if severe

17

HHS risk associations?

Cardiovascular event [stroke or MI]
Sepsis
Medications: Glucocorticoids and thiazides

18

HHS diagnosis?

Hyperglycemia
Hypovolemia
Osmolality

19

Treatment for HHS? (vs DKA)

Fluids:
More slowly due to increased risk of cerebral oedema
Insulin:
More slowly as more sensitive (e.g. 3units/hour)
Sodium:
Avoid rapid fluctuations – e.g. ≤0.5mmol/l/hr
May need to consider 0.45% Saline*
Co-morbidities more likely
Screen for vascular event (eg. silent MI), sepsis
LMWH for all unless contra-indicated