Diabetic Ketoacidosis

5,383 views

Published on

0 Comments
11 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
5,383
On SlideShare
0
From Embeds
0
Number of Embeds
12
Actions
Shares
0
Downloads
328
Comments
0
Likes
11
Embeds 0
No embeds

No notes for slide
  • Diabetic Ketoacidosis

    1. 1. Diabetic Ketoacidosis April Cope PharmD candidate Presentation at SUNY Downstate
    2. 2. Objectives <ul><li>Physiology and pathophysiology overview </li></ul><ul><li>Diagnosis of diabetes </li></ul><ul><li>Types of diabetes </li></ul><ul><li>Treatment options for diabetes </li></ul><ul><li>Complications of diabetes </li></ul><ul><li>Type 1 Diabetes in detail </li></ul><ul><li>Diabetic Ketoacidosis </li></ul><ul><li>Patient Case </li></ul>
    3. 3. Physiology Overview
    4. 4. Physiology Overview
    5. 5. Physiology Overview
    6. 6. Diagnosis of Diabetes <ul><li>Any one of the following </li></ul><ul><ul><li>Symptoms plus RBG > 200 mg/dL </li></ul></ul><ul><ul><li>FPG > 126 mg/dL </li></ul></ul><ul><ul><li>Two hour plasma glucose >200 mg/dL during OGT </li></ul></ul><ul><li>Pre-diabetes </li></ul><ul><ul><li>Impaired Fasting Glucose (IFG) </li></ul></ul><ul><ul><li>Impaired Glucose Tolerance (IGT) </li></ul></ul><ul><li>Must be confirmed on a later date </li></ul>
    7. 7. Types of Diabetes <ul><li>Type 1 Diabetes </li></ul><ul><li>Type 2 Diabetes </li></ul><ul><li>Other Specific Types </li></ul><ul><li>Gestational Diabetes </li></ul>
    8. 8. Type 2 Diabetes <ul><li>Epidemiology </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Characteristics </li></ul><ul><li>Screening </li></ul>
    9. 9. Other Specific Types <ul><li>Genetic Defects </li></ul><ul><ul><li>Beta cell function </li></ul></ul><ul><ul><li>Insulin action </li></ul></ul><ul><li>Diseases </li></ul><ul><li>Drug/Chemical Induced </li></ul><ul><li>Infection Induced </li></ul><ul><li>Immune Mediated </li></ul><ul><li>Genetic Syndromes associated with diabetes </li></ul>
    10. 10. Gestational Diabetes <ul><li>High Risk Patients </li></ul><ul><li>Low Risk Patients </li></ul><ul><li>Testing </li></ul><ul><li>Treatment and Goals </li></ul>
    11. 11. Treatment Options <ul><li>Non-pharmacological Treatments </li></ul><ul><li>Oral medications </li></ul><ul><li>Exogenous Insulin </li></ul>
    12. 12. Non-Pharmacological Treatments <ul><li>Medical Nutrition Therapy </li></ul><ul><li>Exercise </li></ul><ul><li>Proper Monitoring </li></ul><ul><li>Education </li></ul>
    13. 13. Oral Medications <ul><li>Sulfonylureas </li></ul><ul><li>Alpha-Glucosidase Inhibitors </li></ul><ul><li>Meglitinides </li></ul><ul><li>Thiazolidinediones </li></ul><ul><li>Biguanides </li></ul>
    14. 14. Sulfonylureas <ul><li>Mechanism of Action </li></ul><ul><li>Medications Available </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Adverse Effects </li></ul>
    15. 15. Alpha-Glucosidase Inhibitors <ul><li>Mechanism of Action </li></ul><ul><li>Medications Available </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Adverse Effects </li></ul>
    16. 16. Meglitinides <ul><li>Mechanism of Action </li></ul><ul><li>Medications Available </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Adverse Effects </li></ul>
    17. 17. Thiazolidinediones <ul><li>Mechanism of Action </li></ul><ul><li>Medications Available </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Adverse Effects </li></ul>
    18. 18. Biguanides <ul><li>Mechanism of Action </li></ul><ul><li>Medications Available </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Adverse Effects </li></ul>
    19. 19. Exogenous Insulin <ul><li>Rapid Acting </li></ul><ul><li>Short Acting </li></ul><ul><li>Intermediate Acting </li></ul><ul><li>Long Acting </li></ul><ul><li>Mixed Insulins </li></ul><ul><li>Future Possibilities </li></ul>
    20. 20. Complications of Diabetes <ul><li>Neuropathy </li></ul><ul><li>Retinopathy </li></ul><ul><li>Nephropathy </li></ul><ul><li>Infection and Impaired healing </li></ul><ul><li>Amputations </li></ul><ul><li>Cardiovascular Event </li></ul>
    21. 21. Neuropathy <ul><li>Types of Neuropathy </li></ul><ul><ul><li>Peripheral sensory neuropathy </li></ul></ul><ul><ul><li>Motor neuropathy </li></ul></ul><ul><ul><li>Autonomic neuropathy </li></ul></ul><ul><li>Pathophysiology </li></ul><ul><li>Signs and Symptoms </li></ul><ul><li>Treatment </li></ul>
    22. 22. Retinopathy <ul><li>Microvascular disease </li></ul><ul><li>Types of Retinopathy </li></ul><ul><ul><li>Nonproliferative </li></ul></ul><ul><ul><li>Proliferative </li></ul></ul><ul><li>Treatment </li></ul>
    23. 23. Nephropathy <ul><li>Epidemiology </li></ul><ul><li>Signs and Symptoms </li></ul><ul><li>Nephrotic Syndrome </li></ul><ul><li>Further Complications </li></ul><ul><li>Treatment </li></ul>
    24. 24. Infection and Impaired Healing <ul><li>Increased Infections </li></ul><ul><li>Unusual Infections </li></ul><ul><li>Impaired Healing </li></ul><ul><li>Treatments </li></ul>
    25. 25. Amputations <ul><li>Epidemiology </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Goals </li></ul><ul><li>Prognosis </li></ul>
    26. 26. Cardiovascular Events <ul><li>Atherosclerosis </li></ul><ul><li>Heart Disease </li></ul><ul><ul><li>Heart Failure </li></ul></ul><ul><ul><li>Myocardial Infarction </li></ul></ul><ul><li>Peripheral Vascular Disease </li></ul><ul><li>Cerebral Vascular Accident </li></ul>
    27. 27. Type 1 Diabetes <ul><li>Epidemiology </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Characteristics </li></ul><ul><li>Screening </li></ul><ul><li>Treatment </li></ul>
    28. 28. Diabetic Ketoacidosis <ul><li>Pathophysiology </li></ul><ul><li>Signs and Symptoms </li></ul><ul><li>Diagnosis </li></ul><ul><li>Complications </li></ul><ul><li>Treatment </li></ul>
    29. 30. DKA Signs and Symptoms <ul><li>Clinical Presentation </li></ul><ul><li>Laboratory Data </li></ul><ul><li>Other </li></ul>
    30. 31. DKA Complications <ul><li>Complications of associated illness </li></ul><ul><li>Hypokalemia </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>Acute pulmonary edema </li></ul><ul><li>Other complications </li></ul>
    31. 32. DKA Treatment <ul><li>Fluid Administration </li></ul><ul><li>Insulin </li></ul><ul><li>Potassium </li></ul><ul><li>Other Electrolytes </li></ul><ul><li>Other Medications </li></ul>
    32. 33. Patient Case <ul><li>V.H. is an 18 yo BF presented to the ER on 6/29/05 with: </li></ul><ul><li>CC: “My stomach and back hurt” </li></ul><ul><li>HPI: Abdomen & back pain x 1 day, vomiting since 12 AM </li></ul><ul><li>PMH: Type 1 Diabetes Mellitus, diagnosed 13 years ago </li></ul><ul><li>Family History: Non-Contributory </li></ul><ul><li>Social History: Non-smoker, no alcohol use, no IVDA, lives with mother </li></ul>
    33. 34. Patient Case <ul><li>Allergies: NKDA </li></ul><ul><li>Past Medication History: </li></ul><ul><li>Novolin R 12 units AM, 12 units PM </li></ul><ul><li>Novolin 16 units AM, 16 units PM </li></ul><ul><li>Vital Signs </li></ul><ul><li>BP: 155/101 T: 97.7 RR: 20 P: 126 </li></ul><ul><li>Ht: 5’5” Wt: 125 lbs. CrCl: 81.82 </li></ul>
    34. 35. Patient Case <ul><li>PE: facial grimace, dry oral mucosa, tachycardic </li></ul><ul><li>HEENT: eyes nml, ENT nml, pharynx nml, dry oral mucosa </li></ul><ul><li>Neck: supple, nml inspection </li></ul><ul><li>Resp: breath sounds nml, no respiratory distress </li></ul><ul><li>CVS: RRR, heart sounds nml, tachycardia </li></ul><ul><li>Abd: soft, no tenderness, nml BS, no distention </li></ul><ul><li>Ext: non-tender, nml ROM, no pedal edema </li></ul><ul><li>Neuro: A&O x 3, mood/affect nml, CNs nml as tested, no motor/sensory deficit </li></ul><ul><li>Pain scale: 5/10, patient describes a dull, constant ache </li></ul>
    35. 36. Patient Case <ul><li>Lab Data </li></ul><ul><li>Radiologic Data </li></ul><ul><ul><li>EKG showed sinus tachycardia </li></ul></ul>
    36. 37. Patient Problem <ul><li>Diabetic Ketoacidosis due to urosepsis </li></ul><ul><ul><li>Objective data </li></ul></ul><ul><ul><li>arterial pH = 7.324 Cl = 109 CO2= 11 </li></ul></ul><ul><ul><li>anion gap = 25 RBG = 217 K+ = 4.1 </li></ul></ul><ul><ul><li>arterial pCO2 = 23 UA = ketones/protein/glucose </li></ul></ul><ul><ul><li>WBC = 14.8 ANC = 1364 EKG= sinus tachy </li></ul></ul><ul><ul><li>Subjective data </li></ul></ul><ul><ul><li>N/V, abdominal pain, normal temp </li></ul></ul>
    37. 38. Pharmacotherapeutic Goal <ul><li>Correct anion gap </li></ul><ul><li>Correct acidosis </li></ul><ul><li>Prevent further production of ketones </li></ul><ul><li>Normalize lab values </li></ul><ul><li>Prevent complications </li></ul><ul><li>Reduce morbidity and mortality </li></ul><ul><li>Increase quality of life </li></ul>
    38. 39. Recommendations for Therapy <ul><li>NS 1 Liter IV wide open, then 1 liter at 125cc/hr </li></ul><ul><li>Reglan 10 mg IVPB </li></ul><ul><li>Pepcid 20 mg IVPB </li></ul><ul><li>Regular Insulin 100 units in 100 mL NS, start at 5cc/hr (0.1 units/kg/hr) </li></ul><ul><li>Levofloxacin 500 mg IVPB </li></ul><ul><li>Admit to MICU, continue IVF: D51/2NS at 150 cc/hr, if BG <90, give D50 1 amp, do not stop infusion until anion gap normalizes. </li></ul>
    39. 40. Recommendations for Therapy <ul><li>6/30/05: anion gap normalized, d/c insulin infusion, begin subcutaneous injections: NPH/regular 70/30 28 units AM and 20 units PM </li></ul><ul><li>6/30/05: K+ = 2.5/2.8. Begin: </li></ul><ul><ul><li>KCl 20 mEq in 100 cc NS IVPB x 2 doses at 2 hours apart </li></ul></ul><ul><ul><li>KCl 40 mEq p.o. x 2 doses at 1 hour apart </li></ul></ul>
    40. 41. Specific Desired Endpoint <ul><li>No anion gap </li></ul><ul><li>No ketonemia or ketonuria </li></ul><ul><li>No proteinuria </li></ul><ul><li>No metabolic acidosis or respiratory alkalosis </li></ul><ul><li>Resolution of infection </li></ul><ul><li>K+ = 3.5 – 5.0 </li></ul><ul><li>Cl = 98 – 107 </li></ul><ul><li>CO2 = 22 – 31 </li></ul><ul><li>FPG < 126 </li></ul><ul><li>WBC = 4.8 – 10.8 </li></ul>
    41. 42. Specific Desired Endpoint <ul><li>Adherence with medications </li></ul><ul><li>Regular self-glucose monitoring </li></ul><ul><li>No complications </li></ul><ul><li>No ADRs </li></ul><ul><li>Increased quality of life </li></ul>
    42. 43. Monitoring Parameters & Frequency <ul><li>Parameters </li></ul><ul><ul><li>Blood Glucose </li></ul></ul><ul><ul><li>Electrolytes </li></ul></ul><ul><ul><li>CBC w/ diff </li></ul></ul><ul><ul><li>Blood Gases </li></ul></ul><ul><ul><li>UA </li></ul></ul><ul><ul><li>Signs & Symptoms </li></ul></ul><ul><li>Frequency </li></ul><ul><ul><li>Every hour until controlled, then three times daily </li></ul></ul><ul><ul><li>Twice daily until normal, then once daily </li></ul></ul><ul><ul><li>Once daily </li></ul></ul><ul><ul><li>Twice daily until normal, then once daily </li></ul></ul><ul><ul><li>Once daily </li></ul></ul><ul><ul><li>Continuously </li></ul></ul>
    43. 44. Patient Counseling <ul><li>Importance of medication adherence </li></ul><ul><li>Proper injection technique </li></ul><ul><li>Re-teach self-glucose monitoring </li></ul><ul><li>Educate patient and family about complications </li></ul><ul><li>Importance of regular MD appointments </li></ul><ul><li>Ways to prevent UTIs </li></ul><ul><li>Q&A with patient and family </li></ul>
    44. 45. References <ul><li>Julie C. Oki, William L. Isley “Diabetes Mellitus” Pharmacotherapy A Pathophysiologic Approach. Ed. Joseph T. Dipiro, New York, McGraw Hill. Fifth Edition: 1335-1358 </li></ul><ul><li>Stephen N. Davis, Daryl K. Granner “Insulin, Oral Hypoglycemic Agents, and the Pharmacology of the Endocrine Pancreas” The Pharmacological Basis of Therapeutics . Ed. Alfred Goodman Gilman, New York, McGraw Hill. Tenth Edition: 1679-1714 </li></ul><ul><li>www.harrisonsonline.com . July 2005. Accessed July 6-10, 2005 </li></ul>
    45. 46. References <ul><li>www.crlonline.com . July 2005. Accessed July 6-10, 2005 </li></ul><ul><li>www.guidelines.gov . July 2005. Accessed July 9, 2005 </li></ul><ul><li>www.efactsonline.com . July 2005. Accessed July 6-9, 2005 </li></ul><ul><li>www.cdc.gov . July 2005. Accessed July 9, 2005 </li></ul><ul><li>“ Management of Diabetes Mellitus” by Dr. Elaena Quattrocchi (Supplemental Lecture to Pharmacotherapeutics IV, Fall 2004) </li></ul>

    ×