Management of DKA Presentation

8/7/2019 Management of DKA Presentation

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MUHAMMED YESUF(M D)

University of Gondar


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Presentation outliney Overviewy History

y Epidemiologyy Pathophysiolgyy Clinical presentationy Dx and DDXy Rx

y Monitoringy DKA Resolutiony Complicationsy Sick day rule


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Overviewy One of the common and life threatening acute

complication of DM

y Results from absolute insulin deficiency and itsresultant metabolic alterations

yAccounts for 16% of DM related deaths


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Historyy First full description

y Jullius Dreschfeld 1886

y Universally fatal till 1920sy By 1930 MR 29%

y By 1950 MR


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Epidemiologyy In type I

y In young (


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Pathophysiologyy Insulin deficiency

y Increased counter regulatory hormones (Glucagon,cathecolamins, cortisol, GH)

Hyperglycemiay Impaired glucose utilization

y Decreased insulin - decreased GLUT 4

y Increased glucose productiony

Gluconogenesisy Glyconogynolysis

Hyperglycemiay Draws water from cells Volume depletion

y Induces glucosuria with osmotic diuresis


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Volume depletion/ DHN depends on

y Duration of hyperglycemia

y Level of renal functiony Pt fluid intake


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Ketoacidosis

keton bodies from increase lipolysis

Decreased insulin

Lipolysis

Glycerol FFA

Maloyl CoA

Gluconogenesis TG, VLDL KB


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y Electrolyte disturbance

Na

balance of water shift from ICF to ECF Vs Osmoticdiuresis

hyperglycemia causes a sodium drop of 1meq ofNa for every 62mg/dl rise of glucose

corrected serum Na = measured Na + (SG(mg/dl) /42)or

= measured Na + (SG (mmol/L) /2.3)


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y K

Measured K can be high, low, normal. Generally there is

3-5 mg/Kg lossurinary loss

GI loss

Loss from cells

Serum K is increase b/c of decreased insulin andhyperosmolarity. Acidosis plays less role


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y Phosphate

Negative P balance

decreased intakephoshaturia

Serum level can be normal or increased b/c of

decreased insulin

acidosis

y Bicarbonate

Always low


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Table : Total body deficits of water and electrolytes in DKA

DKA

Total water(l) 6

Water(ml/kg) 100

Na(meq/kg) 7-10

Cl(meq/kg) 3-5

K(meq/kg) 3-5

Po4(mmol/kg) 5-7

Mg(meq/kg) 1-2Ca(meq/kg) 1-2


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Clinical presentationy Sx

y Early poly Sx

Wt lossy Later neurologic Sx (lethargy, focal signs, obtundation,

Coma)

Because of increased plasma osmolality. It

occurs when the effective plasma osmolality is 320 330.And it can be calculated as


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Effective Posm= [2*Na (meq/L)] + [glucose (mg/dl)/18]

Or

= [2*Na (mmol/L)] + [glucose (mmol/L)]

Effective Posm= [measured Posm]-[BUN (mg/dl) /2.8]

Or

= [measured Posm]-[BUN (mmol/L)]


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yAbdominal pain, nausea and vomiting

Abd pain associated with the degree of acidosis and could

be due to delayed gastric emptying or illusy Symptoms of precipitating factors


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y TABLEFactors Most Often Associated with the Development of Diabetic Ketoacidosis

y Factor

Approximate frequency(%)y Infection

35y Omission of insulin or inadequate insulin

30y Initial presentation of diabetes mellitus

20y Medical illness

10y Unknown

5


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y Signs

y Signs of volume depletion

y

Tachycardia, hypotensiony Dry mucusmembrane, reduced skin turgor

y Tachypnea, kussmauls respiration

y Acetone breath

y

Abdominal tendernesy Altered mental status


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y Lab abnormality

y Serum glucose

y

Elevated usually < 600 mg/dl. Could be >900mg/dl incomatose pt. why?

y Could be normal euglycemic DKA

y Starvation

y Pregnancy

y Liver diseasey Prior Rx with insulin


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y Serum electrolytesy Na

y K variable

y Py Bicarbonate-low

Not the total body amount reflected

y BUN,Cry Could be elevated b/c of volume depletion

y Acetoacetate falsely elevates Cr

y CBCy Leucocytosis-b/c of increased cortisol and cathecolamines

y Can indicate infection


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y U/A

y Urine ketone

y UTI

y Diabetic nephropathy

y Plasma osmolality

y Calculated as described before

y Usu in DKA 300-320

y Serum ketones

y Nitropruside isnot a good method

y False negative b/c B-OHB is not detected by nitroprusside

y False positive with drugs like captopril,pencillamine,mesna


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y ABGy ECGy PH and bicarbonate

y

Bicarbonate12Additional lab studies

y Urine culturey Sputum culturey Blood culturey CXRy A1Cy Amylase lipase


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y DDX

y Alcoholic ketoacidosis

y

Starvation ketosisy Anion gap acidosises

such asy Lactic acidosis

y

Salicylate intoxicationy Methanol/ethylene glycol intoxication

y Rhabdomyolysis


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Table :Diagnostic criteria for DKA and classifications

parameters Mild Moderate Severe

Plasma glucose(mg/dl) >250 >250 >250

Arterial PH 7.25-7.30 7.00-7.24 12 >12Mentation alert Alert/drowsy Stupor/coma


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TREATMENTy Initial evaluation

y ABC

y

Mentationaltered-NG Tube

y Volume status

y Precipitating factors

May need emergency Rx


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Goals of Rx

y Improving circulatory volume and tissue perfusion

y

Reducing blood glucose and serum osmolality to normallevel

y Clearing ketone from serum and urine at a steady state

y Correcting the electrolyte imbalance

y

Identifying precipitating factors


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Components of Rx

y Fluid

y

Insuliny electrolytes


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FLUID MXy It will

y Increase intra vascular volume

y

Decrease BG (30-70mg/l) trough increase insuliny Hemodilution sensitivity

y Urinary loss

y Decrease counter regulatory hormones

The fluid deficit should be corrected over 24hrs


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y Rate depends on Pt volume status

Generally 10-15ml/Kg NS

Roughly the fluid can be given like thisy 1L-30 min

y 1L-2hrs

y 1L-4hrs

y 1L-6hrsy Then 1L every 6 hrs


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y Type of fluid depends on

y Glucose level

y

Osmolalityy Electrolyte composition

So initially NS then NS

when BG


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Fluid initially then insulin Vs simultaneous??????


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INSULINMultiple dosing styles

1. 0.1u/kg bolus followed by 0.1u/kg continuous infusion

2. 0.14u/kg continuous infusion3. S C administration for mild DKA

0.3u/kg followed by 0.1u/kg till BG


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4.??our protocol

0.3u/kg 1/2iv 1/2im/sc

Then 0.1u/kg im/sc q hr till BG is


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After resolution

y Naive Pts 0.5-0.8u/kg calculated to be given as

combination with 2/3 M and 1/3Ey Known diabetics put on the previous dose

NB :regular insulin and the standing should overlap for1-2 hr


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y Sliding scale

y BG q 4 hr and for every 50mg/dl increase above

150mg/dl increase the insulin by 5iu up to a maximum of20iu

y For pts not feeding,in stressful condition

Standing dose with correction???


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ELECTROLYTESy Potassium

y 5.3meq/ly Give insuliny No k

So k replacement is when serum k is


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y Bicarbonate

Not routine

I

ndicationsy PH


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y Phosphorous

y Not routine

y

Indicationsy Cardiac dysfunction

y Hemolytic anemia

y Resp depression

y Serum level


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DKA RESOLUTONy General improvement in sx

y Pt able to feed

y Normal anion gap 7.3


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Cerebral edema

Dxic criteria(murei etal)y

Abnormal response to painy Decorticate,decerebrate posturing

y CN palsy

y Abnormal resp pattern

y Fluctuating LOC

y Sustained bradycardya

y Incontinence

y More non specific-vomiting, headache, lethargy, elevated DBP


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y RX of cerebral oedema

y Mannitol 0.5-1gm/kg over 15-30 min, if no response repeatafter 20-30 min

y 3%Saline 5-10mg/kg over 30min

y Hyper ventilation

y Surgical


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Special considerations

pregnancyy

fetal mortality as high as 30% and increased to 60% when theDKA is associated with coma

Childreny be alert to headache and reduced LOC


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SICK DAYRULEy Golden rule Never stop taking your insulin,b/c when

you are sick the body sugar increases

y Foods and drinks-take non sugary fluids, continueeating

y Blood glucose and urinary ketone q2-4hr

y Insulin mxy BG>7mmol/l-increase the usual insulin by 10%

y UK +ve-increase insulin by 20% of the daily dosey Calculate and take a correction insulin dose

could be repeated q2-4hr


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THE END

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Management of DKA Presentation

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