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1

Diabetic ketoacidosis
- Pathophysiology

Hyperglycaemia
- Due to insulin deficiency

Glucose leaks into urine
- Glycosuria
- Loss of electrolytes
- Leads to dehydration

Loss of fluid can cause kidney damage and lead to hypovolumemic shock

Increased lipolysis
- Increases FFA thus ketones
- High ketone levels causes acidosis by dissociating into H+ and anions.

2

Physiological compensation of acidosis

Increased buffering
- H+/K+ pump

Respiratory compensation
- Hyperventilation

Renal excretion of H+
- Slow

Renal loss of Na+ and K+

3

Diabetic ketoacidosis precipitating factors

Infections

Erroneous/ missed insulin

MI

Previously undiagnosed T1 DM

Drugs that increase glucose [e.g steroids]


4

Diabetic ketoacidosis symptoms

Thirst, polyuria

Weakness, malaise

Drowsiness, confusion

Acidosis:
- Nausea
- Vommiting
- Abdominal pain
- Breathlessness

5

Diabetic ketoacidosis clinical features

Usually young for T1 DM

Relative/ complete insulin deficiency

Normal/ low sodium

Low Blood glucose

Low bicarbonate

High serum ketones

6

Management of diabetic ketoacidosis

Check and diagnose precipitating cause

Rehydrate/ monitor fluid balance

control glucose [insulin]

Monitor electrolytes

Prevention of clot
- LMW heparin

Access GCS

Decrease risk of aspiration if unconscious [NG tube?]

7

Hyperosmolar hyperglycaemic state

Relative insulin deficiency

Insulin not high enough for lipolysis
- Glucose increases via increased hepatic glucose output

Hyperglycaemia increases osmotic diuresis
- Dehydration--> shock
- More profound in elderly/ weak

8

Hyperosmolar hyperglycaemic state
- Clinical features

Usually older

Hypernatraemia

High glucose >40mmol/L

No ketone, normal pH

Increased risk of mortality compared to DKA

Corrected by correcting dehydration

9

Management of Hyperosmolar hyperglycaemic state

Fluid replace but done cautiously [due to age of patient]
- Rehydration done with fluid balance monitored

Fluid administered too quickly = possible pulmonary oedema

Lower glucose with fixed insulin rate
- Only if glucose does not improve after fluids

10

Hypoglycaemia in diabetes

Usually due to inappropiate insulin dosing

Symptoms
- Shaky
- Tachycardia
- Sweating
- Dizzy
- Anxiety
- Blurry vision, headache

Treatment
- Small treatment [sweet, sugary drink]

11

Hypoglycaemic coma treatment

IM/ IV glucagon

IV dextrose

12

Effects of insulin deficiency on adipose tissue

Increased lipolysis

Reduced esterification of fat

Hepatic synthesis of ketone bodies
- Ketosis occurs when ketone production exceeds its utilisation and clearance.

13

Signs of diabeteic ketoacidosis

Hyperglycaemia and dehydration:
- Dry mouth
- Sunken eyes
- Postural/ supine hypotension
- Hypothermia
- Coma

Acidosis
- Facial flush
- Hyperventilation
- Ketone breath
- Ketouria

14

Treatment of minor hypoglycaemic episode

20g carbohydrate sugary drink

Fruit juice

Glucose tablet

Glucose gel

Followed by starchy food