Diabetic Ketoacidosis Management - THD Internal Medicine ：糖尿病酮症酸中毒的管理- THD内科.ppt

Diabetic Ketoacidosis Management Heidi Chamberlain Shea, MD Endocrine Associates of Dallas Goals of Discussion Pathophysiology of DKA Biochemical criteria for DKA Treatment of DKA Prevention of DKA Hyperosmolar Nonketoic Syndrome Epidemiology Annual incidence in U.S. 5-8 per 1000 diabetic subjects 2.8% of all diabetic admissions are due to DKA Overall mortality rate ranges from 2-10% Higher is older patients DKAPrecipitating Factors Failure to take insulin Failure to increase insulin Illness/Infection Pneumonia MI Stroke Acute stress Trauma Emotional Medical Stress Counterregulatory hormones Oppose insulin Stimulate glucagon release Hypovolmemia Increases glucagon and catecholamines Decreased renal blood flow Decreases glucagon degradation by the kidney Diabetic Ketoacidosis Due to: Severe insulin deficiency Excess counterregulatory hormones Glucagon Epinephrine Cortisol Growth hormone Role of Insulin Required for transport of glucose into Muscle Adipose Liver Inhibits lipolysis Absence of insulin Glucose accumulates in the blood Liver Uses amino acids for gluconeogenesis Converts fatty acids into ketone bodies Acetone, Acetoacetate, β-hydroxybutyrate Increased counterregulatory hormones Counterregulatory Hormones - DKA Signs and Symptoms of DKA Polyuria, polydipsia Enuresis Dehydration Tachycardia Orthostasis Abdominal pain Nausea Vomiting Fruity breath Acetone Kussmaul breathing Mental status changes Combative Drunk Coma Lab Findings Hyperglycemia Anion gap acidosis (Na + K) – (Cl + Bicarb) 12 Bicarbonate 15 mEq/L pH 7.3 Urine ketones and serum ketones Hyperosmolarity Differential Diagnosis Anion Gap Acidosis Alcoholic ketoacidosis Lactic acidosis Renal failure Ethylene glycol or methyl alcohol poisoning Starvation in late pregnancy or lactation (rare) Atypical Presentations DKA can be present with BS 300 Impaired gluconeogenesis Liver disease Acute alcohol ingestion Prolonged fasting Insulin-independent glucose is high (pregnancy) Chr