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Diabetic keto acidocis

1. Diabetic ketoacidosis (dka) & Hyperglycaemic hyperosmolar state (hhs) Dr. Md. Albin Jadid Medical Officer Department of Cardiology

2. Diabetes Mellitus: An Overview Diabetes mellitus is defined as chronic/persistent hyperglycemia, due to deficiency of insulin secretion or of insulin action or both. Several pathological processes are involved in causing diabetes. These processes are regulated by genetic and/or environmental factors.

3. Classification of Diabetes Type 1 Diabetes Mellitus (T1DM). Type 2 Diabetes Mellitus (T2DM). Gestational Diabetes Mellitus (GDM). Other specific types or secondary diabetes mellitus.

4. Typical features of DM Polyuria. Polydipsia. Polyphagia. Weight loss. General weakness.

5. Atypical features of DM Atypical manifestations are non-specific. A short list includes: Non-healing infection. Infertility or repeated pregnancy loss. Undue fatigability. Pruritus valvae . etc

6. Confirmation of Diagnosis by Test Blood glucose tests: Blood glucose assay is done by glucose oxidase method using auto-analyzer from plasma. It is done during three tests. Oral Glucose Tolerance Test - Gold standard test. Fasting Plasma Glucose. (may miss diagnosis of IGT & DM) Random Plasma Glucose. (can suspect DM only)

7. OGTT Gold standard test. In this procedure two blood glucose levels are determined - At fasting. - 2 hours after 75g of oral glucose intake.

8. OGTT: Interpretation Blood Glucose Normal IFG IGT Diabetes At fasting ( mmol /L) <6.1 6.1 to 6.9 <7.0 >/= 7.0 and and and Or/ and After Glucose ( mmol /L) <7.8 <7.8 7.8 to <11.1 >/= 11.10

9. DM diagnosed with its complications MicroVascular complications: - Diabetic retinopathy. - Diabetic nephropathy. - Diabetic neuropathy. MacroVascular Complications: - Coronary artery disease. - Cerebrovascular disease. - Peripheral vascular disease . # Type 2 DM shows more of this type of presentation.

10. Role of Insulin

11. Hyperglycemic Emergencies Diabetic ketoacidosis (DKA). Hyperglycaemic hyperosmolar state (HHS).

12. Diabetic keto acidosis (DKA) A state of absolute or relative insulin deficiency aggrevated by ensuing hyperclycemia , dehydration & acidosis producing derangements in intermediary metabolism, including production of serum acetone. It is commonly found in Type I DM. But it also occurs in other types of diabetes during stressful situations.

13. Triad of Diabetic Ketoacidosis Acidosis (pH <7.3 and/or bicarbonate <15 mmol /L) Hyperglycemia (Blood glucose >15 mmol /L) Ketosis (Ketones present in blood and/or urine) DKA

14. Causes of DKA Undiagnosed diabetes. Omission of insulin dose. Injudicious reduction of insulin dose. Intercurrent illness, especially acute infection. Trauma. Pregnancy.

15. Clinical Features of DKA DKA develops rapidly (hours to days). Symptoms of uncontrolled diabetes precedes. Weakness, vomiting, impairment of level of consciousness, acute abdomen. Dehydration is the most obvious clinical feature with dry skin & tongue, low bp , rapid weak pulse. Acidotic breathing is characteristic; there may be acetone smell in breath.

16. Diagnosis of DKA by biochemical features Blood glucose: usually >15 mmol /L. Acidosis – arterial pH <7.3 and/or bicarbonate <15 mmol /L). Ketone bodies in blood & urine are greatly increased. Serum osmolarity is variable.

17. Treatment components of DKA Management Fluid replacement. Insulin. Potassium replacement. Bicarbonate use. Monitoring –clinically, biochemically & others Nursing Care.

18. Management of DKA 1. Fluid replacement: To infuse initially normal saline (0.9% NaCl) rapidly, then 0.9% or 0.45% NaCl calculating against clinical & biochemical status. When blood glucose comes down to 14.0 mmol/L, 5% dextrose is to be started.

19. 2. Short acting Insulin: If infusion pump is available, infused at a rate of 0.1 unit/kg/hour; otherwise, 10-20 units bolus i.m. is given, followed by 0.1 unit/kg i.m. hourly. Hourly fall of blood glucose should be in the range of 3-4 mmol/L; otherwise insulin dose should be increased. Insulin dose is reduced when blood glucose comes to 14.0 mmol/L. Usual sub-cutaneous regimen of insulin may be started when the patient stable clinically & biochemically, and able to take oral food.

20. 3. Potassium replacement: depends on blood level of K+... If K+ <3.5 mmol/L – 40 mmol/hr. K+ infusion. If K+ 3.5-5.5 mmol/L – 20 mmol/hr. K+ infusion in each litre fluid. If K+ >5.5 mmol/L – not to give K+.

21. 4. Sodium bicarbonate: In severely acidotic patient (pH <7.0) sodium bicarbonate is to be infused slowly. 5. Monitoring: Assessment of clinical conditions. Blood glucose, electrolytes, arterial blood gas frequently (1-4 hourly) until stable. Blood/Urine ketone. Other tests as required.

22. Complications of DKA Cerebral oedema. Circulatory failure. Thromboembolism. DIC, etc. ## overall mortality for DKA is 2% or less.

23. Hyperglycemic Hyperosmolar state (HHS)/ Hyperosmolar nonketotic coma (HONK) HHS is a combination of Severe degree of hyperclycemia, Dehydration & Hyperosmolarity, without significant ketonuria. Usually seen as complication of elderly type 2 DM patients. Here residual insulin reserve prevents ketosis.

24. Causes of HONK Lack of proper treatment of DM. Any acute stress e.g. I nfection, Myocardial infarction, Stroke, Trauma. Compromised fluid intake. Drugs e.g. G lucocorticoids, diuretics.

25. Clinical Features of HONK Develops slowly (days to weeks). Symptoms of uncontrolled diabetes precedes. Dehydration is profound. Impairment of consciousness is common.

26. Diagnosis of HONK Blood glucose: usually >30 mmol /L. Hyperosmolarity : effective serum osmolarity >320 mosm /kg. No acidosis: arterial pH >7.3; plasma bicarbonate > 15meq/L. Absence of significant ketonemia / ketonuria .

27. Principles of Management of HONK Hospitalization. Clinical assessment. Determination of blood glucose, osmolarity , electrolytes, arterial blood gas with pH. Complete blood picture, urea etc. Treatment institution is to be done immediately without waiting for laboratory reports.

28. Management of HONK Rapid change is plasma osmolarity should be checked. Less insulin is required than DKA. 5% dextrose & lower insulin dose are started at a higher blood glucose level. Sodium bicarbonate is not required.

29. Complication of HONK Cerebral oedema. Circulatory failure. Thromboembolism, DIC etc. Overall mortality for HONK is 10-20%.

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