Diabetic Ketoacidosis (DKA)

Diabetic Ketoacidosis (DKA)

Diabetic Ketoacidosis (DKA) Dr. Bara AlMakadma, 2019 Recall definitions Relevant reminders on pertinent pathophysiology of DM Types of DM that can cause DKA and when Objectives How does DKA happen (clinically relevant pathophysiology)

Recognize You need to understand those aspects to be able to imagine and recognize why the patient develop these symptoms! At the time of referral, and at first sight Ask the right questions. Quickly confirm Know how to diagnose Know the differential

The principles of treatment When you know the principles behind treating DKA you will NEVER get it wrong; and you shouldnt because that would be dangerous. Diabetes mellitus a chronic metabolic disease characterized by elevated plasma glucose levels because of: insulin deficiency

impaired action of insulin secondary to insulin resistance or a combination of both abnormalities What is diabetes? What are the types of diabetes?

https://www.diabetes.co. uk/diabetes-types.html Which types of diabetes are pertinent to DKA? Type 1 What is gluconeogenesis? Gluconeogenesis (GNG) is a metabolic pathway that results in the generation of glucose from certain non-carbohydrate carbon substrates This happens when your body starves

What is the difference between ketoacidosis and diabetic ketoacidosis? AAFP What other important ketoacidosis should you know about? Alcoholic ketoacidosis The following are VERY IMPORTANT

EMERGENCIES: High blood sugar But low cell sugars Your cells are starving, and they are angry

How does DKA happen and why? How does DKA happen? Remember the concept: Understand that despite blood sugar accumulating outside the cells, they cant go in. Hence the

cells starve and resort to gluconeogenesis Subsequently, excess ketones (through the fat gluconeogenesis pathway) Therefore transcellular shifts and

acidosis Pathophysiolo gy in a nutshell DKA is caused by uncontrolled lipolysis (not proteolysis) which results in an excess of free fatty acids that are ultimately converted to ketone bodies

High Anion Gap acidosis to be specific Because ketone bodies are keto-anions They are not usually measured Simple formula of:

(Na+K) -Cl-HCO3 So what is the definition of Diabetic Ketoacidosis? Diabetic ketoacidosis (DKA) may be a complication existing type 1 diabetes mellitus or be the first presentation, accounting for around 6% of cases. Rarely, under

conditions of extreme stress, patients with type 2 diabetes mellitus may also develop DKA. Whilst DKA remains a serious condition mortality rates have decreased from 8% to under 1% in the past 20 years. Why? Because of lectures such as this!

increased recognition and standardization of treatment What precipitates it? The most common precipitating factors of DKA are infection, missed insulin doses and myocardial infarction.

Features of this illness ABDOMINAL PAIN POLYURIA, POLYDIPSIA, DEHYDRATION KUSSMAUL RESPIRATION (DEEP HYPERVENTILATION) ACETONE-SMELLING BREATH ('PEAR DROPS' SMELL)

How to Diagnose? American Diabetes Association (2009) Joint British Diabetes Societies (2013) Key points: Key points: glucose > 13.8 mmol/l glucose > 11 mmol/l or known diabetes pH < 7.30

mellitus serum bicarbonate <18 mmol/l pH < 7.3 anion gap > 10 bicarbonate < 15 mmol/l ketonaemia ketones > 3 mmol/l or urine ketones ++ on dipstick

The principles of management Concepts you MUST know Management fluid replacement: most patients with DKA are deplete around 5-8 liters. Isotonic saline is used initially. Please see an example fluid regime below. insulin: an intravenous infusion should be started at 0.1 unit/kg/hour. Once blood glucose is < 15 mmol/l an

infusion of 5% dextrose should be started correction of hypokalemia long-acting insulin should be continued, short-acting insulin should be stopped JBDS example of fluid replacement regime for patient with

a systolic BP on admission 90mmHg and over Please note that slower infusion may be indicated in young adults (aged 18-25 years) as they are at greater risk of cerebral edema. Hence in the pediatric age group you may specific dose PER KG PER HOUR JBDS potassium guidelines Potassium level in first 24 hours (mmol/L)

Potassium replacement in mmol/L of infusion solution Over 5.5 Nil 3.5-5.5 40 mmol/L Below 3.5 Senior review as additional potassium

needs to be given al s c o ol l u r to c o y pro w lo ital l Fo sp ho Complications of DKA and its Treatment

Gastric stasis thromboembolism arrhythmias secondary to hyperkalaemia/iatrog enic hypokalaemia iatrogenic due to incorrect fluid therapy: cerebral oedema*, hypokalaemia, hypoglycaemia

acute respiratory distress syndrome acute kidney injury Because at we care!

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