رايط الشرح علي اليوتيوب https://youtu.be/D3RnpX-rkdE

1. BY
dr: Mohammed Bahgat Mohammed Sofyan
Assistant lecturer of medical biochemistry,
Faculty of medicine, Al-Azhar university
(Assiut branch)
1

2. ‫رمضان‬
‫كريم‬
2

3. ‫يارمضان‬ ‫أهال‬
3

4. ‫صورة‬ ‫كل‬ ‫على‬ ‫اضغط‬
‫الشاش‬ ‫عرض‬ ‫وضع‬ ‫في‬
‫ة‬
‫قنواتنا‬ ‫على‬ ‫وادعمنا‬
‫اإلنترنت‬ ‫على‬

5. 5

6. 6

7. CAUSES OF KETONEMIA & KETONURIA
A_ Decreased availability of carbohydrates as starvation or
frequent vomiting.
B_ Decreased used of carbohydrates as DM Type I and type II with
stress conditions, Glycogen storage disease, Alkalosis.
C_ Increased metabolic needs as fever, pregnancy, severe
thyrotoxicosis, and protein-calorie malnutrition.
7

8. CAUSES OF KETONEMIA &
KETONURIA
8

9. ROTHERA TEST
Principle
In an alkaline medium, acetoacetic
acid will react with sodium
nitroprusside to form a purple
colour.
9

10. PARADOXICAL SITUATION
When a patient initially presents in ketoacidosis, the test for
ketones may be only weakly positive.
With therapy B-hydroxybutyrate is converted to acetoacetate
and the ketosis appears to worsen.
Note that: The strip test detects acetoacetate only.
10

11. Paradoxical action
CRF, renal tubular acidosis ➡ kidney can't secret
H ➡ leads to alkaline urine inspite of acidosis (
paradoxical alkalinuria)
paradoxical aciduria caused by vomiting that
causes aciduria inspite of Alkalosis.
CRF, renal tubular acidosis H terces t'nac yendik
)airunilakla lacixodarap ( sisodica fo etipsni eniru enilakla ot sdael
CRF, renal tubular acidosis H terces t'nac yendik
)airunilakla lacixodarap ( sisodica fo etipsni eniru enilakla ot sdael
11

12. METABOLIC ACIDOSIS
pH ➡low
HCO3 ➡ low
PCO2 ➡low
K ➡ Hyperkalaemia
AG ➡high
Urine ➡acidic.
‫في‬ ‫يخش‬ ‫ممكن‬ ‫ده‬ ‫المريض‬
Irritability, coma,...... death.
12

13. DIABETIC KETOACIDOSIS (DKA)
13

14. DKA is an acute, major, life-threatening
complication of diabetes characterized
by hyperglycemia, ketoacidosis, and
ketonuria.
14

15. PATHOPHYSIOLOGY
SYMPTOMS AND SIGNS
• 1_ Diabetes mellitus ➡ hyperglycemia ➡ glucosuria
• 2_ ⬆Glucose in blood and serum ➡ ⬆ Blood and urine osmolarity
• 3_ Osmotic diuresis ➡ dehydration
• 4 _ Diabetes mellitus ➡ No insulin ➡ no ketolysis ➡ ketosis ➡ ketonuria
• 5_ Ketosis ➡ ⬇ pH and causes ➡ Kussmaul respirations, ie, rapid, shallow breathing
• 6_ Ketosis ➡ ⬆ ketoacids ➡ nausea vomiting
• 7_ acetone produces the fruity breath odor
• 8_ Glucosuria leads to osmotic diuresis, dehydration, and hyperosmolarity
• 9_ Hyperglycemia, osmotic diuresis, serum hyperosmolarity, and metabolic acidosis
result in severe electrolyte disturbances.
• 10_ LIPOLYSIS ➡ ⬆AA ➡ ⬆BUN
15

16. PATHOPHYSIOLOGY
SYMPTOMS AND SIGNS
• 11_ The most common early symptoms of DKA are the insidious
increase in polydipsia and polyuria.
• 12_ Altered consciousness (eg, mild disorientation, confusion); frank
coma is uncommon but may occur when the condition is neglected or
with severe dehydration/acidosis
• 13_ hyperglycemia ➡ Malaise, generalized weakness, and fatigability
• 14_ hyperglycemia ➡ Diabetics are susceptible to infections
• 15_ General signs of DKA :
• Dry skin, Labored respiration, Dry mucous membranes, Decreased skin
turgor and Decreased reflexes, Tachycardia, Hypotension, Tachypnea,
and Hypothermia
16

17. 17

18. Biochemically DKA is defined as
1_ an increase in the serum concentration of ketones greater than 5
mEq/L
2_ a blood sugar level greater than 250 mg/dL (although it is usually much
higher)
3_ a blood (usually arterial) pH less than 7.3. Ketonemia and ketonuria
are characteristic
4_ a serum bicarbonate level of 18 mEq/L or less (less than 5 mEq/L is
indicative of severe DKA).
6_ increased anion gap
7_ increased serum osmolarity
8_ increased serum uric acid.
•
18

19. 19

20. Causes
DKA occurs mainly in patients with type 1 diabetes, but it is not
uncommon in some patients with type 2 diabetes. (most likely latent
autoimmune diabetes of adults [LADA).
1_The most common scenarios for diabetic ketoacidosis (DKA) are
underlying or concomitant infection (40%)
2_ missed or disrupted insulin treatments (25%)
3_ Newly diagnosed, previously unknown diabetes (15%).
4_Other associated causes make up roughly 20% in the various scenarios.
20

21. LABORATORY STUDIES FOR DIABETIC KETOACIDOSIS (DKA)
SHOULD BE SCHEDULED AS FOLLOWS
1_ Blood tests for glucose every 1-2 h until the patient is stable, then every 4-6 h
2_Serum electrolyte determinations every 1-2 h until the patient is stable, then
every 4-6 h
3_ Initial blood urea nitrogen (BUN)
4_ Initial arterial blood gas (ABG) measurements, followed with bicarbonate as
necessary
21

22. DKA
DKA is defined clinically as an acute state of
severe uncontrolled diabetes associated with
ketoacidosis that requires emergency treatment
with insulin and intravenous fluids.
22

23. Lab investigation
Biochemically, DKA is defined as:
1_ an increase in the serum concentration of ketones greater than 5 mEq/L
2_ a blood sugar level greater than 250 mg/dL (although it is usually much
higher)
3_ a blood (usually arterial) pH less than 7.3. Ketonemia and ketonuria are
characteristic
4_ a serum bicarbonate level of 18 mEq/L or less (less than 5 mEq/L is indicative
of severe DKA).
6_ increased anion Gap greater than 10 mEq/L in mild cases and greater than
12 mEq/L in moderate and severe cases).
7_ increased serum osmolarity, increased (greater than 290 mOsm/L)
8_ increased serum uric acid.
23

24. Other investigation
SERUM k
First in DKA there is A normal or even elevated serum potassium concentration, once
insulin treatment is started The serum potassium concentration can drop precipitously ➡
so great care must be taken to repeatedly monitor serum potassium levels.
CBC
Even in the absence of infection, the CBC shows an increased white blood cell (WBC)
count in patients with diabetic ketoacidosis. High WBC counts (greater than 15 X 109/L)
or marked left shift may suggest underlying infection.
24

25. Other investigation
BUN frequently increased .
Serum or capillary B-hydroxybutyrate can be used to follow response to
treatment in patients with DKA. Levels greater than 0.5 mmol/L are
considered abnormal, and levels of 3 mmol/L correlate with the need for
treatment for DKA.
Urine Dipstick Testing➡ ketonuria with paradoxical situations (See
ketonuria).
⬆ amylase and ⬇ P may be present
25

26. Complications Associated with DKA
sepsis and diffuse ischemic processes.
Myocardial INFARCTION, DVT.
Acute gastric dilatation, Erosive gastritis.
Respiratory distress.
Infection (most commonly, urinary tract infections)
Hypophosphatemia
26

27. IMAGING STUDIES
Chest X ray ➡ To rule out a pulmonary infection such as pneumonia
CT and MRI ➡ To detect early cerebral edema
Do not delay administration of hypertonic saline or mannitol in those
pediatric cases where cerebral edema is suspected, as many changes
may be seen late on head imaging.
27

28. Management GOALS
Fluid resuscitation
Reversal of the acidosis and ketosis
Reduction in the plasma glucose concentration to normal
Replenishment of electrolyte and volume losses
Identification of the underlying cause
•
28

29. MANAGEMENT GOALS
fluid loss with intravenous fluids
correction of hyperglycemia with insulin
correction of electrolyte disturbances, particularly potassium
loss
correction of acid-base balance; and management of
concurrent infection (if present).
29

30. REFERENCES
• _ https://www.medscape.com
• _ https://labtestsonline.org
• _ https://www.wikipedia.org
• _ https ps://www.labcorp.com
• _ https://www.uptodate.com
• _ https://www.ncbi.nlm.nih.gov Home - PubMed – NCBI
• _TIETZ textbook of clinical chemistry and molecular diagnostics, sixth edition 2018.
• _Essential of clinical pathology book; 1st edition; Shirish M Kawthalkar; 2010.
• _Essential of biochemistry book ;1st edition; 2012.
• _ Harper's illustrated biochemistry 30th edition 2015.
• _ Lippincott's illustrated review of biochemistry sixth edition 2014.
• _ Lecturea Notes Clinical Biochemistry, 9th Edition Walker, Simon, 2103.
• _Many audios and videos from Well-known, trusted professors who study from accredited
books.
• _ Clinical chemistry from principles to practice 2nd Edition dr Ola H. Demerdash, second edition
30

31. ‫اليوتيوب‬ ‫علي‬ ‫البحث‬ ‫أو‬ ،‫اليوتيوب‬ ‫علي‬ ‫قناتي‬ ‫دي‬
‫د‬ ‫باسم‬
.
‫سفيان‬ ‫بهجت‬ ‫محمد‬
،
‫هللا‬ ‫شاء‬ ‫إن‬ ‫نستمر‬ ‫حتى‬ ‫بالقناة‬ ‫وتشتركوا‬ ‫تتابعوني‬ ‫ياريت‬
https://www.youtube.com/channel/UCaYs1d8s0ntZvteHS3mMmGA
‫ب‬ ‫الفيس‬ ‫في‬ ‫البحث‬ ‫أو‬ ،‫انضمامكم‬ ‫يشرفنا‬ ‫الفيسبوك‬ ‫علي‬ ‫بتاعتي‬ ‫الصفحة‬ ‫دي‬
DMBMS2018
،
‫هللا‬ ‫شاء‬ ‫إن‬ ‫نستمر‬ ‫حتى‬ ‫تتابعوني‬ ‫ياريت‬
https://www.facebook.com/DMBMS2018/
‫باسم‬ ‫التلجرام‬ ‫علي‬ ‫قناتي‬ ‫ودي‬
ِ ‫للناس‬ ‫أنفعهم‬ ‫الناس‬ ‫خير‬
📚
‫هللا‬ ‫شاء‬ ‫إن‬ ‫نستمر‬ ‫حتى‬ ‫تتابعوني‬ ‫ِريت‬‫ا‬‫ي‬
https://t.me/DMBMS2020
‫على‬ ‫بروفايلي‬
‫لينكيدإن‬
‫وتعملولي‬ ‫تتابعوني‬ ‫ياريت‬
endorsement
‫مهاراتي‬ ‫على‬
https://www.linkedin.com/in/mohammed-bahgat-sofyan-8ba012142/
‫موقع‬ ‫على‬ ‫بروفايلي‬ ‫وده‬
SlideShare
‫تتابعونا‬ ‫ياريت‬
https://www.slideshare.net/MohammedBahgatMohamm1
‫وده‬
‫بروفايلي‬
‫الشخصي‬
‫الفيسبوك‬ ‫علي‬
https://www.facebook.com/mohammed.bahgat.165
‫الفيسبوك‬ ‫على‬ ‫بنا‬ ‫الخاص‬ ‫اللوجوا‬ ‫وده‬
#
‫دمحمد‬
_
‫بهجت‬
_
‫سفيان‬
_
medical_biochimestry 31

32. My logo
#
‫دمحمد‬
_
‫بهجت‬
_
‫سفيان‬
_
medical_biochimestry
32

33. THANK YOU
Meet on the
best later, God
willing
33