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,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,#,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,#,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,#,D,iabetic ketoacidosis(DKA),emergency department of shengjing hospital zhang hong lei,Diabetic ketoacidosis(DKA)eme,case,Mr wang,，,M,，,52 years old,chief complaint,：,p,olydipsia,polyuria,weakness for1week,，,vomiting for 10 hour,physical 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/L,BUN:15.9mmol/L,Cr:147mmol/L,K+:8mmol/L,Na+:118mmol/L,Cl-:80mmol/L,Glu:33mmol/L,urinalysis:,ketone:3+,gravity:1.024,glu:4+,case Mr wang，M，52 years old,2,problem,what is the diagnosis,what is the reason of hyper,kalemia,and,hyponatremia,what is the reason of,Metabolic acidosis,how to dispose the disease if you are the ER doctor on call,problem what is the diagnosis,3,Introduction,DKA is a syndrome in which,insulin deficiency,and,glucagon,excess,combine to produce a,hyperglycemic,dehydrated,acidotic,patient with profound electrolyte imbalance,Introduction DKA is a,4,Pathophysiology,Liver,Muscle,Adipose,tissue,Gluconeogenesis,Ketogenesis,Glucose Utilization,Lipolysis,Insulin,Glucagon,Epinephrine,Cortisol,Grownth hormone,PathophysiologyLiverMuscleAdip,5,Pathophysiology,Pathophysiology,6,Pathophysiology,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 circulation 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 stores.,Pathophysiology Insulin d,7,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 alteration 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 Insulin d,8,Pathophysiology,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 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.,The acidosis cause the body to increase lung ventilation and rid the body of excess acid with,Kussmauls respiration,Pathophysiology,9,Etiology,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 occur in type 2 patients and may be associated with any type of stress,such as sepsis or gastrointestinal(GI)bleeding,Etiology DKA may be c,10,Diagnostic Strategies,History,Clinically,most patients with DKA complain of a recent history of polydipsia,polyuria,polyphagia,visual blurring,weakness,weight loss,nausea,vomiting,and abdominal pain.,Diagnostic Strategies History,11,Diagnostic Strategies,Physical Examination,Typical findings include tachypnea with Kussmauls respiration,tachycardia,frank hypotension,the odor of acetone on the breath,and signs of dehydration,Diagnostic StrategiesPhysical,12,Diagnostic Strategies,Laboratory 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,7.3).,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 or,physical stressors.,Treatment is aimed at fluid replacement over the first 24 to 48 hours,insulin replacement,and potassium replacement.,Summary Diabetic Ketoaci,28,key,what is the diagnosis,DKA,what is the reason of hyper,kalemia,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-poor fluid intake;and increased GI,renal,and insensible losses,what is the reason of,Metabolic acidosi,s,Metabolic acidosis with an anion gap is primarily the result of elevat
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