Diabetic ketoacidosis coma: diagnosis and aggressive treatment

2021-07-31 10:45 PM

Diabetic ketoacidosis, which is the result of severe insulin deficiency, due to the patient's discontinuation or reduction of insulin dose, infection, myocardial infarction

Diabetic ketoacidosis includes a group of diabetic syndromes characterized by severe beta-cell dysfunction and an altered clinical course. These syndromes do not fit into the traditional types of diabetes defined by the American Diabetes Association (ADA). To date, efforts to differentiate patients with ketoacidosis into clinically distinct subgroups have resulted in four different classification schemes: the ADA system, the modified ADA system, and the ADA-based system. on the body mass index (BMI) and the Aß system (based on the presence or absence of autoantibodies and the presence or absence of beta reserve cell function).

In a longitudinal study comparing four classification schemes for accuracy and predictive value, the Aß system was shown to be the most accurate in predicting long-term insulin dependence 12 months after the index of acidosis. ketones, with 99% sensitivity and 96% specificity.

Diabetic ketoacidosis is the result of severe insulin deficiency. This complication is common in patients with insulin-dependent diabetes. Common causes are patients stopping or reducing the dose of insulin they are taking, infection, myocardial infarction ...

Definite diagnosis

Clinical symptoms

Disturbance of consciousness of varying degrees, ranging from arousal to a deep coma.

Nausea, vomiting, abdominal pain and hyperventilation (rapid and deep breathing, Kussmaul breathing).

Signs of dehydration: dry skin, decreased skin elasticity, dry mucous membranes, little urine output, hypotension, or shock.

Clinical manifestations of decompensated factors: respiratory and urinary infections...

Subclinical symptoms

Hyperglycemia: common in the range: 14mmol/l < blood glucose < 44mmol/l.

Arterial blood gases: metabolic acidosis with increased anion gap.

Blood ketones, positive urine ketones.

Hypokalemia.

Diagnosing the decompensated cause of diabetic ketoacidosis

Infection.

Non-compliance with treatment regimen (stop or decrease insulin dose).

Failure to adhere to a diabetic diet.

Prolonged stress.

Acute myocardial infarction, cerebrovascular accident.

Differential diagnosis

Table of Differentiate between diabetic ketoacidosis and hyperosmolar coma

* Estimated osmotic pressure = 2 x [(sodium (mmol/l)] + glucose (mmol/l)] Anion gap = (Na+) - (Cl- + HCO3-)

The principles of treatment

Life function control (ABC steps).

Aggressive potassium compensation, even in the absence of hypokalemia.

Monitor capillary blood sugar every 1 hour until the patient is stable, do every 3 hours to adjust the insulin dose. Electrolyte test every 6 hours, arterial blood gas every 12 hours until the patient is stable.

Diagnosis and treatment of the cause

Fluid compensation

If there is hypotension: isotonic saline, fast infusion rate (500ml/15 minutes), ensure central venous pressure 10-12cm of water.

Isotonic saline infusion of 15-20ml/kg/hour, if heart failure is not present, in the first few hours for patients who are hypovolemic but not in shock.

After the adequate circulating volume has been compensated:

+ Infuse sodium chloride 0.45% 4-14ml/kg/hour if sodium correction is normal or elevated.

Continue isotonic sodium infusion if corrected sodium is decreased.

+ Infuse more sugar when blood sugar is 10mmol/l).

Compensate potassium

If baseline potassium concentration is < 3.5 mmol/l, maintain insulin and intravenous infusion of 20 - 30 mmol/h until potassium concentration is > 3.5 mmol/l.

- If the initial potassium concentration is between 3.5 - 5.3mmol/l, intravenous fluids containing potassium phase 20mmol/l should be infused to ensure the serum potassium concentration is between 4 - 5mmol/l.

If baseline potassium is > 5.3mmol/l, do not compensate for potassium, check serum potassium every 3 hours and monitor ECG continuously.

Insulin

Bolus 0.1 unit/kg followed by a continuous intravenous infusion of 0.1 unit/kg/hour.

Continuous insulin infusion until ketoacidosis clears, blood glucose < 11mmol/l and switch to subcutaneous insulin.

Infusion of bicarbonate to patients with pH < 7.00

If the pH is between 6.9 and 7.0, infuse 250ml of 1.4% sodium bicarbonate solution over 2 hours.

If pH < 6.9, infuse 500 ml of 1.4% sodium bicarbonate solution over 2 hours.

Then repeat the arterial blood pH test.

Treat the cause of decompensation

Appropriate antibiotics, specific to the clinical situation.

Anticoagulation depends on the diagnosis.

Prevention

Diabetic patients must be closely monitored for disease progression, complete periodic medical examination, and change the dosage of treatment drugs depending on the patient's progress.

Examination, detection, and treatment of comorbidities such as infections, cardiovascular diseases.

Guide and advise patients not to give up treatment and have the most reasonable diet.