Diabetic Ketoacidosis.pptx

1. Diabetic Ketoacidosis Presenter: Dr Vinod Kumar Moderator: Dr Sarita Ramchandani

2. Overview Introduction Pathogenesis Clinical features Diagnosis Laboratory findings Management and prevention Differential diagnosis Summary 2 27-05-2023 Dr Vinod Kumar

3. Diagnosis ? • A 13-year-old girl with a past medical history of anxiety is brought to the emergency room for nausea, vomiting, & abdominal pain. She also reports of ↑ed urinary frequency. • On physical exam, she is lethargic & markedly dehydrated with dry mucous membranes & sunken eyes. Her abdominal exam is normal. • Laboratory results - ↑ed serum glucose 400 mg/dL & K+ 4.9mEq/L. Urinalysis- +ve for ketones. • IV fluids given, admitted to the ICU for close monitoring & administration of an insulin drip. 3 27-05-2023 Dr Vinod Kumar

4. Introduction 4 DKA is a serious acute complications of Diabetes Mellitus. Significant risk of death and/or morbidity especially with delayed treatment. The prognosis of DKA is worse in the extremes of age, with a mortality rates of 5-10%. With the new advances of therapy, DKA mortality ↓ed to < 2%. Before discovery & use of Insulin (1922) the mortality was 100%. 27-05-2023 Dr Vinod Kumar

5. Introduction • HHS and DKA are not mutually exclusive but rather 2 conditions that both result from some degree of insulin deficiency. • They can and often do occur simultaneously. In fact, 1/3rd of patients admitted for hyperglyceamia exhibit characteristics of both HHS & DKA. 5 27-05-2023 Dr Vinod Kumar

6. Definition • DKA is defined as the presence of all 3 of the following: (i) Hyperglycemia (glucose >250 mg/dL) (ii) Ketosis (iii) Acidemia (pH <7.3). 6 27-05-2023 Dr Vinod Kumar

7. Pathophysiology 7 27-05-2023 Dr Vinod Kumar

8. Role of Insulin • Required for transport of glucose into: • Muscle • Adipose • Liver • Inhibits lipolysis • Effects of absence of insulin: Glucose accumulates in the blood. Uses amino acids for gluconeogenesis Converts fatty acids into ketone bodies : Acetone, Acetoacetate, β- hydroxybutyrate. 8 27-05-2023 Dr Vinod Kumar

9. Precipitating events Infection(Pneumonia / UTI / Gastroenteritis / Sepsis) Inadequate insulin administration Infarction(cerebral, coronary, mesenteric, peripheral) Drugs (cocaine) Pregnancy. 9 27-05-2023 Dr Vinod Kumar

10. Presentation Symptoms • Nausea/vomiting • Thirst/polyuria • Abdominal pain • Shortness of breath Physical findings • Tachycardia • Dehydration/hypotension • Tachypnea /Kussmaul respirations/respiratory distress • Fruity odour in breath. • Abdominal tenderness(may resemble acute pancreatitis/surgical abdomen) • Lethargy/obtundation/cerebral edema/possibly coma. 10 27-05-2023 Dr Vinod Kumar

11. Diagnosis (Initial evaluation) 11 • Identify precipitating event leading to elevated glucose (pregnancy, infection, omission of insulin, MI, CNS event) Identify • Assess hemodynamic status • Assess volume status & degree of dehydration • Assess presence of ketonemia & acid-base disturbance Assess • Examine for presence of infection Examine 27-05-2023 Dr Vinod Kumar

12. Diagnosis ( Lab Investigations) Complete blood count Serum ketones/ Urine ketones + sugar Calculate serum osmolality & anion gap Urinalysis & urine culture Consider blood culture Consider chest X-ray Acid-base assessment 12 27-05-2023 Dr Vinod Kumar

13. Treatment of DKA Initial hospital management : • Replace fluid and electrolytes • IV Insulin therapy • Watch for complications • Treat causes Once resolved: • Continue insulin therapy • Prevent recurrence 13 27-05-2023 Dr Vinod Kumar

14. FLUID REPLACEMENT Administer NS as indicated to maintain hemodynamic status, then follow general guidelines: NS for first 4 hrs. Consider 0.45% NS thereafter. Change to D5 & 0.45% NS when blood glucose ≤250 mg/dL. 14 27-05-2023 Dr Vinod Kumar

15. FLUID REPLACEMENT 15 Hours Volume 1st hour 1 L 2nd hour 1 L 3rd hour 500ml – 1 L 4th hour 500ml – 1 L 5th hour 500ml – 1 L Total 1st 5 hours 3.5- 5L 6-12 hours 250– 500 mL/hr 27-05-2023 Dr Vinod Kumar

16. INSULIN MANAGEMENT Regular insulin 10 U IV stat (for adults) / 0.15 U/kg IV stat. Start regular insulin infusion 0.1 U/kg/h / 5 U/h. ↑e insulin by 1 U /h every 1–2 hr if <10% ↓e in glucose/no improvement in acid-base status. ↓e insulin by 1–2 U/h (0.05–0.1U/kg/h) when glucose ≤250 mg/dL &/or progressive improvement in clinical status with ↓e in glucose of >75 mg/dl/h. Don’t ↓e insulin infusion to <1U/h. 16 27-05-2023 Dr Vinod Kumar

17. INSULIN MANAGEMENT Maintain glucose b/w 140 & 180 mg/dL. If BSL ↓es to <80 mg/dl, stop insulin infusion for no >1 hr & restart infusion. If BSL consistently <100 mg/dl, change IV fluids to D10 to maintain BSL b/w 140 & 180 mg/dL. Once patient is able to eat, consider change to S/C insulin: Overlap short-acting insulin S/C & continue IV infusion for 1–2 hr. For pts. with previous insulin dose: return to prior dose of insulin. For pts. with newly diagnosed diabetes: full-dose S/C insulin based on 0.6 U/kg/day. 17 27-05-2023 Dr Vinod Kumar

18. Start S/C insulin: Anion gap normal Serum HCO3- ↑es to >15mEq/L Patient able to eat Mental status improves 18 27-05-2023 Dr Vinod Kumar

19. Na+ REPLACEMENT Calculate effective Sr. Na+ = Sr. Na+ + 1.6 (BG -100)/100 0.9% NaCl is infused @ 15–20ml/kg/wt/h or greater during 1st hour (∼1– 1.5L in avg. adult). Subsequent choice for fluid replacement depends on the state of hydration, serum electrolyte levels, & urinary output. 0.45% NaCl infused @ 4–14ml/kg/h is appropriate if the corrected Sr. Na+ is N/↑ed; 0.9% NaCl at a similar rate is appropriate if corrected Sr. Na+ is low. 19 27-05-2023 Dr Vinod Kumar

20. K+ REPLACEMENT • Don’t administer K+ if Sr. K+ >5.5 mEq/L or patient is anuric. • Use KCl but alternate with KPO4 if there is severe phosphate depletion & patient is unable to take phosphate by mouth. • Add IV K+ to each litre of fluid administered unless contraindicated. 20 Sr. K+ (mEq/L) Additional K required <3.5 - 4.0 40mEq/L 3.5–4.5 20mEq/L 4.5–5.5 10mEq/L >5.5 Stop K+ infusion 27-05-2023 Dr Vinod Kumar

21. PHOSPHATE Hypophasphatemia may develop during ↑ed glucose usage If Sr. level <1mg/dl then phosphate supplementation considered + monitor for hypocalcemia & hypomagnesemia No benefit demonstrated in RCT . 21 27-05-2023 Dr Vinod Kumar

22. BICARBONATE Clinical trials don’t support the routine use of HCO3- replacement HCO3- replacement & rapid reversal of acidosis can impair cardiac function, reduce tissue oxygenation and promote hypokalemia & hypocalcemia. In presence of severe acidosis pH<6.9, in hemodynamic instability with pH<7.1 and hyperkalemia with ECG findings, HCO3- therapy considered . In presence of severe acidosis (arterial pH <6.9), ADA advises HCO3- [50 mmol/L (meq/L) of Na2HCO3- in 200 mL of sterile water with 10 meq/L KCl/h for 2 h until the pH>7.0]. 22 27-05-2023 Dr Vinod Kumar

23. MONITORING Flow sheet mantained tabulating mental status, vital signs,insulin dose,fluid and electrolyte administered and urine output Capillary glucose 1-2hrly,electrolytes especially K+, HCO3- & phosphate) and anion gap every 4 hrly for first 24 hrs Monitor BP, pulse, respiration, fluid intake & output every 1-4 h 23 27-05-2023 Dr Vinod Kumar

24. Blood Glucose monitoring • Check initial blood glucose (BG) q1h. Goal - to ↓e 50-75mg/dL/h • Once stable ( 3 consecutive values ↓ed in target range), change BG monitoring to q2h. • Resume q1h monitoring for each change in insulin infusion rate • Add dextrose 5% to IV fluids when BG <250mg/dL • For Goal BG is 150-200 mg/dL until anion gap treated 24 27-05-2023 Dr Vinod Kumar

25. ONCE DKA RESOLVED • Most patients require 0.5-0.6U/kg/day • Highly insulin resistant patients: 0.8- 1U/kg/day • Give subcutaneous insulin at least 2 hrs prior to weaning insulin infusion. 25 27-05-2023 Dr Vinod Kumar

26. COMPLICATIONS OF DKA Shock (If not improving with fluids, then consider MI) Vascular thrombosis • Severe dehydration • Cerebral vessels - occurs hrs to days after DKA Pulmonary Edema (Result of aggressive fluid resuscitation) Cerebral Edema • First 24 hrs • Mental status changes • May require intubation with hyperventilation 26 27-05-2023 Dr Vinod Kumar

27. CLINICAL ERRORS • Giving insulin without sufficient fluids • Using hypertonic glucose solutions Fluid shift & shock • Premature K+ administration before insulin has begun to act Hyperkalemia • Recurrent ketoacidosis • Premature discontinuation of insulin & fluid when ketones still present • Failure to administer K+ once levels falling Hypokalemia Hypoglycemia (Insufficient glucose administration) 27 27-05-2023 Dr Vinod Kumar

28. Differential diagnosis 28 27-05-2023 Dr Vinod Kumar

29. Compare & Contrast 29 VALUE DKA HHS Plasma glucose (mg/dl) > 250 > 600 Arterial pH < 7.30 > 7.30 Serum bicarbonate (mEq/L) <15 >15 Serum Osmolarity (mOsm/L) Variable >320 Urine and serum ketones Positive Trace 27-05-2023 Dr Vinod Kumar

30. Compare & Constrast 30 VALUE DKA HHS Anion gap >12 <12 Mental status Alert, drowsy to stupor and coma Stupor/coma Sodium (mEq/L) 125-135 135-145 Pottassium (mEq/L) Normal to High Normal Creatinine (mg/dl) Slight Increase Moderate increase 27-05-2023 Dr Vinod Kumar

31. Summary • A 13yr old girl with a past h/o of anxiety is brought to the emergency room for nausea, vomiting, and abdominal pain. She also reports ↑ed urinary frequency. On physical exam, she is lethargic and markedly dehydrated with dry mucous membranes and sunken eyes. Her abdominal exam is normal. Laboratory results show ↑ed serum glucose of 400 mg/dL and Potassium is 4.9mEq/L. A urinalysis is positive for ketones. She is given fluids and admitted to the ICU for close monitoring and administration of an insulin drip. 31 27-05-2023 Dr Vinod Kumar

32. Thank you! 32 27-05-2023 Dr Vinod Kumar

Diabetic Ketoacidosis.pptx

Diabetic Ketoacidosis.pptx

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