DKA

DIABETIC EMERGENCIES

NasruddinKamaruddin

RazziSiti SurayaSarah AliahShuhaidaRohaida

Nurfauzani

DIABETIC KETOACIDOSIS

ROHAIDA CHE MOHD ABDULLAHRAZZI HAJEMI

• Major medical emergency

• Serious cause morbidity

• In type 1 DM

• Usually due to (causes) :– Unknown or newly diagnosed cases of type 1

diabetes– Missed or inadequate doses of insulin, or

spoiled insulin– Intercurrent infection, lose their appetite, stop

or drstically reduced their dose of insulin– Stress, with increasing insulin resistance and

requirement eg: infection, trauma, surgery, myocardial infarction, and stroke.

LACK OF INSULIN1. DECREASED CATABOLISM (glucose)

Hyperglycemia - fatigue

Glycosuria – vulvitis

Osmotic diuresis – polyuria, polidipsia

Salt n water depletion – tachycardia, - hypotension

- dehydration

• Dehydration with decreased perfusion to the tissues leads to lactic acidosis, which contributes to more profound acidosis.

2. INCREASED ANABOLISM

Gluconeogenesis - wastingGlycogenolysis

Lipolysis - loss of weight

Hyperketonemia

Acidosis – hyperventilationPeripheral vasodilation –

hypotension, hypothermia

Diabetic Ketoacidosis

3. INCREASED SECRETION

GlucagonCostisol

CathecolamineGrowth hormone

ANTAGONIZED INSULIN

DEATH !!!

Clinical feature

• As above…• Vomiting• Blurred vision• Abdominal pain (children)• Confusion, drowsiness• Cold peripheries /peripheral cyanosis• Ketone breath (smell of acetone) • Coma (uncommon)

METABOLIC ACIDOSIS

pH - <7.3 / 7.25 () (N – 7.35-7.45)

HCO3 - ?

pH = log 6.1 + [HCO3-]

0.03pCO2

HCO3 - ()

WHY develop hyperventilation?

• The combination of ketoacid formation and dehydration results in metabolic acidosis, and, for compensatory alkalosis,

• rapid deep breathing (Kussmaul respirations) may be manifested at advanced stages

• Kussmaul breathing – to wash out the CO2. thus – patient develop hyperventilation

• The resulting metabolic acidosis – forces the hydrogen ions into cells, displacing potassium ions (whish may lost in urine or through vomiting)

•

H + H + K+

K+ H + H +

K+ H +

K+ H + K+

H + K+

K+

K+

Diagnostic Criteria

• Random Blood Sugar > 11.1 mmol/L

• Ketonemia > 90mg/dL , ketonuria >5000mg/24hr

• Aterial blood gases, pH<7.3/7.25

• HCO3 <15 mmol/L

INVESTIGATION

• Random blood glucose

• Arterial Blood Gases

• Full blood count

• Renal profile

• CXR

• ECG

• Urine FEME

COMPLICATION

• Cerebral Edema (hyponatremia)

• Aspiration pneumonia (coma)

• Hypokalemia

• Hypomagnesaemia

• Hypophosphatemia

• Thromboembolism

REFERENCES

• Oxford Handbook Clinical Medicine

• Davidson’s principle and practice of medicine

• Lippincott’s biochemistry

THANK YOU