DKA and HHS Abdullah Bani Issa aaaa.pptx

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1. Prepared by Captain :Abdullah Bani Issa Complication Of DM

2. Complication Of DM Acute Complication Chronic Complication Hypoglycemia DKA and HHS Neuropathy Nephropathy Retropathy

3. Diabetic Ketoacidosis Hyperglycemic Hyperosmolar State

4. Diabetic Ketoacidosis

5. • Acute life threatening complication of DM . • DKA predominantly seen in type 1 DM . • DKA represents body’s response to cellular starvation due to insulin deficiency & counter regulatory hormone excess . * Introduction :-

6. DKA

7. Mild DKA Moderate DKA Severe DKA Plasma Glucose > 250 mg / dl > 250 mg / dl > 250 mg / dl Arterial PH 7.25 – 7.30 7.0 – 7.24 < 7.0 Serum Bicarbonate 15 – 18 10 – 15 < 10 Urine Ketones + + + Anion Gap > 10 > 12 > 12 Alteration in Sensorium Alert Alert / Drowsy Stupor / Coma Classification

8. Insulin Deficiency is the primary defect in patients with DKA * Pathophysiology :-

9. * Precipitating Factors Of DKA :- - Omission or reduced daily insulin injection . - Infection . - Pancreatitis . - Myocardial Infraction . - Mesenteric Ischemia . - Renal Insufficiency . - CVA . - Pulmonary embolism . - GI hemorrhage . Heart related illness . Parenteral / enteral alimentation . Rhabdomyolysis . - Severe Burns .

10. • Dehydration . • Hyperventilation . • Ketotic breath . • Tachycardia and hypotension . • Disturbed conscious state and shock . • Alteration of consciousness correlate better with elevated serum osmolality ( > 320 mOsm / L) than with severity of metabolic acidosis . * Signs of DKA :-

11. • Polyuria . • Polydipsia . • Nausea and vomiting . • Abdominal Pain . • Breathing difficulty . * Symptoms :-

12. - Serum Glucose . - Serum Electrolytes . - Complete blood count . - Renal function test . - Serum & urine ketones . - Blood gas analysis . * Lab Investigations :-

13. - Blood cultures . - Sputum collection . - Urine analysis & Culture . - Liver function tests & Coagulation Profile . - Cardiac enzymes . - Thyroid function tests . * Lab Investigations :-

14. • Chest X ray . • ECG . • USG Abdomen . • CT Head . • Lumbar Puncture * Radiology :-

15. Management of DKA

16. • Volume Repletion . • Reversal of metabolic consequences of insulin insufficiency . • Correction of acid-base & electrolyte imbalances . • Recognition & Treatment of precipitating causes . • Avoidance of complications . * Goals of Treatment :-

17. Complete initial evaluation * Management of DKA :- Potassium I/V fluids Insulin

18. • Correcting the hyperosmolar state and dehydration is the initial aim of therapy . • Insulin therapy should be undertaken only after the patient is stable hemodynamically . * Approach to therapy :-

19. -- Single most important step . • Fluid deficit around 100ml/kg ( 5 - 10L ) . • Helps in Restore I/V volume . • Perfuse vital organs . • Increase GFR . • Decrease serum Glucose & Ketone levels . • To restore normal tonicity . * Fluid Resuscitation :-

20. -- NS most frequently administered fluid • 1 litre in 30 min • 2 litres in 2 hours • 2 litres in 2-6 hours • 2 litres in 6-12 hours * Fluid Resuscitation :-

21. • 2 – 3 L of 0.9% saline over first 1 – 3 h (10 – 15 mL/kg per hour) . • 0.45% saline at 150 – 300 mL/h; change to 5% glucose and 0.45% saline at 100 – 200 mL/h when plasma glucose reaches 250 mg/dl . * Fluid Resuscitation :-

22. -- Mechanism of Action: • Inhibit gluconeogenesis, lipolysis, catabolic hormone secretion, production of ketoacids . • Promote potassium, glucose & phosphate uptake in tissues . * Insulin therapy :-

23. • Ideal way to administer insulin by continuous infusion of small doses of regular insulin 0.1unit/kg/hr once hypokalemia is excluded . • I/M or S/C administration of regular insulin should be avoided as insulin absorption may be erratic in volume depleted & vasocostricted patient . * Insulin therapy :-

24. • Goal is to decrease Glucose by 50-75mg/dl/ hr . • Infusion should continue until anion gap normalized . • S/C insulin should bridge for at least one hour before discontinuation of I/V insulin . • Insulin administration should be W/H if K < 3.3 mEq till K is supplemented . * Insulin therapy :-

25. -- Can consider switch to SC insulin when: - ABG normalized . - BS < 250 mg/dl . - Insulin IV requirements < 2U/h . - Patient able to eat . - Hemodynamically stable . -- Overlap insulin IV with 1 st SC insulin by 2-4hto avoid recurrent ketosis . -- T2 DM patients with DKA: - Don’t necessarily have to be continued on insulin . - Once acute stress resolved, many do well on OHA . DKA: Switch to S.C. insulin

26. -- Deficiency is due to :- • Decreased insulin levels . • Metabolic Acidosis . • Osmotic Diuresis . • Frequent Vomiting . * Potassium Correction :-

27. • To maintain a normal extracellular K + conc during the acute phase of therapy and to replace intra-cellular deficits over a period of days . * Goal of K Replacement :-

28. • Routine use of supplemental bicarbonate in Rx of DKA is not recommended . • Can be given if PH Is less than 6.9 . * Bicarbonate :-

29. • Periodical assessment of vital signs . • Level of consciousness . • Hourly urine output . • Serum glucose Q1H . • Serum Potassium Q2H . * Monitoring :-

30. • Cerebral Edema . * Major complication of DKA :-

31. • A metabolic emergency that occurs in diabetic patient usually Type 2 Diabetes Mellitus . • Characterized by uncontrolled hyperglycemia that induces hyperosmolar state and dehydration without significant ketoacidosis . * Hyperglycemia Hyperosmolar State (HHS) :-

32. • Plasma glucose level of 600 mg / dL or greater . • Effective serum osmolality of 320 mOsm / kg or greater . • Profound dehydration ( 8 - 12 L ) with elevated serum urea nitrogen ( BUN ) - to - creatinine ratio . • Small ketonuria and absent - to - low ketonemia . • Bicarbonate concentration greater than 15 mEq / L . • Some alteration in consciousness . * Diagnostic features :-

33. * DKA Vs. HHS :- DKA HHS Glucose 250 - 600 > 600 Sodium 125 – 135 135 – 145 Potassium Normal / inc Normal Bicarbonate < 15 meq / l Normal / Slightly reduced Arterial PH < 7.3 > 7.3 Anion Gap Increased Normal / Slightly increased PCO₂ 20 – 30 Normal Osmolality 300 – 320 > 320

34. • Occurs only in type 2 DM . • Could be initial presentation of the diabetic state . • Elderly . • Obtundation to coma . • Severe dehydration invariable . • May have associated lactic acidosis due to hypoxia . • Precipitating factors similar to DKA . • Mortality rate is high . * Clinical features :-

35. -- Symptoms of hyperglycemia : - Polydipsia . - Polyuria . - Lethargic . -- Others : - Weight loss . - Loss of consciousness . * Symptoms :-

36. -- A wide variety of focal and global neurologic changes may be present : • Drowsiness and lethargy . • Delirium . • Coma . • Focal or generalized seizures . • Visual changes or disturbances . • Hemiparesis . • Sensory deficits . * Symptoms :-

37. - Dehydrated : dry skin , lips , mucous membrane , loss skin turgor . - Vital sign : tachycardia (early dehydration) , hypotension (later) , temperature . - Systemic examination to ruled out the cause . * Physical examination :-

38. - Plasma glucose Hyperglycemia: CBG : > 600 mg / dl . - ABG PH > 7.3 . HCO3 > 15 mmol / l . - Serum Osmolality > 320 mmol / l . * Lab studies :-

39. ** Treatment Goals :- • Correction of hypovolemia . • Identify and treating underlying cause . • Correcting electrolyte abnormalities . • Gradual correction of hyperglycemia and osmolarity . • Frequent monitoring . * Management :-

40. Management

41. Harrison’s Principles Of International Medicine 18 th Edition References Tintinalli’s Emergency Medicine A Comprehensive Study Guide 7th Edition

42. Thanks For Listening