Diabetic Ketoacidosis DKA
..... is a state of absolute or relative insulin deficiency aggravated by ensuing hyperglycemia, dehydration, and acidosis-producing derangements in intermediary metabolism. The most common causes are underlying infection, disruption of insulin treatment, and new onset of diabetes. DKA is defined clinically as an acute state of severe uncontrolled diabetes associated with ketoacidosis that requires emergency treatment with insulin and intravenous fluids
Nausea and vomiting usually occur and may be associated with diffuse abdominal pain, decreased appetite, and anorexia. Altered consciousness in the form of mild disorientation or confusion can occur. Although frank coma is uncommon, it may occur when the condition is neglected or if dehydration or acidosis is severe.
Among the symptoms of DKA associated with possible intercurrent infection are fever, dysuria, coughing, malaise, chills, chest pain, shortness of breath, and generalized aches and pains,.
Symptoms of hyperglycemia associated with diabetic ketoacidosis may include thirst, polyuria, polydipsia, and nocturia.
Signs of acidosis may include shallow rapid breathing or air hunger (Kussmaul or sighing respiration), abdominal tenderness, and disturbance of consciousness. Although these signs are not usual in all cases of diabetic ketoacidosis (DKA), their presence signifies a severe form of DKA.
Signs of dehydration include a weak and rapid pulse, dry tongue and skin, hypotension, and increased capillary refill time.
Managing diabetic ketoacidosis (DKA) in an intensive care unit during the first 24-48 hours always is advisable. When treating patients with DKA, the following points must be considered and closely monitored:
- Correction of fluid loss with intravenous fluids
- Correction of hyperglycemia with insulin
- Correction of electrolyte disturbances, particularly potassium loss
- Correction of acid-base balance
- Treatment of concurrent infection, if present
It is essential to maintain extreme vigilance for any concomitant process, such as infection, cerebrovascular accident, myocardial infarction, sepsis, or deep venous thrombosis
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the term hyperosmolar nonketotic state (HNS
) is preferred to denote an acute metabolic complication of diabetes mellitus characterized by impaired mental status and elevated plasma osmolality in a patient with hyperglycemia. Criteria for HNS include serum osmolality of 320 mOsm/kg, plasma glucose level greater than 600 mg/dL (>33.3 mmol/L), profound dehydration, no ketoacidosis, pH of 7.3, HCO3
greater than 15 mEq/L, and the absence of severe ketosis.
HNS is the initial presentation of DM for 30-40% of patients. Most cases of HNS occur in patients with type 2 DM, characterized by insulin resistance and defective insulin secretion. HNS has been reported in patients with type 1 DM, in whom diabetic ketoacidosis (DKA) is more common. Both HNS and DKA may occur in the same individual, which suggests these 2 states of uncontrolled DM differ only in the magnitude of dehydration and the severity of acidosis.
HNS usually evolves over a period of days to weeks, as opposed to DKA, which develops over the course of a few days. Increasing thirst with polyuria, polydipsia, and weight loss characterize HNS. To quench their thirst, many patients consume beverages containing glucose, including juices and soda. Attempt to quantitate the volume ingested over the preceding 24 hours to try to estimate the degree of diuresis with which the patient is presenting.
All patients with HNS require hospitalization, and most should be admitted directly to the intensive care unit (ICU). When available, an endocrinologist should direct the care of these patients. The main goals of treatment are to (1) vigorously rehydrate the patient while maintaining electrolyte homeostasis; (2) correct hyperglycemia; (3) treat underlying diseases; and (4) monitor and assist cardiovascular, pulmonary, renal, and CNS function.
Hyperosmolar Coma Workup
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