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Diabetic Ketoacidosis (Management (Circulation (Fluid resus (Osmotic…
Diabetic Ketoacidosis
Management
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Breathing
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May fatigue, aim low C02 if mech vent
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Circulation
IV access, ART line for repeated blood sampling
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IDC if low GCS, very ill, young
Disability
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Glucose management
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Aim initially to cease catabolism with more gradual return to normoglycaemia (monitor urine/blood ketones for catabolism)
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Likely require glucose replacement as well (5% Dex) as BSL falls, aim adequate insulin replacement without hypoglycaemia
Electrolytes
Potassium replacement, particularly as rehydrate and insulin therapy, usually post initial fluid bolus
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No evidence for Bicarb for acidosis (increased risk cerebral oedema, paradoxical CNS acidosis and prolonged hospital stay)
Ongoing management
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Appropriate environment, probably HDU/ICU for hourly BSL, ketones, ABG, titration of insulin infusion, K+ replacement, fluid resus
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Investigating causes
Septic workup (blood cultures, urine cultures), consider Abx
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Exclude other physiological stressors: AMI, pancreatitis
For new patients: additional autoimmune screen (thyroid, coeliac)
Definitions
Endocrine/metabolic disorder due to lack of insulin. Glucose cannot be utilised so ketogenesis occurs for energy substrates in heart and kidney
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Assessment of severity
Clinical
GCS - possibly reduced secondary to: inability to utilise glucose, acidaemia, hypocarbia, fatigue, cerebral oedema
Hydration status: Severe (>7% - poor perfusion, tachycardia, hypotension)
Biochemical
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UEC
Appear Hyperkalaemic (H+ exchange for K+) but will be whole body K+ deplete (renal losses and dehydration). Requires repeated monitoring
Hyponatraemia common from renal losses (compensation for hyperglycaemia). Avoid rapid changes in Na+
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ABG
Expect metabolic acidosis (keto/lactate) with resp compensation (low Bicarb, low C02)
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