1、糖尿病酮症酸中毒英文糖尿病酮症酸中毒英文case Mr wang，M，52 years oldchief complaint：polydipsia,polyuria,weakness for1week，vomiting for 10 hourphysical exam:tachypnea,BP 150/90mmHg,HR:120bpm,SaO2:99%ABG:PH:7.06,PaCO2:12mmHg,PaO2:117mmmHg,HCO3-:3.4mmol/L,Lactate:3.1mmol/L,BE:-24.7mmol/L，AG:34.6mmol/LBUN:15.9mmol/L,Cr:147m
2、mol/LK+:8mmol/L,Na+:118mmol/L,Cl-:80mmol/L,Glu:33mmol/Lurinalysis:ketone:3+,gravity:1.024,glu:4+2021/4/272problem what is the diagnosiswhat is the reason of hyperkalemia and hyponatremiawhat is the reason of Metabolic acidosishow to dispose the disease if you are the ER doctor on call2021/4/273 Intr
3、oduction DKA is a syndrome in which insulin deficiency and glucagonexcess combine to produce a hyperglycemic,dehydrated,acidotic patient with profound electrolyte imbalance2021/4/274Pathophysiology2021/4/275Pathophysiology2021/4/276Pathophysiology Insulin deficiency and glucagon elevation results in
4、 hyperglycemia,which in turn cause glycosuria Glucose in the renal tubules draws water,sodium,potassium,magnesium,calcium,phosphorus,and other ions from the circulation into the urine This osmotic diuresis combined with poor intake and vomiting produces the profound dehydration and electrolyte imbal
5、ance associated with DKA As a result of acidosis and dehydration,however,the initial reported values for these electrolytes may be higher than actual body stores.2021/4/277Pathophysiology Insulin deficiency results in activation of lipase that increases circulating free fatty acid(FFA)levels.Long-ch
6、ain FFAs,now circulating in abundance as a result of insulin deficiency,are partially oxidized and converted in the liver to acetoacetate and-hydroxybutyrate.This alteration of liver metabolism to oxidize FFAs to ketones rather than the normal process of re-esterification to triglycerides appears to
7、 correlate directly with the altered glucagon/insulin ratio in the portal blood.2021/4/278Pathophysiology Glucagon is elevated fourfold to fivefold in DKA and is the most influential ketogenic hormone.Despite the increased pathologic glucagon-mediated production of ketones,the body acts as it does i
8、n any form of starvation,to decrease the peripheral tissues use of ketones as fuel.The combination of increased ketone production with decreased ketone use leads to ketoacidosis.The acidosis cause the body to increase lung ventilation and rid the body of excess acid with Kussmauls respiration2021/4/
9、279Etiology DKA may be caused by cessation of insulin intake or by physical or emotional stress despite continued insulin therapy.Most often,DKA occurs in patients with type 1 diabetes and is associated with inadequate administration of insulin,infection,or myocardial infarction(MI).DKA can also occ
10、ur in type 2 patients and may be associated with any type of stress,such as sepsis or gastrointestinal(GI)bleeding2021/4/2710Diagnostic Strategies History Clinically,most patients with DKA complain of a recent history of polydipsia,polyuria,polyphagia,visual blurring,weakness,weight loss,nausea,vomi
11、ting,and abdominal pain.2021/4/2711Diagnostic StrategiesPhysical Examination Typical findings include tachypnea with Kussmauls respiration,tachycardia,frank hypotension,the odor of acetone on the breath,and signs of dehydration2021/4/2712Diagnostic StrategiesLaboratory Tests On the patients arrival
12、to the ED,serum and urine glucose and ketones,electrolytes,and arterial blood gases(ABGs)should be checked.Glucose is usually elevated above 350 mg/dL;however,euglycemic DKA(blood glucose 200 mg/dL),ketonemia,acidemia(pH 7.3).DKA can be caused by any condition that reduces insulin availability or ac
13、tivity or that increases glucagon.Precipitating events usually include infections,surgery,and emotional orphysical stressors.Treatment is aimed at fluid replacement over the first 24 to 48 hours,insulin replacement,and potassium replacement.2021/4/2728keywhat is the diagnosis DKAwhat is the reason o
14、f hyperkalemia and hyponatremia As a result of acidosis and dehydration,however,the initial reported values for potassium may be higher than actual body stores.Sodium is often low in the presence of significant dehydration because it is strongly affected by hyperglycemia;hypertriglyceridemia;salt-po
15、or fluid intake;and increased GI,renal,and insensible losseswhat is the reason of Metabolic acidosis Metabolic acidosis with an anion gap is primarily the result of elevated plasma levels of acetoacetate and-hydroxybutyrate,how to dispose the disease if you are the ER doctor on call Treatment is aimed at fluid replacement over the first 24 to 48 hours,insulin replacement,and potassium replacement2021/4/2729 thanks for attention2021/4/2730
