Diabetic Ketoacidosis, Hyperglycemic Hyperosmolar State and ...
Hyperglycemic crises
Click here to load reader
-
Upload
mohamed-badr -
Category
Health & Medicine
-
view
868 -
download
1
Transcript of Hyperglycemic crises
HyperglycemicCrisisDKA, HHSLactic AcidosisHypoglycemia
DKA is a l i fe-threatening complication in Pt. with DM
DKA occurs mostly in type 1 DM frequently presented to hospitals with DKA for the first time at onset
DKA is less common in type 2 DM, but it may occur in situations of physiologic stress. Search a cause?
Definit ion
PATHOGENESIS
Osmotic Diuresis
Renal Hypoperfusion
Impaired Excretion ofKetones & Hydrogen ions
Fluid & Electrolyte Depletion
Vomiting
AcidosisHyperglycemia
Glycosuria
Glucose Ketones
Ketoacidosis is a state of
uncontrolled catabolism associated with
insulin deficiency.
1. Hyperglycemia : gluconeogenesis, glycogenolysis , glucose uptake into ↓cell (underutilization)
2. Ketosis (acidosis) : lipolysis, ketogenesis ,
↓ Peripheral tissue uptake ketone -- ketonemia 3. Hypertriglyceridemia : ↑free fatty acid
4. Osmotic diuresis ,dehydration : hyperglycemia -- ) renal loss glucose, Na & K -- )electrolyte imbalance 5. Volume depletion : hyperglycemia, glucosuria & osmotic diuresis -- dehydration6. Insulin resistance FA,Acidosis , Counter Reg hormones7.Increase coagulability8. Increase Proinflammatory cytokines
Pathophysiology
CLINICAL FEATURES
• Polyuria leading to Oliguria
• Dehydration, Thirst
• Hypotension, Tachycardia,
• Peripheral circulatory failure
• Ketosis
• Hyperventilation
• Vomiting
• Abdominal pain (acute abdomen)
• Drowsiness, Coma
1. Glucose & ketone in serum & urine 2. Serum electrolyte, BUN, Cr, Ca, PO4,Mg 3. Blood gas : capillary or arterial blood gas ABG4. EKG : hypo/ hyperkalemia5. CBC ,UA 6.Consider the ppt factors cardiac enzyme, bld culture ect….
Lab
DDiagnosisiagnosisSevere HyperglycemiaSevere Hyperglycemia1.1. Serum glucose > ~300 mg/dlSerum glucose > ~300 mg/dl
DD< euglycemic Ketosis> pregnancy, alcolhol drinking, stravation >
ASSESSMENT OF ABG1.1. Acidosis : serum HCO3 < 15 mEq/ml or pH < Acidosis : serum HCO3 < 15 mEq/ml or pH <
7.257.25 severity of DKA Mild : HCO3 > 15-18 mq/L & pH > 7.3 Alert
2. Moderate : HCO3 10-15 mq/L & pH 7.1-7.3 ~
3. Severe : HCO3 < 10 mq/L & pH < 7.1
< wide anion gap: >15 mEq/L>
DKA1.1. Ketone : positive ketone in urine Ketone : positive ketone in urine
and / orand / or serum serum B hydroxybutyrateB hydroxybutyrate
Anion gapaverage anion gap for healthy adults is 8-12 mEq/L The concentrations are expressed in units of
milliequivalents/liter (mEq/L) or in millimoles/litre (mmol/L).[edit] With potassiumIt is calculated by subtracting the serum concentrations of
chloride and bicarbonate (anions) from the concentrations of sodium plus potassium (cations):= ( [Na+]+[K+] ) − ( [Cl−]+[HCO3−] )
[edit] Without potassium (Daily practice)However, the potassium is frequently ignored because
potassium concentrations, being very low, usually have little effect on the calculated gap. This leaves the following equation:= ( [Na+] ) − ( [Cl−]+[HCO3−] )
13
DKA- Monitoring Admission ? Observation, ?Home, ?Ward and ? ICU2 IV’s, Oxygen, cardiac monitor, continuous vitals, pulse oxFoley to monitor I &OInitially blood work every 1-2 hours If pH is less that 6.9 be frightenedNasogastric, AnticoagulantAntibiotic
14
DKA- MonitoringStandard blood work
Glucose, lytes with calculated anion,ABG, MagBun & creatinine, calculate GFRBeta-hydroxybutyrate or serum ketonesUACBCEKG Infection-cultures,chest xrayCardiac status-cardiac enzymes
15
Diabetic Ketoacidosis: Treatment involves 5 key components:
MonitoringFluid resuscitation / Electrolyte repletionInsulinTreating underlying cause
16
DKA- Fluids Deficits are typically 100 ml per kg Fluid replacement will lower glucoseInitial Tx usually fluid, fluid, fluidInitial resuscitation 15-20 ml/kg stat for severe
dehydration with normal saline 1l,1l,1l,then 500ml X4 hours, reassess/reassess Once glucose below 250, switch to D5W/.45% N saline or D5W/.9% saline (separate or
Mix)
17
InsulinDelay insulin if Hypokalemic until corrected
??? 10 units R Insulin IV, .15 units/kg , Not Recommended Only if pharmacy delay infusionInsulin infusion pump, most
protocols 5-7 units per hour, .1 units/kg/hr adjusted every 1 or 2 hours
Patient to ICUStop insulin drip when sugar is less
than 250
20
Electrolytes- KWhole body potassium deficits exist. (3-5 mmol/kg)Acidosis increases KGlucose + Insulin lowers KStart K with K less than 5 mmol and adequate urine
outputIf initial K less than 3.3 mmol replete, and then start insulin when K above 3.3
mmol/L
21
Electrolytes- KCommonly under repleted
Resident mistakenly uses the replacement of potassium protocol, which vastly under repletes potassium
Watch like a hawk!!!!Replace/repete/replace/repeteHco3 potentiate electrolyte defecit not recommeded
except in deep coma or severe acidosisPhosphate replaced with K as K phosphate of ~ effect
Bicarbonate Beneficial ONLY if patient is
severely acidotic or nearing cardiorespiratory collapse
HCO3 + H = carbonic acid = H2O + CO2 in ECF
CO2 readily enters cells, where reverse reaction occurs, i.e., H is produced intracellularly, leading to intracellular acidosis
HypokalemiaParadoxical acidosis of CSFAdverse effects on oxyHb
dissociation curve: tissue hypoxia
Overshoot alkalosisAcceleration of ketogenesis by
raising pHCerebral edemaLocal necrosis
23
Electrolytes- Mg A serum deficit usually exists of .5-1 mmol per L
Consider repleting if less than 1.8 mg/dL
•Hypoglycemia •Electrolyte imbalance •Hyperglycemia •Metabolic acidosis •Cerebral edema•Hypoxemia,ARDS•Thrombotic events:CVA,MI
Complication
HHSMild Type 2 DiabeticOld agePolyurea from Hyperglycemia and from Impaired
renal functionSevere dehydration CNS Manifestation very evident (cellular
dehydration)Insulin is enough to inhibit ketosis but not
hyperglycemiaCritical and prognosis is badSame management as DKA
29
Dx Criteria for HHS
Glucose > 600
Arterial pH <7.30Serum bicarb <15 mEq Urine and Serum ketones- smallB-hydroxybutyrate- n or elevatedAnion gap-variablePatient is stupor/comaOsmalality >320 mOsm/kgOsmolality = (2 x (Na + K)) + (BUN /
2.8) + (glucose / 18)Trachtenbarg David, Diabetic Ketoacidosis, American Family Physician, 2005;71:1705-1714
Lactic acidosis
Diabetic type 2 receiving BIGUANIDE (metformin)Suffering from IHD,Chr resp impairement,heart
failure,liver impairement,renal impairement and severe anemia (Metabolite accumulation &increase lactic acid)
Same line of management of DKA
Thank you