Date post: | 03-Apr-2018 |
Category: |
Documents |
Upload: | eric-chye-teck |
View: | 240 times |
Download: | 10 times |
of 33
7/28/2019 Diabetic Ketoacidosis(DKA)
1/33
Diabetic
Ketoacidosis(DKA)
7/28/2019 Diabetic Ketoacidosis(DKA)
2/33
Definition DKA - acidosis accompanied by the accumulation
of ketone bodies in diabetes patient. (1)
Consist of the biochemical triad of ketonemia,hyperglycemia, and acidemia. (2)
Most patients with DKA have autoimmune type 1
diabetes , however patients with type 2 diabetesare also at risk during catabolic stress of acuteillness. (3)
7/28/2019 Diabetic Ketoacidosis(DKA)
3/33
Pathophysiology Absolute or relative insulin deficiency accompanied by
an increase in counter-regulatory hormones whichenhances hepatic gluconeogenesis , glycogenolysis ,and lipolysis. (3,4)
Absolute insulin deficiency may occur in certaincondition such as undiagnosed type 1 diabetes andpatient who miss their insulin doses. (5)
Relative insulin deficiency may occur whenconcentrations of counterregulatory hormonesincrease in response to stress conditions. (5)
7/28/2019 Diabetic Ketoacidosis(DKA)
4/33
Gluconeogenesis and glycogenolysis will increase
the blood glucose level and causinghyperglycemia.(3)
Lipolysis increase serum fatty acids which will
undergo oxidation as an alternative energy sourceto produce ketone bodies resulting ketonemia andmetabolic acidosis. (3)
Fluid depletion can occur due to hyperglycemiainduce osmotic diuresis, vomiting due toketoacidosis and inability to take in fluid due todiminished level of consciousness. (2)
7/28/2019 Diabetic Ketoacidosis(DKA)
5/33
Sign and symptoms Dry skin
Characteristic acetone (ketotic) breath odor
Nausea, vomiting, or abdominal pain
Tachypnea
Hypotension
Tachycardia
Hypothermia Polyuria, polydipsia, and nocturia
7/28/2019 Diabetic Ketoacidosis(DKA)
6/33
Diagnostic criteria (3)
DIABETES CARE, VOLUME 32, NUMBER 7, JULY 2009
7/28/2019 Diabetic Ketoacidosis(DKA)
7/33
Goals of therapy
Expansion of the intravascular volume.
Correction of deficit in fluids, electrolyte & acid
base status.
Initiation of intravenous insulin infusiontherapy.
Assessment and monitoring of therapy.
Treatment of concurrent infection if present.
7/28/2019 Diabetic Ketoacidosis(DKA)
8/33
General management issues1. Fluid administration and deficits the most important initial therapeutic intervention
to restore circulatory volume, clearance of ketonesand correction of electrolytes imbalance.
Typical deficits in DKA:
Water (ml/kg) 100
Sodium (mmol/kg) 7-10
Chloride (mmol/kg) 3-5
Potassium (mmol/kg) 3-5
7/28/2019 Diabetic Ketoacidosis(DKA)
9/33
2. Insulin therapy
Insulin has the effects of suppression ofketogenesis, reduction of blood glucose andcorrection of electrolyte imbalance
Administration of intravenous insulin infusionat a fixed rate of 0.1 units/kg is recommended
Priming dose of insulin is not necessaryprovided if the insulin infusion is startedpromptly at a dose of at least 0.1 unit/kg/hr .(Kitabchi 2008)(2)
7/28/2019 Diabetic Ketoacidosis(DKA)
10/33
3. Metabolic treatment targets
The recommended targets areReduction of blood ketone concentration by 0.5
mmol/L/hr
Increase in venous bicarbonate by 3 mmol/L/hrReduce capillary blood glucose by 3 mmol/L/hrSerum potassium level should be maintain
between 4-5 mmol/L
If these rates are not achieved then the fixed rateof intravenous insulin infusion should beincreased.
7/28/2019 Diabetic Ketoacidosis(DKA)
11/33
4. Intravenous glucose concentration
Administration of intravenous infusion of 10%glucose is necessary in order to avoidhypoglycemia and to allow the continuation of a
fixed rate IVII to suppress ketogenesis.
Introduction of 10 % glucose is recommendedwhen the blood glucose falls below 14mmol/L
IVII should not be discontinued until the patientis eating and drinking normally.
7/28/2019 Diabetic Ketoacidosis(DKA)
12/33
Management pathway
Joint British Diabetes Societies Inpatient Care
Group. The Management of Diabetic Ketoacidosis
in Adults (March 2010).
7/28/2019 Diabetic Ketoacidosis(DKA)
13/33
1. Immediate management upon
diagnosis at the first hourAims
Start IV 0.9% sodium chloride solution
Start a fixed rate IVII after starting fluid therapyEstablished monitoring regime hourly blood
glucose, ketone measurement and at least 2 hourlyserum potassium for the 1st 6 hours
Clinical and biochemical assessment of the patient
7/28/2019 Diabetic Ketoacidosis(DKA)
14/33
Actions
1.Intravenous access and initial investigation ABC, IV fluid replacement, clinical assessment,
lab investigation, and consider precipitatingcauses and treat appropriately.
2.Restoration of circulating volume
SBP below 90 mmHg give 500ml of 0.9% Naclover 10-15 minutes.
Once SBP above 90 mmHg follow fluidreplacement as in table 1
7/28/2019 Diabetic Ketoacidosis(DKA)
15/33
Table 1
7/28/2019 Diabetic Ketoacidosis(DKA)
16/33
Fluid replacement (Sarawak handbook 3rd ed)
1 liter NS in 1 hour
Then 1 liter in 2 hour Then 1 liter in 4 hour
Then 1 liter in 6 hour
Then 1 liter in 8 hour
Potassium replacement
More than 5 mmol/L no need add KCl
4.5 5.0 mmol/L add 1 g KCl each liter 3.5 4.5 mmol/L add 2 g KCl each liter
3 3.5 mmol/L add 3 g KCl each liter
Less than 3 add 4 g KCl each liter
7/28/2019 Diabetic Ketoacidosis(DKA)
17/33
3. Potassium replacement
Serum K is often high on admission (although totalbody potassium is low) but falls precipitously upontreatment with insulin.
To maintain K level at 4-5 mmol/L with 20-40
mmol/L K.
4. Starting a fixed rate intravenous insulin infusion
50 units of insulin made up to 50 ml of NS and
infused at a fixed rate of 0.1 unit/kg/hr Only give stat dose of insulin if there is a delay in
setting up a fixed rate of IVII.
7/28/2019 Diabetic Ketoacidosis(DKA)
18/33
2. 60 minutes to 6 hours
Aims
Clear the ketones from blood and suppressketogenesis
Achieve a rate of fall of ketones of at least 0.5mmol/L/hr
Or bicarbonate should rise by 3 mmol/L/hr andblood glucose should fall by 3 mmol/L/hr
Maintain serum K and avoid hypoglycemia
7/28/2019 Diabetic Ketoacidosis(DKA)
19/33
Actions
1.Reassess patient and monitor vital signs Consider urinary catheterisation isfincontinent oranuric
Accurate fluid balance chart, minimum urine
output 0.5ml/kg/hr
2.Review metabolic parameters
Assess the resolution of ketoacidosis
Calculate the rate of change of ketone level fall orglucose or rise in bicarbonate
Ketone falling at least 0.5mmol/L/hr, bicarbonaterise at least 3 mmol/L/hr or glucose falling at least
3 mmol/L/hr
7/28/2019 Diabetic Ketoacidosis(DKA)
20/33
Increase the rate of intravenous insulin infusion ifthe ketone or glucocose level did not fall orbicarbonate level did not increase as above.
Continue the IVII until ketones less than 0.3mmol/L, venous pH over 7.3 and/or venousbicarbonate over 18 mmol/L
If glucose falls below 14 mmol/L, 10% glucoseshould be given at 125ml/hr with 0.9% Naclsolution.
7/28/2019 Diabetic Ketoacidosis(DKA)
21/33
6 to 12 hoursAims
Ensure that clinical and biochemical parameters areimproving
Continue IV fluid replacement and IVII
Assess for complications of treatment example fluid
overload or cerebral edemaAvoid hypoglycemia
Actions
1. Reassess and monitor patient vital sign2. Review of biochemical and metabolic
parameters
Resolution of DKA is defined as ketones less than
0.3 mmol/L, and venous pH over 7.3
7/28/2019 Diabetic Ketoacidosis(DKA)
22/33
12 to 24 hours
By 24 hours the ketonemia and acidosis shouldhave resolved.
Aims
Ensure all parameters are improving or havenormalised.
Continue iv fluids if not eating or drinking
Reassess for complications of treatmentTransfer to subcutaneous insulin if patient eating
and drinking normally
7/28/2019 Diabetic Ketoacidosis(DKA)
23/33
Actions
1. Reassess and monitor patient vital sign
2. Review of biochemical and metabolicparameters
Resolution is defined as ketones < 0.3 mmol/L,venous pH > 7.3
3. Subcutaneous insulin is started before IVinsulin is discontinued. Ideally givesubcutaneous fast acting insulin and a meal anddiscontinue IV insulin one hour later.
7/28/2019 Diabetic Ketoacidosis(DKA)
24/33
Complication of DKA treatment
Hypokalemia and hyperkalemiaPotentially life threatening
Risk of acute renal failure associated with severedehydration and therefore recommend that no
potassium should be given with initial fluid resuscitation
K will always falls as the DKA is treated with insulin andrecommended that 0.9% Nacl solution with potassium40 mmol/L is given as long K level below 5.5 mmol/Land patient is passing urine.
Joint British Diabetes Societies Inpatient Care Group.The Mana ement of Diabetic Ketoacidosis in Adults March 2010 .
7/28/2019 Diabetic Ketoacidosis(DKA)
25/33
Hypoglycemia
Blood glucose may fall very rapidly as ketoacidosisis corrected and is a common mistake to allow theblood glucose drop to hypoglycemic levels
This may result a rebound ketosis by counter
regulatory hormones.Severe hypoglycemia can associate with cardiac
arrhythmias brain injury and death.
Once blood glucose drops to 14 mmol/L
intravenous glucose 10% should be given to patient
Joint British Diabetes Societies Inpatient Care Group.The Mana ement of Diabetic Ketoacidosis in Adults March 2010 .
7/28/2019 Diabetic Ketoacidosis(DKA)
26/33
Cerebral edema
More common in childrenExact cause is unknown but recent studies suggest
that cerebral hypoperfusion with subsequentreperfusion may be the mechanism operating.
Pulmonary edema
Rapid infusion of crystalloids over a short period oftime increase the risk of complication
Elderly and impaired cardiac function patient alsoat the risk of developing pulmonary edema
Joint British Diabetes Societies Inpatient Care Group.The Mana ement of Diabetic Ketoacidosis in Adults March 2010 .
7/28/2019 Diabetic Ketoacidosis(DKA)
27/33
Recommendation and discussion
1. Arterial vs venous measurement?
Difference btw arterial and venous pH is 0.02-0.15 units and bicarbonate is 1.88mmol/L
Not really affect the diagnosis or managementof DKA
Venous blood are easily obtained
Measure venous rather than arterialbicarbonate and pH
Joint British Diabetes Societies Inpatient Care Group.The Mana ement of Diabetic Ketoacidosis in Adults March 2010 .
7/28/2019 Diabetic Ketoacidosis(DKA)
28/33
2. Colloid vs crystalloid
Many guideline suggest that in hypotensive patientsinitial fluid resuscitation should use colloid.
However hypotension results from a loss ofelectrolyte solution and it is more physiological to
replace with crystalloid fluid.
It is recommended that 0.9% sodium chloridesolution should be the fluid of choice for
resuscitation in all clinical areas as it supports safepractice and is available ready to use.
Joint British Diabetes Societies Inpatient Care Group.The Mana ement of Diabetic Ketoacidosis in Adults March 2010 .
7/28/2019 Diabetic Ketoacidosis(DKA)
29/33
0.9% Nacl vs compound sodium
Joint British Diabetes Societies Inpatient Care Group.The Mana ement of Diabetic Ketoacidosis in Adults March 2010 .
7/28/2019 Diabetic Ketoacidosis(DKA)
30/33
3. Initiating treatment with a priming dose of
insulin? Is not really necessary if the insulin infusion is
started promptly at a dose of at least 0.1unit/kg/hr
4. Intravenous phosphate?
No evidence of benefit of phosphate replacement
However, in the presence of respiratory andskeletal muscle weakness, phosphatereplacement should be considered.
Joint British Diabetes Societies Inpatient Care Group.The Mana ement of Diabetic Ketoacidosis in Adults March 2010 .
7/28/2019 Diabetic Ketoacidosis(DKA)
31/33
5. Intravenous bicarbonate?
Is not indicated Adequate fluid and insulin therapy will resolve
the acidosis
Acidosis is an adaptive response to improve
oxygen delivery to the tissue causing a rightshift to the oxygen dissociation curve .
Excessive bicarbonate may cause a rise in CO2partial pressure in CSF and may lead to a CSFacidosis.
Use of bicarbonate may increase the risk ofcerebral edema in children and young adults
Joint British Diabetes Societies Inpatient Care Group.The Mana ement of Diabetic Ketoacidosis in Adults March 2010 .
7/28/2019 Diabetic Ketoacidosis(DKA)
32/33
Thank you
7/28/2019 Diabetic Ketoacidosis(DKA)
33/33