تم تحميل هذا الملف من
منتديات تمريض مستشفى غزة الاوروبي
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لتحميل اجمل واروع المحاضرات فقط قم بزيارتنا وسوف تكون من الاوائل
مع تحيات المدير العام
علاء شعت
تم تحميل هذا الملف من
منتديات تمريض مستشفى غزة الاوروبي
http://egh-nsg.forumpalestine.com/
لتحميل اجمل واروع المحاضرات فقط قم بزيارتنا وسوف تكون من الاوائل
مع تحيات المدير العام
علاء شعت
This is the fifth lecture. it is based on guidelines by NHS UK. the guidelines based are freely available in internet. the source and the used literature are trusted and accurate. i hope this level of a knowledge about the management side of the DKA touches the all areas of patient survival. patho-physiology not discussed here but will be discussed in another lecture in details. to a intern and final year MBBS students or ERPM students must process a level of knowledge described by the lecture. definitely more you read more knowledge you get. get the idea in the lecture and principles of management. so you will be much accurate in a ward. always take superior advice while managing emergencies.
Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but it is not uncommon in some patients with type 2 diabetes. This condition is a complex disordered metabolic state characterized by hyperglycemia, ketoacidosis, and ketonuria.
This presentation is based on JBDS and BSPDE guidelines in adult and Paediatric DKA management. A comparison of adult vs paediatric management is included.
11 most common pitfalls in the management of DKA including diagnosis, when to call ICU team, potassium replacement, fluid replacement, transition to subcutaneous insulin, post DKA management including follow up after discharge
this power point descripe diabetic ketoacidosis in pediatric age group .. we talk about the risk of it .. management specially (fluid management) as case study .. complications and the treatment of brain oedema .. i hope to be auseful one .. enjoy
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
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http://sandymillin.wordpress.com/iateflwebinar2024
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The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
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unwillingness to rectify this violation through action requires accountability.
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students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
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• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
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A Strategic Approach: GenAI in EducationPeter Windle
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1. Journal club of Sulaimania
General Teaching Hospital
Prepared by
Dr. Mohamed Shekhani.
2. Introduction
• It is the metabolic abnormality of type 1 diabetes.
• Near patient testing for the ketones is now readily available for
monitoring allowing for a shift away from using glucose levels to
drive treatment decisions in the management of DKA.
• National UK guidelines have been developed to reflect the
development in technology.
• They are evidence based where possible but are also drawn from
accumulated multiprofessional knowledge & consensus agreement.
3. Pathophysiology & diagnosis
• Usually occurs as a consequence of insulin deficiency.
• This enhances hepatic glucose production.
• Enhanced fat breakdown increases serum free fatty acids that are then
metabolised producing large quantities of ketones & metabolic acidosis.
• Fluid depletion is a serious problem caused by osmotic diuresis.
• Electrolyte shifts & depletion are, in part, related to the osmotic
diuresis.
• Hyper & hypokalaemia are particular dangers.
• Absolute diagnostic criteria do not exist, but the following are proposed:
• Ketonaemia =>3 mmol/l by ketone meter, or significant ketonuria (> 2+
on standard urine sticks)
• BS >11 mmol/l or known DM
• Venous bicarbonate (HCO3)< 15 mmol/l &or venous pH <7.3.
4. Developments in management
• Recent developments now allow us to focus on:
• The underlying abnormality (ketonaemia), which simplifies the treat-
ment of those who present with modest elevation of blood glucose but
with acidosis secondary to ketonaemia ‘euglycaemic diabetic
ketoacidosis’.
• Blood glucose is routinely checked at the bedside, but portable ketone
meters now also allow bedside measurement of 3-beta-hydroxybutyrate.
• The resolution of DKA depends upon the suppression of ketonaemia,
therefore the measurement of blood ketones now represents best
practice in monitoring the response to treatment.
• Access to blood gas& blood electrolyte measurements is now usually
available within a few minutes of blood being taken.
• Glucose, ketones and electrolytes,including bicarbonate&venous pH,
should be assessed at, or near, the bedside.
5. DM specialist teams:
• (DST) involvement shortens patient stay and improves outcomes.
• All patients should be reviewed by a member of the DST prior to
discharge, not undertaking this is a governance issue.
6. General management issues:
• The most important initial therapeutic intervention is appropriate
fluid replacement followed by insulin administration.
• The main aims of fluid replacement are to:
• Restore circulatory volume.
• Clear ketones.
• Correct electrolyte imbalance.
• The aim of the first few litres of fluid is to correct any
hypotension, replenish the intravascular deficit &counteract the
effects of the osmotic diuresis with rectification of electrolyte
disturbance.
• In RF or HF, elderly& adolescents, the rate / volume of fluid
replacement may need to be modified.
7. Severity assessment:
• The presence of one or more of the following may indicate severe
DKA &admission to a level 2/high dependency unit environment;
insertion of CVL& immediate senior review should be considered:
• Blood ketones>6 mmol/l
• Bicarbonate level < 5 mmol/l
• Venous/arterial pH < 7.1
• Hypokalaemia on admission (< 3.5 mmol/l)
• Glasgow Coma Scale <12 or abnormal AVPU (Alert,Voice, Pain,
Unresponsive) scale
• Oxygen saturation < 92% on air (assuming normal baseline
respiratory function)
• Systolic BP<90 mmHg
• PR>100 or <60 bpm.
8. Insulin therapy& metabolic treatment targets:
• A fixed rate IV insulin infusion (FRIVII) calculated on 0.1
units/kg infusion is recommended.
• Patient demographics are changing&patients with DKA are now
more likely to be obese or suffering with other insulin-resistant
states, including pregnancy leading to the re-emergence of FRIVII
in adults.
• The FRIVII may need to be adjusted; the recommended targets
are:
• Reduction of the blood ketone concentration by 0.5 mmol/l/hour
• If ketone meter not available, the venous bicarbonate should rise
by 3 mmol/l/hour& capillary blood glucose fall by 3 mmol/l/hour
• Potassium should be maintained between 4.0 -5.0 mmol/l.
9. IV glucose concentration:
• The management should be focused on clearing ketones as well as
normalising blood glucose.
• It is often necessary to administer an (iv) infusion of 10% glucose
via an iv pump in order to avoid hypoglycaemia&permit the
continuation of a FRIVII to suppress ketogenesis.
• Introduction of 10% glucose is recommended when the blood
glucose falls below 14 mmol/l.
• It is important to continue 0.9% sodium chloride solution concur-
rently via an iv pump.
10. Continuation of long-acting insulin analogues:
• Continuation of long-acting analogues (insulin detemir –
Levemir®, insulin glargine – Lantus®) during the initial
management of DKA provides background insulin when the iv
insulin is discontinued&avoids rebound hyperglycaemia when iv
insulin is stopped &avoids excess length of stay.
11. Serious complications:
• Hypokalaemia&hyperkalaemia are potentially life-threatening
conditions during the management of DKA.
• There is a risk of ARF associated with severe dehydration therefore no
potassium be prescribed with the initial fluid resuscitation or if the
serum potassium level remains above 5.5 mmol/l.
• Potassium will almost always fall as the DKA is treated with insulin,
thus it is recommended that 0.9% sodium chloride solution with
potassium 40 mmol/l (ready-mixed) is prescribed as long as the serum
potassium <5.5 mmol/l & the patient is passing urine.
• If the serum potassium falls below 3.5 mmol/l the potassium regimen
needs review.
• All aspects of potassium use must comply with local & national
guidance.
• Other serious complications include cerebral &pulmonary.
• Close attention to fluid balance&slower fluid replacement is recom-
mended for younger adults; for children <18 years of age.
12. Conclusion & summary:
• DKA is a medical emergency with a significant morbidity&mortality.
• It is now recommended that FRIVII be used with bedside measurement
of metabolic parameters.
• The DST should always be involved as soon as possible and ideally
within 24 hours because this has been demonstrated to be associated
with a better patient experience &reduced length of stay.
• In the management of diabetic ketoacidosis the following guidance
should therefore be followed:
• Measure blood ketones, venous (not arterial) pH & bicarbonate & use
results as treatment markers
• Monitor ketones &glucose using bedside meters, when available &
operating within their quality assurance range
• Monitor electrolytes on blood gas analysers with intermittent laboratory
confirmation
• Replace ‘sliding scale’ insulin with weight-based FRIVII
• Involve the DST as soon as possible
• Continue long-acting insulin analogues as normal.