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DiabeticKetoacidosisManagement HeidiChamberlainShea MDEndocrineAssociatesofDallas GoalsofDiscussion PathophysiologyofDKABiochemicalcriteriaforDKATreatmentofDKAPreventionofDKAHyperosmolarNonketoicSyndrome Epidemiology AnnualincidenceinU S 5 8per1000diabeticsubjects2 8 ofalldiabeticadmissionsareduetoDKAOverallmortalityraterangesfrom2 10 Higherisolderpatients DKAPrecipitatingFactors FailuretotakeinsulinFailuretoincreaseinsulinIllness InfectionPneumoniaMIStrokeAcutestressTraumaEmotional MedicalStressCounterregulatoryhormonesOpposeinsulinStimulateglucagonreleaseHypovolmemiaIncreasesglucagonandcatecholaminesDecreasedrenalbloodflowDecreasesglucagondegradationbythekidney DiabeticKetoacidosis Dueto SevereinsulindeficiencyExcesscounterregulatoryhormonesGlucagonEpinephrineCortisolGrowthhormone RoleofInsulin RequiredfortransportofglucoseintoMuscleAdiposeLiverInhibitslipolysisAbsenceofinsulinGlucoseaccumulatesinthebloodLiverUsesaminoacidsforgluconeogenesisConvertsfattyacidsintoketonebodiesAcetone Acetoacetate hydroxybutyrateIncreasedcounterregulatoryhormones CounterregulatoryHormones DKA InsulinDeficiency Glucoseuptake Proteolysis Lipolysis AminoAcids Glycerol FreeFattyAcids GluconeogenesisGlycogenolysis Hyperglycemia Ketogenesis Acidosis Osmoticdiuresis Dehydration SignsandSymptomsofDKA Polyuria polydipsiaEnuresisDehydrationTachycardiaOrthostasisAbdominalpainNauseaVomiting FruitybreathAcetoneKussmaulbreathingMentalstatuschangesCombativeDrunkComa LabFindings HyperglycemiaAniongapacidosis Na K Cl Bicarb 12Bicarbonate 15mEq LpH 7 3UrineketonesandserumketonesHyperosmolarity DifferentialDiagnosisAnionGapAcidosis AlcoholicketoacidosisLacticacidosisRenalfailureEthyleneglycolormethylalcoholpoisoningStarvationinlatepregnancyorlactation rare AtypicalPresentations DKAcanbepresentwithBS 300ImpairedgluconeogenesisLiverdiseaseAcutealcoholingestionProlongedfastingInsulin independentglucoseishigh pregnancy ChronicpoorcontrolbuttakinginsulinBedsideurineketonesfalsenegativesMeasureacetoacetatenot hydroxybutyrateSendbloodtolab TreatmentofDKA InitialhospitalmanagementReplacefluidandelectrolytesIVInsulintherapyGlucoseadministrationWatchforcomplicationsDisconnectinsulinpumpOnceresolvedConverttohomeinsulinregimenPreventrecurrence TreatmentofDKAFluidsandElectrolytes FluidreplacementRestoresperfusionofthetissuesLowerscounterregulatoryhormonesAveragefluiddeficit3 5litersInitialresuscitation1 2litersofnormalsalineoverthefirst2hoursSlowerratesof500cc hrx4hrsor250cc hrx4hoursWhenfluidoverloadisaconcernIfhypernatremiadevelops NScanbeused TreatmentofDKAFluidsandElectrolytes HyperkalemiainitiallypresentResolvesquicklywithinsulindripOnceurineoutputispresentandK 5 0 add20 40meqKCLperliter PhosphatedeficitMaywanttouseKphosBicarbonatenotgivenunlesspH 7orbicarbonate 5mmol L TreatmentofDKAInsulinTherapy IVbolusof0 1 0 2units kg 10units regularinsulinFollowwithhourlyregularinsulininfusionGlucoselevelsDecrease75 100mg dlhourMinimizerapidfluidshiftsContinueIVinsulinuntilurineisfreeofketones TreatmentofDKAGlucoseAdministration SupplementalglucoseHypoglycemiaoccursInsulinhasrestoredglucoseuptakeSuppressedglucagonPreventsrapiddeclineinplasmaosmolalityRapiddecreaseininsulincouldleadtocerebraledemaGlucosedecreasesbeforeketonelevelsdecreaseStartglucosewhenplasmaglucose 300mg dl Insulin GlucoseInfusionforDKA ComplicationsofDKA InfectionPrecipitatesDKAFeverLeukocytosiscanbesecondarytoacidosisShockIfnotimprovingwithfluidsr oMIVascularthrombosisSeveredehydrationCerebralvesselsOccurshourstodaysafterDKAPulmonaryEdemaResultofaggressivefluidresuscitation CerebralEdemaFirst24hoursMentalstatuschangesTx MannitolMayrequireintubationwithhyperventilation OnceDKAResolvedTreatment Mostpatientsrequire0 5 0 6units kg dayPubertalorhighlyinsulinresistantpatients0 8 1 0units kg dayLongactinginsulin1 2 2 3dailyrequirementNPH Lente UltralenteorLantusShortactinginsulin1 3 1 2givenatmealsRegular Humalog NovologGiveinsulinatleast2hourspriortoweaninginsulininfusion PreventionofDKASickDayRules NeveromitinsulinCutlongactinginhalfPreventdehydrationandhypoglycemiaMonitorbloodsugarsfrequentlyMonitorforketosisProvidesupplementalfastactinginsulinTreatunderlyingtriggersMaintaincontactwithmedicalteam GoalsofDiscussion PathophysiologyofDKABiochemicalcriteriaforDKATreatmentofDKAPreventionofDKAHyperosmolarNonketoicSyndrome HyperosmolarNonketoticSyndrome ExtremehyperglycemiaanddehydrationUnabletoexcreteglucoseasquicklyasitenterstheextracellularspaceMaximumhepaticglucoseoutputresultsinaplateauofplasmaglucosenohigherthan300 500mg dlWhensumofglucoseexcretionplusmetabolismislessthantheratewhichglucoseentersextracellularspace HyperosmolarNonketoticSyndrome ExtremehyperglycemiaandhyperosmolarityHighmortality 12 46 AtriskOlderpatientswithintercurrentillnessImpairedabilitytoingestfluidsUrinevolumefallsDecreasedglucoseexcretionElevatedglucosecausesCNSdysfunctionandfluidintakeimpairedNoketonesSomeinsulinmaybepresentExtremehyperglycemiainhibitslipolysis HyperosmolarNonketoticSyndromePresentation ExtremedehydrationSupineororthostatichypotensionConfusioncomaNeurologicalfindingsSeizuresTransienthemiparesisHyperreflexiaGeneralizedareflexia HyperosmolarNonketoticSyndromePresentation Glucose 600mg dlSodiumNormal elevatedorlowPotassiumNormalorelevatedBicarbonate 15mEq LOsmolality 320mOsm L HyperosmolarNonketoticSyndromeTreatment FluidrepletionNS2 3litersrapidlyTotaldeficit 10litersReplete infirst6hoursInsulinMakesureperfusionisadequateInsulindrip0 1U kg hrTreatunderlyingprecipitatingillness Clini
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