diabetic ketoacidosis management - thd internal medicine ：糖尿病酮症酸中毒的管理- thd内科

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1、DiabeticKetoacidosisManagementHeidiChamberlainShea,MDEndocrineAssociatesofDallasGoalsofDiscussionPathophysiologyofDKABiochemicalcriteriaforDKATreatmentofDKAPreventionofDKAHyperosmolarNonketoicSyndromeEpidemiologyAnnualincidenceinU.S.5-8per1000diabeticsubjects2.8%ofalldiabeticadmissionsared

2、uetoDKAOverallmortalityraterangesfrom2-10%HigherisolderpatientsDKAPrecipitatingFactorsFailuretotakeinsulinFailuretoincreaseinsulinIllness/InfectionPneumoniaMIStrokeAcutestressTraumaEmotionalMedicalStressCounterregulatoryhormonesOpposeinsulinStimulateglucagonreleaseHypovolmemiaIncreasesgluc

3、agonandcatecholaminesDecreasedrenalbloodflowDecreasesglucagondegradationbythekidneyDiabeticKetoacidosisDueto:SevereinsulindeficiencyExcesscounterregulatoryhormonesGlucagonEpinephrineCortisolGrowthhormoneRoleofInsulinRequiredfortransportofglucoseintoMuscleAdiposeLiverInhibitslipolysisAbsenc

4、eofinsulinGlucoseaccumulatesinthebloodLiverUsesaminoacidsforgluconeogenesisConvertsfattyacidsintoketonebodiesAcetone,Acetoacetate,β-hydroxybutyrateIncreasedcounterregulatoryhormonesCounterregulatoryHormones-DKAIncreasesinsulinresistanceActivatesglycogenolysisandgluconeogenesisActivateslipo

5、lysisInhibitsinsulinsecretionEpinephrineXXXXGlucagonXCortisolXXGrowthHormoneXXXInsulinDeficiencyGlucoseuptakeProteolysisLipolysisAminoAcidsGlycerolFreeFattyAcidsGluconeogenesisGlycogenolysisHyperglycemiaKetogenesisAcidosisOsmoticdiuresisDehydrationSignsandSymptomsofDKAPolyuria,polydipsiaEn

6、uresisDehydrationTachycardiaOrthostasisAbdominalpainNauseaVomitingFruitybreathAcetoneKussmaulbreathingMentalstatuschangesCombativeDrunkComaLabFindingsHyperglycemiaAniongapacidosis(Na+K)–(Cl+Bicarb)>12Bicarbonate<15mEq/LpH<7.3UrineketonesandserumketonesHyperosmolarityDifferentialDiagnosisA

7、nionGapAcidosisAlcoholicketoacidosisLacticacidosisRenalfailureEthyleneglycolormethylalcoholpoisoningStarvationinlatepregnancyorlactation(rare)AtypicalPresentationsDKAcanbepresentwithBS<300ImpairedgluconeogenesisLiverdiseaseAcutealcoholingestionProlongedfasting