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Diabetic Ketoacidosis
an acute, life threatening metabolic acidosis complicating IDDM and some cases of NIDDM with intercurrent illness (infection or surgery) usually coupled with an increase in glucagon concentration with two metabolic consequences:
1) Maximal gluconeogenesis with impaired peripheral utilization of glucose 2) activation of the ketogenic process and development of metabolic acidosis.
Gluconeogenesis
Maximal gluconeogenesis occurs as glucagon lowers the concentration of F2,6bisphosphate which is the intermediate that activate glycolysis and inhibit gluconeogenesis. This results in hyperglycemia and osmotic diuresis with a resultant dehydration characteristic of DKA.
Ketogenesis
Clinical Presentation
anorexia, N/V, along with polydepsia and polyuria for about 24 hrs. followed by stupor (or coma). Abdominal pain and tenderness could be present (remember DDx of acute abdomen). Kussmaul breathing with fruity odor acetone Sings of dehydration ( HR, postural BP, etc.) normal or low temperature: NB.: if fever is present it suggests infection while leukocytosis alone is not because DKA per se can cause fever.
Sources of acid include acetoacetate and BHB along with lactate, FFA, & PO4 Sodium is low due to dilutional effect of shifting of fluid to the ECF. Sodium leveld below 110 mmol/L suggest either:
Initial potassium could be normal or high but this is misleading since there is a huge totalbody potassium deficit. Prerenal azotemia is a reflection of the volume depletion. Serum amylase might be elevated and frank pancreatitis can occur.
Diagnosis of DKA in IDDM patient is not that difficult. The problem is pointing towards the cause of acidosis with anion gap in a person who is not known diabetic. Causes to consider: 1) lactic acidosis. 2) uremia. 3) alcoholic ketoaciosis (see later) 4) certain poisonings.
The initial step in diagnostic approach is testing urine for glucose and ketones.
bicarbonate:
indicated in sever acidosis (pH 7.0 or below) or with hypotension (that can be caused by acidosis alone) stop the infusion at pH 7.2 to avoid alkalosis upon reversal of ketosis.
THERAPUTIC CONSIDERATIONS
1) Plasma glucose will invariably fall more rapidly than ketones. So, dont stop insulin unless reversal of ketosis occur. 2) plasma ketones are not very helpful in assessing clinical response. So use the pH and anion gap instead. AG = (Na+K) - (Cl+HCO3)
sheet outlining amounts and timing of insulin and fluids together with record of vital signs, urine volume, and blood chemistries. Without such a record therapy tends to be chaotic. Patients are not doctors so we have to make sure that each patient receives intensive detailed instructions about how to avoid this potentially disastrous complication of diabetes mellitus.
Acute gastric dilatation or erosive gastritis by vomiting blood or coffee-ground material Cerebral edema obtundation or coma with or without neuro. Signs, especially if occurring with initial improvement. Hyperkalemia cardiac arrest hypokalemia cardiac arrythmias. Infection is known by fever hypoglycemia is considered when there is adrenergic or neuorologic signs or rebound ketosis.
Insulin resistance: unremitting acidosis after 4-6 hrs of Rx MI: chest pain, appearance of HF, hypotension despite adequate fluids. Mucormycosis: facial pain, bloody nasal discharge, blurred vision, proptosis. ARDS: hypoxemia in absence of pneumonia, COPD, or HF Vascular thrombosis: stroke-like picture or signs of ischemia in nonnervous tissue.