DISEDIAKAN OLEH:-

NAMA : PETER HOWES WILFRED AHMIN

NO KPT : ooo-I-I
NO MATRIK : PB I]ioIo-oo
lnLroducLlon lnLroducLlon
O Diabeiic leioacidosis (DKA) is an ACUTE, MA}OR,
LIFE-THREATENING complicaiion of diabeies.
O DKA is defined:
4 Clinically as an acuie siaie of seveie unconiiolled
diabeies ilai iequiies emeigency iieaimeni wiil insulin
and iniiavenous fluids.
4 Bioclemically as an inciease in ile seium conceniiaiion
of leiones gieaiei ilan mEq]L, a blood glucose level of
gieaiei ilan :o mg]dL (alilougl ii is usually mucl
liglei), blood pH of less ilan .:, and a bicaibonaie
level of i mEq]L oi less.
Loacldosls
Keioacidosis iesulis fiom a lacl of insulin. In piaciice ii is
usually due io:
siopping insulin oi ieducing ile dose eiilei in eiioi oi
delibeiaiely
iesisiance io insulin duiing infeciions oi oilei
inieicuiieni illness.
ile uniecognised onsei of Type i diabeies.
9aLhophyslology 9aLhophyslology
O DKA is claiacieiized by lypeiglycemia, acidosis, and leionuiia.
O DKA is consequence of absoluie oi ielaiive insulin deficiency
wiil inciease in couniei-iegulaioiy loimones .
OInsulin and couniei-iegulaioiy loimone
i. Gluconeogenesis and glycogenolysis Hypeiglycemia .
:. Lipolysis Fiee Faiiy Acids Keiogenesis Keionemia and
leionuiia pH and bicaibonaie seium levels Meiabolic
acidosis Keioacidosis.
9aLhophyslology 9aLhophyslology conL conL
O HypeiglycemiaGlycosuiiaOsmoiic diuiesis
delydiaiion and iissue lypopeifusion.
O Hypeiglycemia, osmoiic diuiesis, seium lypeiosmolaiiiy, and
meiabolic acidosis conceniiaiion disiuibance.
O Osmoiic diuiesis oiassium Sodium loss in ile uiine.
O Higl seium osmolaiiiyDiluiional lyponaiiemia.
auss and 9rclplLaLlng lacLors auss and 9rclplLaLlng lacLors
O Thc most common pvccipitants
i. Infeciions (o-o%): pneumonia,
uiinaiy iiaci infeciions, sepsis,
gasiioenieiiiis
:. Inadequaie insulin iieaimeni
(:o-o%): includes
noncompliance, insulin pump
failuie
. Myocaidial isclemia oi
infaiciion (-%): ofien clinically
"sileni" in diabeiic paiienis
O Othcv pvccipitants
1. CVA
2. ntracranial bleeding
3. Acute pulmonary embolism
4. ntestinal or mesenteric thrombosis
5. ntestinal obstruction
6. Acute pancreatitis
7. Alcohol intoxication or abuse
8. Severe burns, hyperthermia or
hypothermia
9. Endocrine disorders: Cushing's
syndrome, thyrotoxicosis,
acromegaly
10.Total parenteral nutrition
11.Drugs: -blockers, diuretics,
corticosteroids, antipsychotics
llnlcal laLurs llnlcal laLurs
O Sympioms:
i. olydypsia.
:. olyuiia.
. Hypeiglycemia.
. Nausea, leilaigy, anoiexia,
wealness.
. Abdominal pain.
. Reduced moiiliiy of GI.
. Vomiiing.
O Signs:
i. Delydiaiion:
4 Diy slin and mucous .
4 Oiilosiaiic lypoiension.
4 Taclycaidia.
4 Reduced }V.
4 Reduced menial funciion
:. Keiosis:
4 Sweei odoi
4 ussmaul breathing
lagnosls lagnosls
Table -1 Diagnostic criteria for diabetic ketoacidosis and the
hyperosmolar hyperglycemic state
Mild DKA Moderate DKA Severe DKA
Plasma glucose (mg/dL) ~250 ~250 ~250
EIIective serum osmolality (mOsm/kg) Variable Variable Variable
Urine or serum ketones (NP reaction) Positive Positive Positive
Arterial pH 7.257.30 7.007.24 7.00
Serum bicarbonate (mEq/L) 1518 1015 10
Anion gap (mEq/L) ~10 ~12 ~12
Typical mental status Alert Drowsy Stupor or coma

Laboratory and Cther Stud|es for D|abet|c ketoac|dos|s

Test Notes
PIasma gIucose UsuaIIy >13.9 mmoI/L (>250 mg/dL)
ArteriaI bIood gas pH is usuaIIy <7.3
Serum ketones UsuaIIy 7-10 mmoI/L in DKA or >1:2 diIution
Anion gap (eIectroIytes) UsuaIIy >15 in DKA
Serum sodium UsuaIIy Iow
Serum potassium May be high, normaI, or Iow. Potassium IeveI wiII guide management
Serum phosphate
May be normaI or high initiaIIy but usuaIIy decreases with insuIin therapy
Serum amyIase/Iipase May bc high in DKA, unvc!atcd to pancvcatitis. Diagnosis oI pancvcatitis
in DKA shou!d bc bascd on c!inica! judgmcnt and imaging
BIood urea, creatinine IeveIs UsuaIIy eIevated due to dehydration and decreased renaI perfusion
CBC count and differentiaI Leukocytosis is common and may not represent infection.
LeveIs >25 + 109 ceIIs/L shouId warrant diIigent search for infection
Urine and bIood cuItures If suspicion of infection is present
Chest radiography If suspicion of pneumonia or puImonary disorder
ECG
ShouId be done in aII patients to assess effect of potassium status and
ruIe out
ischemia or myocardiaI infarction
CBC = complete blood cell; DKA = diabetic ketoacidosis; ECG = electrocardiography.
ompllcaLlons ompllcaLlons
O Ceiebial edema
O Caidiac dysilyilmia
O ulmonaiy edema
O Nonspecific myocaidial injuiy may occui in seveie DKA.
O Miciovasculai clanges consisieni wiil diabeiic
ieiinopaily.
9rognosls 9rognosls
O Excc!!cnt: especially in youngei paiienis if
inieicuiieni infeciions aie abseni.
O Thc wovst pvognosis: is usually obseived in paiienis
wlo aie oldei wiil seveie inieicuiieni illnesses, eg,
myocaidial infaiciion, sepsis, oi pneumonia, especially
wlen iley aie iieaied ouiside an ICU.
O signs of pooi piognosis: deep coma ai ile iime of
diagnosis, lypoileimia, and oliguiia.
9revent|on of ketoac|dos|s
"""losollo sboolJ oevet be stoppeJ
Insu!in dosc duving i!!ncss ov inIcction
I. Duving i!!ncss ov inIcction youi blood glucose level may iise,
causing you io feel diy, iliisiy and pass ioo mucl uiine. Tle
blood glucose is also lilely io inciease
i. You MUST coniinue io iale youi noimal insulin dose
NEVER siop ii. You may need an incieased dose if youi blood
iesis aie bad. If you aie vomiiing, consuli youi docioi oi ile
diabeiic clinic ai once. If you aie unable io eai, iale youi
caibolydiaie poiiions in liquid foimfoi example, mill,
Lucozade, Ribena
. Tcst youv b!ood iwice a day oi even moie fiequenily
If you coniinue io feel unwell, consuli youi docioi.
s DkA preventab|e?
Youi docioi slould male a plan foi wlen you aie sicl
(called a Sicl Day lan) io lelp leep you fiom geiiing DKA.
On sicl days, you male fiequeni blood sugai clecls
and iale exiia insulin depending on ile sugai level as
well as do lome iesis of uiine oi blood leiones. You
diinl exiia fluid and eai specific foods.
Call youi docioi if youi blood sugai siays ovei :o
mg]dL even ilougl you lave been following youi sicl
day plan.
umary of
LINIAL BOTTOM
DKA occuis in boil iype i and : diabeies. aiienis ai iisl foi DKA
wiil iype : diabeies aie moie lilely io be men, middle-aged, obese, and wiil a
family lisioiy of diabeies and newly diagnosed diabeies.
DKA can iesuli fiom infeciions oi oilei siiessois, sucl as caidiovasculai disease,
bui is mosi commonly due io nonadleience io ile diabeies-caie piogiam,
including iieaimeni and selfmoniioiing.
DKA can also be ile fiisi pieseniaiion of diabeies. A sicl-day managemeni
plan slould be esiablisled foi all paiienis wiil diabeies bui especially
ilose wiil a lisioiy of DKA io avoid iepeaied episodes.
Thc pvimavy goals of iieaimeni foi paiienis wiil
diabeies include coniiolling blood glucose levels and
pieveniing acuie and long-ieim complicaiions. Tlus,
ile diabeiic enducaioi wlo caies foi diabeiic paiienis
musi assisi ilem io develop self-caie managemeni
slills.
frncs frncs
O Cecil Medicine, :id Ed
O Haiiison's iinciples of Inieinal Medicine, iil
Ediiion, :oo
O eMedicine.com Specialiies > Endociinology >
Diabeies Melliius
@hank ?ou @hank ?ou
ny CusLlons ? ny CusLlons ?