DM DKA-HONC resident version

DM DKA-HONC resident version - Hyperglycemic Emergencies...

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Unformatted text preview: Hyperglycemic Emergencies DKA/HONC William Harper, MD, FRCPC Endocrinology & Metabolism Assistant Professor of Medicine, McMaster University Case 40 y.o. male, T1DM x 20y Normally on Novolin 30/70 38/20 Presents with decr LOC, confusion 80/60, P120 reg, JVP < SA, dry mucus mem RR 32, fruity odor to breath CBG 39 mM Case 136 85 160 3.1 18 21 7.29|33|18|95|98% What are the acid-base disturbances? 42 BS Case 136 85 160 3.1 18 21 7.29|33|18|95|98% What other tests need to be done? 42 BS DKA A collection of severe and potentially life- threatening metabolic disturbances: Hyperglycemia Osmotic diuresis Urinary loss of fluids & electrolytes ECFv contraction Depletion of total body K + stores (even though may be hyperkalemic 2 to cell shift) Ketone production Metabolic acidosis Compensatory Respiratory alkalosis (hopefully!) Uncontrolled lipolysis severe TG DKA: Pathophysiology Glucose Pyruvate Acetyl-CoA Ketoacids Krebs + PFK Insulin fat cell TG FFA HSL Liver Cell Fatty Acyl-CoA Insulin - VLDL (TG) Glucagon Insulin + + DKA: Pathophysiology Glucose Pyruvate Acetyl-CoA Ketoacids Krebs + PFK Insulin fat cell TG FFA HSL Liver Cell Fatty Acyl-CoA Insulin - VLDL (TG) Glucagon Insulin + + DKA risk factors T1DM 1 st presentation Acute-illness Insulin omission (inappropriate sick-day management, noncompliance, Eating Disorders) T2DM During stress Ethnicity: African-American, Hispanic Extremes of age Poor glycemic control MDI with CSII DKA: Precipitating Factors Acute illness (MI, GIB, trauma, pancreatitis) New-onset DM Insulin omission Infections 10-20% 5-39% 33% 20-38% DKA: Diagnosis Symptoms & Signs : Polyuria, polydipsia, weight-loss Fatigue N/V, abdominal pain 2200 ECFv, Kussmauls, Acetone breath, mild impairment in cognition Laboratory : pH < 7.3, serum HCO3 < 15 mEq/L, AG > 14 mM Raised serum ketones (and urine ketones) BS > 14 mM (occasionally normal or only mild BS) DKA: Management 1. Monitoring 2. IV Fluid Resuscitation (3-9L deficit) 3. Potassium (no pee no K) K + deficit 3-5 mEq/Kg 1. IV insulin 2. Identify & Rx underlying cause Noncompliance, infection, MI, etc. DKA: Monitoring Consider ICU: pH < 6.9, inadequate respiratory compensation decreased LOC Severe K + disturbance (K + < 3.0 or > 6.0 mEq/L) Stepdown/Telemetry:...
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DM DKA-HONC resident version - Hyperglycemic Emergencies...

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