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    Diabetic Ketoacidosis

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    Maryam Martawiguna
    Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes caused by a lack of insulin and characterized by hyperglycemia, ketonemia, and metabolic acidosis. DKA is most commonly precipitated by infection and occurs at a rate of 4.6 to 8 cases per 1000 person years among diabetics. Early diagnosis and treatment including fluid resuscitation, electrolyte replacement, insulin therapy, and identifying/treating precipitating factors is essential to improving patient outcomes and reducing mortality rates of 4-10%. Euglycemic ketoacidosis is a similar condition with lower blood glucose levels that requires the same treatment approach. SGLT2 inhibitors have been associated with an increased risk

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    Diabetic Ketoacidosis

    Uploaded by

    Maryam Martawiguna
    101 views21 pages
    Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes caused by a lack of insulin and characterized by hyperglycemia, ketonemia, and metabolic acidosis. DKA is most commonly precipitated by infection and occurs at a rate of 4.6 to 8 cases per 1000 person years among diabetics. Early diagnosis and treatment including fluid resuscitation, electrolyte replacement, insulin therapy, and identifying/treating precipitating factors is essential to improving patient outcomes and reducing mortality rates of 4-10%. Euglycemic ketoacidosis is a similar condition with lower blood glucose levels that requires the same treatment approach. SGLT2 inhibitors have been associated with an increased risk

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    Ketoasidosis diabetikum

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    Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes caused by a lack of insulin and characterized by hyperglycemia, ketonemia, and metabolic acidosis. DKA is most commonly precipitated by infection and occurs at a rate of 4.6 to 8 cases per 1000 person years among diabetics. Early diagnosis and treatment including fluid resuscitation, electrolyte replacement, insulin therapy, and identifying/treating precipitating factors is essential to improving patient outcomes and reducing mortality rates of 4-10%. Euglycemic ketoacidosis is a similar condition with lower blood glucose levels that requires the same treatment approach. SGLT2 inhibitors have been associated with an increased risk

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    101 views21 pages

    Diabetic Ketoacidosis

    Uploaded by

    Maryam Martawiguna
    Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes caused by a lack of insulin and characterized by hyperglycemia, ketonemia, and metabolic acidosis. DKA is most commonly precipitated by infection and occurs at a rate of 4.6 to 8 cases per 1000 person years among diabetics. Early diagnosis and treatment including fluid resuscitation, electrolyte replacement, insulin therapy, and identifying/treating precipitating factors is essential to improving patient outcomes and reducing mortality rates of 4-10%. Euglycemic ketoacidosis is a similar condition with lower blood glucose levels that requires the same treatment approach. SGLT2 inhibitors have been associated with an increased risk

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    Diabetic

    Ketoacidosis
    dr. Dwi Adhi Nugraha, Sp.PD
    Introduction
    • Incidence is between 4.6 and 8.0 per 1000 person-years
    among patients with diabetes.
    • Most serious acute metabolic complications of diabetes
    mellitus and are still associated with excess mortality.
    • Estimated mortality rate for DKA is between 4% and 10%.
    • Early diagnosis and management with attention to
    prevention strategies are essential to improve patients
    outcomes.
    • The approach to the diagnosis and treatment of DKA and
    hyperglicemic hyperosmolar state (HHS) are similar.

    CMAJ 2003;168(7):859-66 , BMJ 2019;365:l1114


    Definition
    • Diabetic ketoacidosis is defined by a triad of hyperglycemia (or
    a diagnosis of diabetes), metabolic acidosis, and ketonemia.

    • HHS is defined by severe hyperglycemia, high serum


    osmolality, and dehydration.

    BMJ 2019;365:l1114
    Perkeni 2021
    Pathogenesis

    CMAJ 2003;168(7):859-66 ,
    Precipitating Factor
    • Infection was identified as the most common precipitating
    factor for diabetic ketoacidosis (45%), followed by insulin
    omission (20%).
    • Other precipitating factors are silent myocardial infarction,
    cerebrovascular accident, mesenteric ischemia, acute
    pancreatitis and use of medications such as steroids,
    thiazide diuretics, calcium-channel blockers, propranolol
    and phenytoin.
    • In 2%–10% of cases no obvious precipitating factor can
    be identified
    Diagnose
    • If physical examination reveals dehydration along with a
    high capillary blood glucose level with or without urine or
    increased plasma ketone bodies, acute diabetic
    decompensation should be strongly suspected.

    • DKA patients can present with polyuria, polydipsia,


    nausea, vomiting, abdominal pain, visual disturbance,
    lethargy, altered sensorium, tachycardia, tachypnea, and
    Kussmaul respirations, with a fruity odor to the breath.

    • A definitive diagnosis of DKA or HHS must be confirmed


    through laboratory investigation.
    CMAJ 2003;168(7):859-66 , BMJ 2019;365:l1114
    Perkeni 2021
    Treatment
    • The management of both diabetic ketoacidosis and HHS
    includes fluids (usually administered intravenously),
    electrolytes, and insulin. Identifying the cause of acute
    decompensated diabetes is important, but this should not
    cause any delay in treatment.

    • The goals of management of diabetic ketoacidosis include


    restoration of intravascular volume, prevention and/or
    correction of electrolyte abnormalities, correction of acidosis,
    and correction of hyperglycemia

    BMJ 2019;365:l1114
    Perkeni 2021
    Perkeni 2021
    Complication Related to Treatment
    • Cerebral edema and adult respiratory distress syndrome
    To reduce the risk, it is recommended that physicians correct sodium and
    water deficits gradually and avoid the rapid decline in plasma glucose
    concentration.

    • Hyperchloremic metabolic acidosis


    Usually has no adverse effect and is corrected spontaneously in the
    subsequent 24–48 hours through enhanced renal acid excretion

    • Vascular thrombosis
    Low-dose or low-molecular-weight heparin therapy should be considered for
    prophylaxis in patients at high risk of thrombosis. However, there are no data
    demonstrating its safety or efficacy.

    • Hypoglicemia and hypokalemia


    Low dose IV insulin, give D5% when blood glucose < 250 mg/dl, corrected
    hypokalemia
    CMAJ 2003;168(7):859-66 ,
    Euglicemic Ketoacidosis
    • euKA is characterized by lower (< 200 mg/dL) BG levels;
    therefore, it is improperly defined as euglycemic because it also
    includes episode with BG above the normal range.

    • In euKA, insulin deficiency and insulin resistance are


    often milder, thereby limiting the surge in BG levels.

    • The treatment of euKA in diabetic individuals is similar to that


    of hyperglycemic DKA. Rapid fluid replacement, followed by
    continuous intravenous insulin infusion, correction of
    electrolyte imbalances and dextrose-containing solutions
    when BG levels are below 250 mg/dL, bicarbonate for
    severe acidosis.
    Current Diabetes Reports (2020) 20:25
    Precipitating Factor of euKA
    • euKA are induced by one or more of the following
    precipitating factors: severe infection, discontinuation of or
    inadequate insulin therapy, low carbohydrate intake or
    prolonged fasting, alcohol consumption, intercurrent acute
    events (pancreatitis, myocardial infarction,
    cerebrovascular accident), drugs that affect carbohydrate
    metabolism (e.g., corticosteroids), surgery, and other
    stressful physical and medical conditions.

    Current Diabetes Reports (2020) 20:25


    SGLT2inh Induced euKA
    • Due to the favorable cardiorenal protective effects of SGLT2 inhibitors, their
    use is expected to grow significantly.
    To minimize the risk of DKA/euKA associated with SGLT2i,
    international societies released a position statement that
    recommend:
    1. Stopping SGLT2i at least 24 h prior to elective surgery,
    planned invasive procedures, or anticipated severe stressful
    physical activity
    2. Stopping immediately for emergency surgery or any extreme
    stress event or any situation that might precipitate DKA
    including acute illness
    3. Avoid stopping insulin or decreasing the dose excessively
    4. Avoid excess alcohol intake and very-low-carbohydrate/
    ketogenic diets

    Current Diabetes Reports (2020) 20:25


    Conclussion
    • DKA is serious acute complication of diabetes melitus. Early
    diagnose and treatment improve outcome.

    • Diabetic patients with nausea, vomitus, altered mental status,


    tachypnea, tachycardia, sign of dehidration, with increased
    blood glucose should be assesed carrefully to rule out acute
    decompensation of diabetes melitus.

    • Rehydration, insulin therapy, potassium replacement,


    bicarbonate infussion if severe ascidosis, identification and
    management precipitating factor are key to manage DKA.

    • Beware of euKA when using SGLT2inh.


    Thank You

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