Acute Complication Diabetes Mellitus
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Transcript of Acute Complication Diabetes Mellitus
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ACUTE COMPLICATION
HYPOGLYCAEMIA HYPERGLYCAEMIA CRISISDjoko wahono Soeatmadji
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Ketoacidosis and Hyperosmolar Hyperglycemia HYPERGLYCAEMIA CRISIS
- Mortality Rate Diabetic Ketoacidosis (DKA) : 5 10%;
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PRECIPITATING FACTORS Infection (Pneumonia, UTI)CVAAlcohol abuseMyocardial infarctionTrauma Drugs (steroids, sympathomimetics, thiazides)PancreatitisDiscontinuation of or inadequate insulin in established type 1 diabetes
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PATHOGENESIS net effective action of circulating insulin concomitant elevation of counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone)
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Insulin DefciencyLipolysisHyperglicemia KetogenesisOsmotic diuresisKetoacidosisHyperosmolarityPure DKAPure HHSWickoff and Abrahamson. Joslins Diabetes 2005,p.887
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DIAGNOSIS History and physical examinationLaboratory findingsDifferential diagnosis
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Clinical features of diabetic ketoacidosisPolyuria, nocturia; thirstRapid weight lossMuscular weaknessVisual disturbanceAir hunger-acidotic (Kusmaul) respirationAbdominal pain leg crampsNausea, vomitingConfusion, drowsiness, coma (10%)
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Laboratory findingsPlasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes (with calculated anion gap), osmolalityUrinalysis, urine ketones by dipstickInitial arterial/venous blood gasesComplete blood count with differentialElectrocardiogramBacterial cultures of urine, blood, and throat, etc.Chest X-ray
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DIAGNOSIS OF SEVERE KADHyperglycemia (> 250 mg%)Ketosis (blood/urine)Acidemia (pH < 7.3)(ADA,2003) Hyperglycemia < 300 mg% pH > 7.2 BE > -12 mmol/L Severe symptoms (severe dehydration, shock/ hypotonia, persistent vomiting, drowsiness/coma, grave concomittant/underlying disease) (Wagner,1999)
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Diagnostic criteria for DKA and HHSSerum osmolality :2[measured Na (mEq/l)]glucose (mg/dl)/18Anion gap : (Na+) - (Cl + HCO3) (mEq/l).
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Causes of coma or impaired consciousness in diabetic patientsDiabetic ketoacidosisHyperosmolar non-ketotic hyperglycemiaHypoglycemiaLactic acidosisOther causes:Stroke (more common in diabetic patients) Post-ictal (including hypoglycemia-convulsions also causes a self-correcting lactic acidosis)Cerebral trauma (may follow hypoglycemia)Ethanol intoxication (may induce or exacerbate hypoglycemia in diabetic patients). Drug overdose
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Differential diagnosislactic acidosisingestion of drugs such as salicylate, methanol, ethylene glycol, and paraldehydechronic renal failure
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TRATMENTIV fluid (NS) ( initial : 1 l/hour or 1520 ml kg-1 BW h-1)Insulin (Continuous IV drip/im)K+Bicarbonate (pH < 7)PRECIPITATING FACTOR(S)
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Management of Adult Patients with DKA Complete Initial Evaluation IV fluidInsulinPotassiumBiocarbonate
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Management of Adult Patients with DKA Complete Initial Evaluation; Start i.v. Fluid 1.0 L of 0.9% NaCl per hour initially (15 20 ml/kg/h)IV fluidInsulinPotassiumBiocarbonate
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Typical total body deficits of waterand electrolytes in DKA and HHS*
Total water (L)Water (mg/kg)Na (mEq/kg)Cl (mEq/kg)K (mEq/kg)PO4 (mmol/kg)Mg (mEq/kg)Ca (mEq/kg)61007 103 53 55 71 21 - 2 9100 2005 135 154 63 71 21 - 2
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Guide to initial treatment of diabetic ketoacidosis in adultsFluids and electrolytesVolumes1L/h x 2-3, thereafter adjusted according to needFluidsIsotonic (normal) saline (150 mmol/L) generallyHypotonic (half-normal) saline (75 mmol/L) if serum sodium exceeds 150 mmol/L (no more than 1-2 L-consider 5% dextrose with increased insulin if marked hypernatraemia)5% dextrose 1 L-4-6-hourly when blood glucose has fallen to 270 mg/dl (15 mmol/L) (severely dehydrated patients may require simultaneous saline infusion)Consider sodium bicarbonate ( 700 mL of 1.26% or 100 mL of 8.4% if large vein cannulated) if pH < 7.0 (with extra potassium)
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I. IV FluidsHydration Status ?Hypovolemic shockMild hypotensionCardioogenic shock0.95% NaCl (1 L/h) and/or plasma expanderHemodynamic monitoringEvaluate corrected serum Na+Serum Na highSerum Na normalSerum Na lowSerum glucose reaches 250 mg%Change to D5% with 0.45% NaCl at 150 250 ml/h with adequate insulin (0.05 0.1 u/kg/h) iv infusion(add 1.6 mEq to sodium value)
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II. INSULIN Insulin Regular 0.15 u/kg/bolus/iRI 0.1 u/kg/h/iv infusionIf serum glucose does not fall by 50 70 mg%Insulin Regular 0.4 u/kg/bolus/0.1 u/kg/h/imDouble insulin hourly until glucose fall by 50 70 mg%Give 10 u/h/bolus until glucose fall by 50 70 mg%STABILIZEDStart Subcutaneous InsulinINTRAVENOUSINTRAMUSCULAR
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III. POTASSIUM Hold insulin and give 40 mEq K+/h (2/3 as KCL and 1/3 as KPO4 until K+ 3.3 mEq/LInitial serum K+ 5.0 mEq/LGive 20 30 mEq K+ in each liter of iv fluid (2/3 as KCL and 1/3 as KPO4) to keep serum K+ at 4 5 mEq/LmEqInitial serum K+< 3.3 mEq/LDo not give K+ and check K+ every 2 h Initial serum K+ 3.3 5.5 mEq/L
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IV. ASSESS NEED FOR BICARBONATE pH < 6.9NaHCO3 (100 mmol/L) Dilute in 400 ml H2O infuse at 200 ml/hpH 6.9 - 7NaHCO3 (50 mmol/L) Dilute in 200 ml H2O infuse at 200 ml/hpH > 7No NaHCO3Repeat HCO3 administration every 2 h until pH > 7.0 Monitor serum K+
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V. MAINTENANCE Keep the serum glucose 150 200 mg% until metabolic control is achievedCheck electrolyte creatinine and glucose every 2 4 h. Start NPO, continue IV insuin for 1 2 h to ensure adequate plasma insulin and supplement with RI sc as needed. When the patient can eat initiate a multidose insulin regiment and ajust as needed. Continue to look for precipitating factor(s)
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HYPERGLYCAEMIA HYPEROSMOLAR STATE
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Protocol for the management of adult patients with HHS Diagnostic criteria: blood glucose >600 mg/dl arterial pH >7.3 bicarbonate >15 mEq/l mild ketonuria or ketonemia effective serum osmolality >320 mOsm/kg H2ONa should be corrected for hyperglycemia (for each 100 mg/dl glucose >100 mg/dl, add 1.6 mEq to sodium value for corrected serum value
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Protocol for the management of adult patients with HHS Diagnostic Criteria Blood glucose >600 mg/dl Arterial pH >7.3 Bicarbonate >15 mEq/l Mild ketonuria or ketonemia Effective serum osmolality >320 mOsm/kg H2ONa+ should be corrected for hyperglycemia (for each 100 mg/dl glucose >100 mg/dl, add 1.6 mEq to sodium value for corrected serum value
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Thankyou for your attention