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Diabetic Ketoacidosis, LO 3: Physical and Laboratory Result, DKA must be…

- - - - Decrease intake of food with high carbs and fats
        
        Carbohydrate counting method
      - Avoid high GI food
      - replace saturated fats with monounsaturated and polyunsaturated fatty acids
      - Diabetic and meal timing is very crucial
    - - Resistance training, endurance and combined training consisting of both, has been proven to boost glycaemic control and diabetes outcomes in patients with type 1 diabetes
      - Modify the insulin treatment accustomed to the patient based on their extensiveness of their physical activities
      - Educate patient to check their glucose level before and after exercise
      - Wear appropriate shoes and socks to avoid blisters and sore
      - Drink plenty fluids before during and after exercise
    - - Advice patient to check her foot every day
      - Advice patient to always wash her feet everyday with warm water
      - Advice patient to always wear shoes and socks or slippers
      - Trim the nails of the feet in a straight across manner
      - Check up every now and then with a foot doctor
      - Keep moving the leg for better blood circulation
      - Choose a feet-friendly physical activities
  - - - Counselling regarding the medications
        
        Indication
        
        How it works
        
        How to take - dose, frequency, duration, missed dose
        
        Potential side effects
        
        How to use the device
        
        Maintenance
        
        Storage
      - Therapeutic goals
        
        HbA1c: < 5.7%
        
        Blood glucose (fasting): 70-100 mg/dL
        
        Blood glucose (random): <125 mg/dL
      - Counselling regarding the disease
        
        Brief overview on T1DM, DKA
        
        Why insulin is important?
        
        Complications
      - MISC
        
        Signs and symptoms of hypo/hyperglycaemia and course of action to be taken
        
        Self-monitoring: SMBG
        
        Lifestyle modifications: diet, exercise, etc
- - - - Resting Rate
        
        Heart Rate
        
        Blood pH
        
        PaCO2 and HCO3
        
        PaCO2
        Pt Value: 21 mmHg
        Normal Value: 35 - 45 mmHg
        HCO3
        Pt Value: 7.1 mmHg
        Normal Value: 22-29 mmHg
        
        Compensantory mechanism
        
        Relationship states that the pH of blood is proportional to the ratio of bicarbonate concentration to partial pressure of carbon dioxide
        
        Elimination of carbon dioxide through lungs
        
        CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3–
        
        Serum creatinine
        
        Normal value: 0.59 mg/dL - 1.04 mg/dL
        
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        GFR normal value: 90 ml/min - 120 ml/min
        
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        High WBC
        
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        Pt Value: 7.26
        Normal Value: 7.35-7.45
        
        Production of Ketones
        
        Overwhelming buffering system
        
        Yield hydrogen ions
        
        High hydrogen ions = Low Carbon Dioxide
        
        Pt Value: 123 bpm
        Normal Value: 60 - 100 bpm
        Attenuated baroreceptor sensitivity
        
        Hyperventilation may increase HR
        
        Pt Value: 32 bpm
        Normal Value: 12-16 bpm
        Compensatory Mechanism
        
        Increased respiration
        
        Hyperventilating (Kussmaul breathing)
        
        Excretion of carbon dioxide through lungs (low PaCO2)
      - Pt Value: 101/72 mmHg
        Normal Value: 120/80 mmHg
        Polyuria > Hypovolemia > Dehydration > Slight hypotention
        
        DKA may have dehydration secondary to hypovolemia that could lead to a slight hypotension.
  - - - Excess amount of glucose excreted to urine
    - - Excess amount of ketone excreted to urine
  - - - Electrolytes imbalances
        
        Lead to the release of catecholamine
        
        Increase cardiac output
        
        Cause
        
        dehydration
        
        metabolic acidosis
- - - - supplementary bicarbonate therapy is no longer advised in general because insulin therapy raises the plasma bicarbonate concentration
      - If the pH is 6.9 or lower, bicarbonate therapy may be necessary. It is not advised to utilize bicarbonate on patients whose pH levels are higher than 7.0
      - Infusion of 100 mmol (two ampoules) of bicarbonate in 400 mL of sterile water combined with 20 mEq potassium chloride over a period of two hours and repetition of the infusion until the pH is greater than 7.0
    - - Two-thirds of the potassium should be administered as potassium chloride and one-third as potassium phosphate.
    - - If serum potassium levels are between 3.3 and 5.3 mmol/L (this patient : 4.8 mEq/L), small doses of potassium (20-30 mEq/L) are frequently added to intravenous fluids.
      - If potassium levels exceed 5.3 mmol/L, no replacement is required.
      - If serum potassium falls below 3.3 mEq/L during DKA treatment, insulin should be discontinued and potassium given intravenously
  - - - Change to 5% Dextrose in 0.45% saline (NaCl) at 100 to 200 ml/hour with adequate insulin (0.05 to 0.1 units/kg/hour) as IV infusion
- - - - Blurry vision
        
        Thirsty
        
        SOB
        
        Polyuria
        
        All sugar in the urine reabsorbed
        
        Blood glucose high then filtered
        
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        Constrict blood vessels
        
        Reduce flow of accessible blood and oxygen
        
        Reduces flexibility of blood capillaries
        
        Cause them to shrink and restrict blood flow
        
        Decreased flow of blood and oxygen
        
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        Excess kidney builds up in blood
        
        Force kidneys to work overtime to filter blood
        
        Absorb excess glucose
        
        Kidney unable to keep up
        
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        Damage of blood vessels and nerves
        
        Lose fluid
        
        Swelling of the eye lens
        
        Shape of eye's lens altered
      - Blood glucose levels rise and falls
        
        Body metabolism disrupted and confused
    - - Builds up in blood
        
        Glucose cannot enter cells
  - - - Involve family members in type 1
- - - - resolution of DKA
        
        venous blood pH > 7.3
        
        bicarbonate > 18 mEq/L
        
        blood glucose level < 250 mg/dL
        
        patient can resume her daily insulin without DKA recurrence
        
        absence of ketones in urine
        
        anion gap equal or less than 12 mEq/L
  - - - excessive urination
      - fatigue
      - weight loss
    - - target blood sugar
        
        80 - 130 mg/dL before meal
        
        <180 mg/dL after 2 hours of eating
    - - switch insulin infusion to subcutaneous insulin
- - - - Acute Kidney Injury (AKI)
        
        Osmosis diuresis causes glucosuria
        
        worsen dehydration & ultimate decline in renal function
        
        Impaired metabolism of drug
        
        Therefore, needs reassessment of drug (current therapy)
      - Hypoglacemia
        
        AE: Seizure, arrythmia, cardiovascular events
        
        Hourly blood sugar monitoring is necessary in acute phase of treatment
        
        Occur around 5% - 25% of patients with DKA
      - Hypokalemia
        
        Severe: muscle weakness, cardiac arrythmia, cardiac arrest
        
        May cause other electrolyte disturbances (hyperchloremia hypomagnesemia, hyponatremia)
        
        Repletion of magnesium and potassium is needed
      - Hyperventilation
        
        Could mislead diagnosis of pulmonary/cardiac dysfunction
        
        Frequently observed in severe DKA
      - Acute respiratory failure
        
        Factors
        
        ARDS
        
        pulmonary edema
        
        elevated pulmonary venous pressure
        
        increased pulmonary capillary permeability
        
        pneumonia
      - Others
        
        Thrombotic thrombocytopenic purpura (TTP)
        
        A rare blood disorder characterized by clotting in small blood vessels (thromboses)
        
        cause low platelet count
        
        myocarditis
        
        inflammation of the heart muscle (myocardium)
        
        cerebral edema
        
        swelling in the brain
- - - - recommended total daily dose based on weight: 28 to 33.6 units/day
- - - - Insulinopenia
        
        Metabolic abnormalities in liver, fat, and muscle
        
        Secretion of counter-regulatory hormones
        
        ↑ Growth hormone
        
        ↑ Hepatic glycogenolysis and gluconeogenesis
        
        ↑ Blood glucose levels
        (hyperglycemia)
        
        ↓ Peripheral tissue use of glucose
        
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        ↑ osmolality
        
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        Normal condition
        Both of the processes are usually inhibited by insulin
        
        ↑ Cortisol
        
        ↑ Glucagon
        
        ↑ Catecholamines
        
        Hyperketonemia
        
        ↑ Lipolysis
        
        Catecholamines promotes lipolysis
        
        ↑ Free fatty acids and glycerol in adipocytes
        
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