Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State
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Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State
- 1. Dr. Musanna Nabi Chowdhury Dr. Asmita Paudel Intern Doctors Medicine Unit III/VII
- 2. DIABETES MELLITUS Diabetes mellitus is a clinical syndrome characterised by an increase in plasma blood glucose(hyperglycemia).
- 4. DIABETIC EMERGENCIES 1.Diabetic Ketoacidosis 2.Hyperglycemic Hyperosmolar State 3.Hypoglycemia
- 5. CARDINAL FEATURES • DIABETIC KETOACIDOSIS • hyperketonaemia (≥3.0 mmol/L) or ketonuria (more than • 2+ on standard urine sticks) hyperglycaemia(bloodglucose≥11 mmol/L(approximately • 200 mg/dL)) • metabolic acidosis (venous bicarbonate <15 mmol/L and/ • or venous pH < 7.3 (H+ > 50nmol/L HYPERGLYCEMIC HYPEROSMOLAR STATE • Hypovolaemia • severe hyperglycaemia (> 30 mmol/L (600 mg/dL) • hyperosmolality (serum osmolality >320 mOsmol/kg) • without significant ketonaemia (<3 mmol/L) • or acidosis (pH >7.3 (H+ <50 nmol/L), bicarbonate >15 mmol/L).
- 6. DIAGNOSTIC CRITERIA OF DKA AND HHS Ref:
- 7. PRECIPITATING EVENTS 1.Inadequate insulin administration 2.Infection (pneumonia/UTI/gastro enteritis/sepsis) 3.Infarction(cerebral,coronary,mesenteric,periph eral) 4.Drugs (cocaine) 5.Pregnancy
- 8. PATHOGENESIS
- 9. DIABETIC KETOACIDOSIS Symptoms • Polyuria, thirst •Weight loss •Weakness • Nausea, vomiting Signs Dehydration Hypotension (postural or supine) Cold extremities/ peripheral cyanosis Tachycardia *more common in type 1 diabetes • Leg cramps • Blurred vision • Abdominal pain • Air hunger (Kussmaul breathing) • Smell of acetone • Hypothermia • Delirium, drowsiness, coma (10%) HYPERGLYCEMIC HYPEROSMOLAR STATE Symptoms • Polyuria, thirst • Leg cramps • Altered mental status • Lethargy Signs • Hypothermia • Hypotension • Tachycardia/bradycardia • Severe Dehydration ( about 10-12 L fluid loss in a 100kg person) CLINICAL FEATURES
- 10. INVESTIGATIONS The following investigations are important but should not delay the institution of intravenous fluid and insulin replacement: • Venous blood: for urea and electrolytes, glucose, bicarbonate and acid–base status (venous blood can be used in portable and fixed blood gas analysers, and differences between venous and arterial pH and bicarbonate are minor). • Urine or blood analysis for ketones • Electrocardiogram (ECG). • Infection screen: full blood count, blood and urine culture, C-reactive protein, chest X-ray. Although leucocytosis invariably occurs in DKA, this represents a stress response and does not necessarily indicate infection. Plasma osmolarity = 2[Na+ ] + [glucose] + [urea] The normal value is 280–296 mOsmol/L
- 12. INDICATORS OF SEVERE DKA • Blood ketones >6 mmol/L • Bicarbonate <5 mmol/L • Venous/arterial pH <7.0 (H+ >100 nmol/L) • Hypokalaemia on admission (<3.5 mmol/L) • Glasgow Coma Scale score < 12 or abnormal AVPU scale score (p. 188) • O2 saturation <92% on air • Systolic blood pressure <90 mmHg • Heart rate >100 or <60 beats per minute • Anion gap > 16 mmol/L POOR PROGNOSTIC SIGNS OF HHS • Hypothermia • hypotension (systolic blood pressure <90 mmHg), • tachy- or bradycardia, • severe hypernatraemia (sodium >160 mmol/L), • serum osmolality >360 mOsmol/kg, • presence of other serious comorbidities
- 13. MANAGEMENT