2. DIABETIC KETOACIDOS IS A MAJOR MADICAL EMERGENCY AND REMAINS A SERIOUS CAUSE OF MORBIDITY PRINCIPALLY IN PEOPLE WITH TYPE 1 DM. IT IS DEFINED AS “A MEDICAL EMERGENCY IN WHICH HYPERGLYCEMIA IS ASSOSIATED WITH A METABOLIC ACIDOSIS DUE TO GREATLY RAISED ( > 5 MMOL ) KETONE LEVELS”

3. INFECTIONS SURGERY MI NON COMPLAINCE OR WRONG INSULIN DOSE

4. CARDINAL BICHEMICAL FEATURES OF DKA ARE 1. HYPERGLYCEMIA 2. HYPERKETONEMIA 3. METABOLIC ACIDOSIS

5. GLUCOSE HYPERGLYCEMIA GLYCOSURIA OSMOTIC DIURESIS FLUID & ELECTROLYTE DEFICIENCY RENAL HYPOPERFUSION DECREASED EXCRETION OF KETONES INCREASED H IONS KETONES ACIDOSIS VOMITING FLUID & ELECTROLYTE DEFICIENCY RENAL HYPOPERFUSION DECREASED EXCRETION OF KETONES INCREASED H IONS

6. INSULIN DEFICIENCY INCREASED LIPOLYSIS INCREASE FREE FATTY ACID TAKE UP BY LIVER SUBSTRATE FOR KETONE FORMATION (ACETOACITIC ACID,ACETONE AND BETA HYDROXYBUTYRIC ACID ) PASS INTO BLOOD ACIDOSIS

7. WATER 6 LITRE SODIUM 500 MMOL CHLORIDE 400 MMOL POTASSIUM 350 MMOL

8. SYMPTOMS IN FULMINATING CASES STRICKING FEATURES ARE THOSE OF SALT AND WATER DEPLETION POLYURIA THURST WT LOSS WEAKNESS NAUSEA VOMITING LEG CRAMPS BLURRED VISION ABDOMINAL PAIN

9. LOSS OF SKIN TURGER FURRED TONGUE CRACKED LIPS TACHYCARDIA SMELL OF ACETONE AIR HUNGER HYPOTHERMIA CONFUSION, DROWSINESS AND COMA

10. DIABETIC KETOACIDOSIS IS CONFIRMED BY 1. HYPERGLYCEMIA 2. METABOLIC ACIDOSIS 3. KETONURIA,HYPERKETONEMIA

11. 1. BLOOD GLUCOSE & ELECTROLYTES 2. URINARY KETONES URINE IS STRONGLU +VE FOR KETONE BODIES 3. ABG’S 4. BLOOD CP

12. CXR TO LOOK FOR ANY INFECTION ECG K+ LEVELS UREA & CREATININE RENAL FUNCTION PLASMA OSMOLARITY 2[Na+]+[UREA]+[GLUCOSE] MMOL/L

13. Diagnostic criteria* Blood glucose: >250 mg per dL (13.9 mmol per L) pH: <7.3 Serum bicarbonate: <15 mEq per L Urinary ketone: >=3+ Serum ketone: positive at 1:2 dilutions Serum osmolality: variable Typical deficits Water: 6 L, or 100 mL per kg body weight Sodium: 7 to 10 mEq per kg body weight Potassium: 3 to 5 mEq per kg body weight Phosphate: ~1.0 mmol per kg body weight

14. PRINCIPAL COMPONENTS OF TREATMENT ARE 1. FLUID REPLACEMENT 2. ADMINISTRATION OF SHORT ACTING (REGULAR) INSULIN 3. K+ RERPLACEMENT 4. ADMINISTRATION OF ANTIBIOTICS

15. Protocol for management Asses your ABC’s Asses the consious levels, GCS NG tube Urinary cathetarization Address the circulatory issues, CVP line & plasma expanders if BP not maintained Antibiotics if obvious source of infection Labs, Monitoring, ECGs

16. AVERAGE FLIUD LOSS IS 6 LITRES 3 LITERS FROM EXTRRACELLULAR COMPARTMENT 3 LITERS FROM INTRA CELLULAR COMPARTMENT

17. FIRST WE REPLACE EXTRA CELLULAR FLUID BY 0.9% NaCl 1L 30MIN 1L 1HOUR 1L 2HOURS

18. USE DEXTROSE SALINE OR 5% D/W WHEM BLOOD GLUCOSE IS < 15 mmol/L THOSE >65 YRS OLD OR WITH CCF NEEDS LESS SALINE MORE CAUTIOUSLY

19. START WITH I/V INSULIN INFUSION @ 5U/HRS ALTERNATIVELY 10 – 20 U I/M FOLLOWED BY 5 U/HR I/M BLOOD GLUCOSE CONCENTRATION SHOULD FALL BY 3 –6 mmol/L IF BLOOD GLUCOSE LEVELS DONOT FALL IN FIRST 2 HR THE DOSE OF INSULIN SHOULD BE DOUBLED

20. WHEN LEVEL FALL TO 10 – 15 mmol/L DOSE OF INSULIN SHOULD BE DECREASED TO 1 – 4 mmol/L S/C ROUTE SHOULD BE AVOIDED BECAUSE S/C BLOOD FLOW IS REDUCED IN SHOCKED PT VERY RAPID BLOOD GLUCOSE FALL SHOULD BE AVOIDED BECAUSE IT CAN LEAD TO CEREBRAL OEDEMA

21. AS THE PLASMA K IS OFTEN HIGHER AT PRESENTATION TREATMENT WITH I/V KCL SHOULD BE STARTED CAUTIOSLY S K+ (mmol/L) AMOUNT OF KCL < 3 mmol/L 40 mmol/L <4 mmol/L 30 mmol/L <5 mmol/L 20 mmol/L

22. IN PTS WHO ARE SEVERILY ACIDOTIC pH < 7.0 [H+] > 100mmol/L INFUSION OF NaHCO3 ( 300ml 1.26 % OVER 30 MIN )SHOULD BE CONSIDERED WITH SIMULTANEOUS ADMINISTRATION OF K

23. INFECTION SHOULD BE CAREFULLY SOUGHT AND VIGOROSLY TREATED

24. CATHETERIZATION IF NO URINE OUTPUT FOR > 3 HRS N/G TUBE TO KEEP STOMACH EMPTY IN UNCONCIOUS CVP LINE IF CVS COMPROMISED PLASMA EXPANDER IF BP DOES NOT RISE WITH IV SALINE S/C HEPARIN 5000U/8 HR UNTIL MOBILE IN COMOTOSE, ELDERLY,OBESE

25. BLOOD GLUCOSE & ELECTROLYTES HOURLY FOR 8 HRS VITAL MONITORING HOURLY URINE O/P KETONES ECG ABG’S

26. I/V DEXTROSE AND SALINE SHOULD BE CONTINUED UNTIL PT FEEL ABLE TO EAT AND KEEP FOOD DOWN A SIMILAR AMOUNT OF INSULIN IS GIVEN AS THERE INJECTION OF REGULAR INSULIN S/C INSULIN AT MEAL TIMES AND A DOSE OF INTERMEDIATE ACTING INSULIN AT NIGHT

27. HYPOTENTION CEREBRAL OEDEMA ARDS THROMBOEMBOLISM DIC ACUTE CIRCULATORY FAILURE

28. O hour Start iv insulin 5 u /hr alt give 10-15u i.m. followed by 5 u im thereafter O.9 % NS 1 lt over 30 mins Send urgent electrolytes Urine and serum for ketone levels

29. 30 mins Cont. insulin 5 u/hr iv or im O.9 % NS half lt in 30mins If K levels >5.5 mmol/l no need for KCl, if 3.5- 5.5 mmol/l give 20 mmol kcl If K <3.5 mmol/l then give 40 mmol/l of infused levels If pH <7.O, give 3OO ml sod bicarbonate over 3O mins

30. Hour 1 Cont. insulin 5 u/hr iv or im O.5 lt NS in 1 hr Recheck K levels Recheck vitals every 15 mins

31. Hour 2 Cont. insulin 5 u/hr iv or im O.5 lt NS in 2 hrs Cont. observing vitals & biochemistry

32. When RBS <15 mmol/l Reduce rate of insulin to 1-4 U/hr Change to 5 % dextrose inf 0.5 lt/2 hrs Continue K replacement Recheck every aspect hourly till pt. stable then 2 hrly

33. PLASMA GLUCOSE IS USUALLY HIGH BUT NOT ALWAYS HIGH WCC MAY BE SEEN IN ABSENCE OF INFECTION INFECTION IN ABSENCE OF FEVER CREATININE SOME ESSAYS FOR CREATININE CROSS REACT WITH KETONE BODIES

34. HYPONATREMIA DUE TO OSMOLAR COMPENSATION FOR HYPERGLYCEMIA SERUM AMYLASE RAISED UPTO 10 TIMES

36. WHAT IS THE FIRST STEP IN THE MANAGEMENT OF PT WITH DKA 1. GET AN IV ACCESS AND GIVE INSULIN ACCORDING TO SLIDING SCALE 2. GET AN IV ACCESS AND GIVE IL OF 0.9% NaCl IN 30 MIN 3. GET AN IV ACCESS AND GIVE 50 ML OF 50% DW

37. AMOUNT OF KCL GIVEN IN DKA PT WITH SERUM K+ LEVEL OF <3 mmol/L 1. 20 mmol/L 2. 30 mmol/L 3. 40 mmol/L

38. A 15 YEARS OLD BOY PRESENTED IN EMERGENCY DEPARTMENT WITH COMPLAINTS OF HIGH GRADE FEVER,PRODUCTIVE COUGH WITH YELLOWISH SPUTUM FOR LAST 5 DAYS.HE HAS PERSISTENT VOMITINF AND ABDOMINAL PAIN FOR 2 DAYS AND DROWSINESS FOR ONE DAY. WHAT IS YOUR CLINICAL IMPRESSION? WHAT CLINICAL SIGNS DO YOU SUSPECT IN THIS CASE?

39. BP 80/60mmHg PULSE 110/min, regular. TEMP 97 F R/R 26/min GCS 7/15 PUPILS HAS SLUGGISH REPONSE TO LIGHT,NORMAL SIZED. PLANTARS BILATERAL NON-SPECIFIC THERE IS BRONCHIAL BREATHING IN RIGHT BASAL LUNG THERE ARE SIGNS OF DEHYDRATION,REST OF EXAMINATION IS NORMAL. WHAT IS LIKELY DIAGNOSIS? HOW WILL YOU INVESTIGATE THIS CASE?

40. BSR SERUM KETONES URINARY KETONE SERUM ELECTROLYTES ABGS CP CXR

41. HOW WILL YOU MANAGE THIS PATIENT?