L2: DKA Flashcards
(82 cards)
1
Q
Metabolic Actions of Insulin
A
2
Q
Metabolic Actions of Insulin
- CHO
A
3
Q
Metabolic Actions of Insulin
- PTN
A
4
Q
Metabolic Actions of Insulin
- Lipids
A
5
Q
Metabolic Actions of Insulin
- Electrolytes
A
6
Q
Def of DKA
A
Acute metabolic derangement in IDDM characterized by:
- Hyperglycemia
- Acidosis
- Ketosis
7
Q
Etiology of DKA
A
- Insulin deficiency (absolute or relative)
- Elevation of counter regulatory hormones
- Concomitant reduction of insulin’s effective action
8
Q
Etiology of DKA
- Insulin Deficiency
A
9
Q
Etiology of DKA
- Elevation of counter regulatory hormones
A
10
Q
Etiology of DKA
- Concomitant reduction of insulin’s effective action
A
- This overwhelms homeostatic mechanisms and lead to metabolic decompensation despite the patient taking the usual recommended dose of insulin
11
Q
End Result leading to DKA
A
12
Q
Pathophysiology of DKA
A
- Osmotic diuresis and hypovolemia
- Metabolic acidosis with increased anion gap
- Hypokalemia
13
Q
Pathophysiology of DKA
- Osmotic Diuresis & Hypovolemia
A
14
Q
Pathophysiology of DKA
- Metabolic Acidosis with Increased Anion Gap
A
15
Q
Pathophysiology of DKA
- Hypokalemia
A
16
Q
CP of DKA
A
17
Q
Causes of increased or normal BP in DKA
A
- Increased plasma catecholamine concentrations
- Release of ADH in response to hyperosmolality
- Osmotic pressure from marked hyperglycemia
18
Q
Dx of DKA
A
19
Q
Dx of DKA
- Diabetic
A
20
Q
Dx of DKA
- Keto
A
21
Q
Dx of DKA
- Acidosis
A
22
Q
Dx of DKA
- Relation Between hyperglycemia & Acidosis
A
The degree of hyperglycemia does not correlate with degree of acidosis
23
Q
Severity of DKA
A
24
Q
Calculation of Severity of DKA
A
- Anion Gap
- Corrected Na
- Effective Osmolarity
25
Calculation of Severity of **DKA**
- Anion Gap
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Calculation of Severity of **DKA**
- Corrected Na
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Calculation of Severity of **DKA**
- Effective Osmolarity
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Problems of **DKA**
* Dehydration: moderate to severe
* Hyperglycemia
* Acidosis
* Electrolyte disturbance
* Precipitating factors
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Managment of **DKA**
- Confirmation of diagnosis
- Emergency assessment & management
- Rehydration
- Insulin therapy
- K replacement
- Treatment of acidosis
- Treatment of precipitating factors
30
Managment of **DKA**
- Confirmation of DKA
31
Confirmation of **DKA**
- Blood Sample
32
Emergency Assessment of **DKA**
- Blood Glucose
- BOHB & Urine AAA
- Weight
- DHD
- Consciousness
33
Emergency Assessment of **DKA**
- BOHB & AAA
- blood BOHB
- urine test strips for acetoacetic acid
34
Emergency Assessment of **DKA**
- Glucose
Immediately measure blood glucose
35
Emergency Assessment of **DKA**
- Weight
The current weight should be used for calculations
36
Emergency Assessment of **DKA**
- DHD
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Emergency Assessment of **DKA**
- Consciousness
Assess level of consciousness (Glasgow coma scale)
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Indications of immediate treatment of **DKA** in ICU
39
Emergency Managment of **DKA**
40
Emergency Managment of **DKA**
- Airway
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Emergency Managment of **DKA**
- Breathing
42
Emergency Managment of **DKA**
- Circulation
43
Emergency Managment of **DKA**
- Drugs & Maneuvers
44
Rehydration in **DKA**
- Objectives
- Restore circulating volume
- Replace sodium and the extracellular and intracellular water deficits
- Improve glomerular filtration and enhance clearance of glucose and ketones from the blood
45
Rehydration in **DKA**
- Deficit amount of DKA
- Moderate DKA: >5-7% Dehydration
- Severe DKA: 7 - 10% Dehydration
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Rehydration in **DKA**
- Not in shock with good tissue perfusion
- Volume expansion (resuscitation) should begin immediately with 0.9% saline.
- 10 mL/kg infused over 30 - 60 minutes
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Rehydration in **DKA**
- Not in shock with poor tissue perfussion
- The initial fluid bolus is given more rapidly (e.g., over 15 - 30 minutes)
- A second fluid bolus may be needed to ensure adequate tissue perfusion.
48
Rehydration in **DKA**
- In shock
- Rapidly restore circulatory volume with isotonic saline in 20 mL/kg boluses
- Infuse as quickly as possible
- Reassess circulatory status after each bolus.
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Rehydration in **DKA**
- General Fluid Replacement
Replace the estimated fluid deficit at an even rate over 24 - 48 hr
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Another method for calculation of deficit amount in DKA
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Example of volumes of maintenance + 10% deficit, to be given evenly over 48h
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Rehydration in **DKA**
- Types of Fluids
- IV Fluids
- Oral Fluids
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Rehydration in **DKA**
- IV Fluids
- Saline
- Na
- Glucose
- K
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IV Fluids Rehydration in **DKA**
- Deficit Replacement (Saline)
with a solution that has a tonicity 0.45% to 0.9% saline, with added KCI, potassium phosphate or potassium acetate
55
IV Fluids Rehydration in **DKA**
- Sodium
- should rise by 0.5 mmol/L for each 1 mmol/L t in glucose concentration
- The Na content of the fluid should be 1 if measured serum Na concentration is low & doesn't rise appropriately as the plasma glucose concentration falls
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IV Fluids Rehydration in **DKA**
- Glucose
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IV Fluids Rehydration in **DKA**
- K
20 meq/L fluid taken
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Oral Rehydration in **DKA**
- Severe DHD
- Mild DKA
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Oral Rehydration in **DKA**
- In severe DHD & Acidosis
only sips of cold water
60
Oral Rehydration in **DKA**
- In mild cases of DKA & no vomiting
ORS with the usual volume calculation and subtracted from IV fluids
61
- Oral fluids as rehydration solution or juice only used after clinical improvement and no vomiting and subtracted from IV fluids (within 24hs of starting therapy)
...
62
Can be used with the usual volume calculation and subtracted from IV fluids
...
63
Insulin Therapy in **DKA**
- Time
- At least 1 hour after starting fluid replacement therapy and reversal of shock
64
Insulin Therapy in **DKA**
- Dose
65
Insulin Therapy in **DKA**
- Route
IV Route
66
Insulin Therapy in **DKA**
- Recommended Rate of Blood glucose drop
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Insulin Therapy in **DKA**
- SC Insulin
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K Replacment in **DKA**
- if hypokalemia
- Start K replacement at the time of initial volume expansion and before starting insulin therapy (Insulin causes an intracellular shift of K, which can cause life-threatening hypokalemia)
69
K Replacment in **DKA**
- if normokalemia
- Start replacing K after initial volume expansion and
concurrent with starting insulin therapy.
70
K Replacment in **DKA**
- If Hyperkalemic
Delay K replacement therapy until urine output is documented.
71
K Replacment in **DKA**
- Dose & Duration
- Starting K* concentration in the infusate should be 40 mmol/L then according to serum K*.
- With initial rapid volume expansion, a concentration of 20 mmol/L should be used.
- K* replacement should continue throughout IV fluid therapy.
- The maximum recommended rate of IV K* replacement is usually 0.5 mmol/kg/h.
72
K Replacment in **DKA**
- if hypokalemia persists
If hypokalemia persists despite a maximum rate of potassium replacement, the rate of insulin infusion can be reduced.
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Profound hypokalemia (<2.5 mmol/L) in untreated DKA is rare and necessitates: .....
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TTT of Acidosis in **DKA**
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TTT of Acidosis in **DKA**
- NaHCO3
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TTT of Acidosis in **DKA**
- Dose
Cautiously give 1 - 2 mmol/kg over 60 minutes
77
TTT of Predisposing factors in **DKA**
e.g. treatment of sepsis
78
Prevention of **DKA**
79
CP (Warning Signs) of **Cerebral Edema**
79
Common errors in diagnosis & management of **DKA**
80
CP of **Cerebral Edema**
- Cushing Reflex
81
TTT of **Cerebral Edema**
