1、Diabetic ketoacidosis(DKA)emergency department of shengjing hospital zhang hong leicase 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,Lacta
2、te:3.1mmol/L,BE:-24.7mmol/L，AG:34.6mmol/LBUN:15.9mmol/L,Cr:147mmol/LK+:8mmol/L,Na+:118mmol/L,Cl-:80mmol/L,Glu:33mmol/Lurinalysis:ketone:3+,gravity:1.024,glu:4+problem what is the diagnosiswhat is the reason of hyperkalemia and hyponatremiawhat is the reason of Metabolic acidosishow to dispose the di
3、sease if you are the ER doctor on call Introduction DKA is a syndrome in which insulin deficiency and glucagonexcess combine to produce a hyperglycemic,dehydrated,acidotic patient with profound electrolyte imbalancePathophysiologyLiverMuscleAdiposetissueGluconeogenesisKetogenesisGlucose UtilizationL
4、ipolysisInsulinGlucagonEpinephrineCortisolGrownth hormonePathophysiologyPathophysiology Insulin deficiency and glucagon elevation results in hyperglycemia,which in turn cause glycosuria Glucose in the renal tubules draws water,sodium,potassium,magnesium,calcium,phosphorus,and other ions from the cir
5、culation into the urine This osmotic diuresis combined with poor intake and vomiting produces the profound dehydration and electrolyte imbalance associated with DKA As a result of acidosis and dehydration,however,the initial reported values for these electrolytes may be higher than actual body store
6、s.Pathophysiology Insulin deficiency results in activation of lipase that increases circulating free fatty acid(FFA)levels.Long-chain FFAs,now circulating in abundance as a result of insulin deficiency,are partially oxidized and converted in the liver to acetoacetate and-hydroxybutyrate.This alterat
7、ion of liver metabolism to oxidize FFAs to ketones rather than the normal process of re-esterification to triglycerides appears to correlate directly with the altered glucagon/insulin ratio in the portal blood.Pathophysiology Glucagon is elevated fourfold to fivefold in DKA and is the most influenti
8、al ketogenic hormone.Despite the increased pathologic glucagon-mediated production of ketones,the body acts as it does in 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.Th
9、e acidosis cause the body to increase lung ventilation and rid the body of excess acid with Kussmauls respirationEtiology 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 i
10、s associated with inadequate administration of insulin,infection,or myocardial infarction(MI).DKA can also occur in type 2 patients and may be associated with any type of stress,such as sepsis or gastrointestinal(GI)bleedingDiagnostic Strategies History Clinically,most patients with DKA complain of
11、a recent history of polydipsia,polyuria,polyphagia,visual blurring,weakness,weight loss,nausea,vomiting,and abdominal pain.Diagnostic StrategiesPhysical Examination Typical findings include tachypnea with Kussmauls respiration,tachycardia,frank hypotension,the odor of acetone on the breath,and signs
12、 of dehydrationDiagnostic StrategiesLaboratory Tests On the patients arrival 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.
13、3).DKA can be caused by any condition that reduces insulin availability or activity 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 pota
14、ssium replacement.keywhat is the diagnosis DKAwhat is the reason of 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
15、is strongly affected by hyperglycemia;hypertriglyceridemia;salt-poor 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 replacement
