Diabetes Mellitus

Acute complications
Include :
Diabetes ketoacidosis
Hyperosmolar hyperglycemic state
Hypoglycemia
DIABETIC KETOACIDOSIS
 Outline
• Defination.
• Pathophysiology.
• Precipitating factors.
• Signs and symptoms.
• Diagnosis.
• Management.
• Complications.
 Definition
• It is an acute,major,life-threatening
characterised by hyperglycemia,ketoacidosis
and ketonuria resulting to a complex
disordered metabolic state.
• Mainly common in type 1 diabetes but not
uncommon in some patients with type2
diabetes.
• According to biochemical parameters,its
defined as presence of the following 3
parameters:
1. Hyperglycemia of >11.1mmol/l(rarely
presents with normal blood glucose)
2. Metabolic Acidosis(pH < 7.3 and
bicarbonates of <15mmol/l)
3. Ketonuria or presence of blood ketones.
Pathophysiology
 Precipitating Factors
• Stress
• Infections: UTI, Pneumonia, Gastroenteritis
• Inadequate insulin administration(missed medication
or failed insulin pumps)
• Stroke, MI, PE
• Pregnancy
• Steroids
• Trauma
• Pancreatitis
• Drugs
• Hyperthyroidism
 Symptoms
• Polydipsia,polyuria(most common)
• Abdominal pain,nausea,vomiting,decrease appetite an
anorexia.
• Malaise, generalized weakness and fatigue.
• Altered consciousness(mild,disorientation,confusion a
even coma if severe dehydration and acidosis)
• If there is intercurrent infection ,the following ass
symptoms can be present:fever,cough,chills,chest
pain,dyspnea and urinary symptoms,
 Signs
• Dehydration(dry skin, dry mucous membranes,
decreased skin tugor,prolonged capillary refill time
• Lethargy.
• Tachypnea.
• Rapid deep breathing(kussmaul breathing)
• Hypotension.
• Hypothermia.
• Characteristic acetone (ketotic) breath odor.
• Search for other signs of intercurrent infection.
 DIAGNOSIS
1. History and Examination
a).obtaining patient’s information about
diabetes(date of diagnosis and type of
medication, known complication).
b).Identify precipitating factor.
2. Confirm diagnosis by:
a)Capillary blood glucose>11mmol/L.
b)Urinary or blood ketones.
c) Blood pH <7.3 or bicarbonates<15 mmol/L.
 Investigations
• Blood: urea/electrolyte,glucose,bicarbonates,
LFTs,CBC,arterial blood gases,cardiac
enzymes, blood cultures).
• Chest x-ray.
• Electrocardiogram(ECG).
• Urine culture(midstream urine)
• C.s.f analysis and culture(if meningitis
suspected)
 Management
• The main lines of management include:
– Fluid replacement
– Insulin
– Electrolyte correction.
– Close blood glucose monitoring
NOTE:A patient with DKA should have;
• Atleast 3 IV branullas where insulin infusion
,potassium infusion and IV fluids will be administered
simultaneously.
• Urinary catheter to monitor urinary output.
• NG tube-as gastric dilatation with potential risk of
aspiration.
• Oxygen should be given saturation.aim at SPO2>96%.
• If GCS <8 intubation for airway protection.
• Antibiotic if infection suspected.
• Heparin prophylaxis.
• Fluid replacement:
– 0.9% saline (NaCl) i.v.
• 1 L over 30 mins
• 1 L over 1 hr
• 1 L over 2 hrs
• 1 L over next 4 hrs
• 1 L over next 8 hours
• 1 L over next 12 hours
– When blood glucose ≤ 17 mmol/L (300 mg/dL) or blood glucose falls >
5mmol/L(90mg/dL)
• Switch to 5% dextrose and alternate with normal saline

– Typical requirement is 6 L in first 24 hrs but avoid fluid overload in

elderly patients
– Subsequent fluid requirement should be based on clinical response
including urine output
• Insulin: to be started 1 hour after fluid initiation
Insulin is administered as infusion at :
– Dosage of 0.10 U/kg in 500mls of normal saline to
run over 8 hours
– Check blood glucose hourly initially; if no
reduction in first hour, rate of insulin infusion
should be increased
– Aim for fall in blood glucose of 3-6 mmol/L
(approximately 55-110 mg/dL) per hour.
 Electrolyte
• Potassium:
Potassium levels should be checked after 2 hours, and at 4,8,12,16 and
24 hours until transfer to subcutaneous insulin.
– Do not administer potassium if serum potassium >5.5 mEq/L or
patient is anuric.
– . Potassium infusion should be initiated together with insulin even if
blood potassium levels are normal.
 ONCE DKA RESOLVED…
• Most patients require 0.5-0.75 units/kg/day
• Highly insulin resistant patients –
– 0.8-1.0 units/kg/day
• Give subcutaneous short acting insulin at
least 1- 2 hours prior to weaning insulin
infusion
THANK YOU