ࡱ> _^ +( / 0DArial04 VȷȷԳ0 0DTimes New RomanȷȷԳ0 0 DWingdingsRomanȷȷԳ0 0   @n?" dd@  @@`` vn;d     HG   fAA1?@81 g42d2d 0 ppp@ ^___PPT9@8 0___PPT10 pp?  %$(A patient with  flu Shona McIntyre December 2003 The Patient J. P. 20 years old student Asian, living with sister and brother-in-law Type I diabetic (diagnosed 2 years ago) On Humalog 30 40 units twice a daytPresenting complaint999 attendance One day of: headaches - generalised ache total body aches runny nose, sore throat no features of meningism due to go on holiday the following dayp ( on examinationw Pulse 85, BP 144/85, Temp 36.7 BM 11.1 chest clear hear sounds I + II + 0 soft, non tender abdomen ears and throat NAD Xx What happened next:I said she probably had flu She became angry She insisted she needed admission Said her BM this morning had been 35 and high yesterday I agreed to do a venous gas   and then:She started crying and told me: Self discharged from ward 35 2/52 ago parents disowned her, she wants to die Hasn t checked her BMs since discharge Brother in law phoned the ambulance as concerned she looked unwell Has not taken her insulin for 2 weeks& Venous blood gasBpH 7.127 bicarb 9.9 BE -19.1 Na 134, K 4.23 DIABETIC KETOACIDOSIS,C 4   management TCI d General Medicine IV fluids IV Sliding scale Deliberate self harm team Blood glucose 11.8 Urine: ketones +++ glucose ++Z$cDiabetic Ketoacidosis _can you have DKA with blood glucose in the normal range? How should we be managing DKA in A&E?Euglycaemic ketoacidosis$  4Normal DKA mechanism: less insulin -> increased hepatic glucose production and reduced peripheral glucose uptake increased glucose-> glycosuria, osmotic diuresis ketones produced ->acidosis, vomiting both-> fluid and electrolyte depletion-> decreased renal perfusion -> impaired ketone and hydrogen excretion&P  n  What happens in euglycaemic DKA? Defined as blood glucose less than 16.7mmol/l and bicarb less than 10mmol/l Uncommon but recognised Cause unknown: Increased urinary loss of glucose triggered by hormone counter-regulation Decreased hepatic production of glucose as in a  fasted state 6ss2 Management of DKAbFluid replacement Insulin therapy Electrolyte balance Anticoagulation Finding a cause Monitoring (acLiterature used3 main reviews: Chiasson et al. Diagnosis and treatment of diabetic ketoacidosis and the hyperglycaemic hyperosmolar state. Canadian Medical Association Journal. Apr 2003;168(7):859-866 Kitabchi et al. Management of hyperglycaemic crises in patients with diabetes. Diabetes Care. Jan 2001; 24(1):131-153 Simpson. Diabetes and intensive care- medical management. Care of the Critically Ill. Dec 2001; 17(6):194-197 [>>' 05P,  F Fluid ReplacementHospital protocol: Initially normal saline Once glucose <12mmol/l change to 5% Dex 1L bags over: 1,2,4, and then 6 hourly All the literature supports this. BOM Insulin therapy>Hospital protocol: BM(mmol/l) Insulin(U/hour) (regime A) (regime B) <4 0.5 with dex 0.5 with dex 4.1-10.0 2.0 basal rate 10.1-16.0 4.0 base rate x2 >16.0 6.0 base rate x4 Base rate = daily total units/24 Regime A for patients not previously on insulin, Regime B for patients known to be on insulin.<Z,Z7P  1  Literature,Evidence is for iv continuous not im/sc boluses1,2,3 0.15U/kg iv bolus2 then 0.1 U/kg/hour1,2, check glucose hourly. If not fallen by >3mmol/l double insulin infusion hourly1,2 until glucose falls 3mmol in an hour. 3BM <2 stop for 30mins and repeat BM BM 2-4 4.1-7 7.1-11 >11 U/hr 1 2 4 60/   Q ' T" Electrolyte replacementKHospital protocol: Potassium Venous K+ K+ in IV fluid <3.6 40mmol KCl/l 3.6-5.0 20mmol KCl/l >5.0 no KCl in fluid Literature: 1,2Venous K+ K+ in IV fluid <3.3 hold insulin, give 40mmol KCl/l until above 3.3 3.3-5.0 20-30mmol/l KCl/l >5.0 no KCl but recheck every 2 hours 3Similar to hospital protocol xP%PCP PPP   C       <  ' tF V2 ; Bicarbonate`Controversial Several studies at medium pH (6.9  7.2) These show no improvement in outcome Risks:hypokalaemia, paradoxical CNS intracellular acidosis, worsening acidosis Unethical to do RCT in severe acidosis Use if : pH <7.0 after 1 hour of Rx and unwell Hospital protocol: SpR or Consultant decision11,^AnticoagulationDHospital guidelines: Only in high risk patients 40mg Clexane sc 8++6Finding a CausevHospital protocol: Blood, urine, sputum cultures CXR ECG Start broad spectrum antibiotics until infection excludedww Monitoring]VENOUS gas at 0 hours Venous bicarb, glucose and potassium at 0,2,4,8,24 hours Act on results;SummaryAlways do your ABC but Don t Ever Forget Glucose Have a low threshold for considering DKA as a possible diagnosis even if BM not high There are hospital guidelines which are easily followed and are supported by the literature/P ` gg3` ___ff3` ffB` 3f33f̙` JHBDXb`ff`  F-"nff` fBDXff33` 9 oVPc}` r!Lf.>?" dd@&?lPd@ F lA@" d` n?" dd@   @@``PR    @ ` `,p>>    _ (  T `y  `y"2 B B"o  x H""  "2 B B"o `x H""  "2 B Bt"o Zy H""  "2 B Bto Gx H""  "2 B B o x H""  "$  0  `  RClick to edit Master text styles Second level Third level Fourth level Fifth level!     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H < 0޽hI ? a(80___PPT10.^rtDH+9JMPTW-ZB]W`beik0n_qsuvx{~pOh+'0  $0 T ` l xA patient with "flu"P paAuthorised Useruthuth Watermark Upaul illingworthlu"4ulMicrosoft PowerPoint 4.0i@ͥA @@L @ GDoM  %& &&#TNPPp0 & TNPP &&TNPP    --- !---&~--I}-- |w|wgw - --I -- --Id-- --Xd-- --OX-- --}X-- &&/& &Gy& --4yH-- Arial y|w|wgw y - .%2 A patient with flu' ! !!+ ! .--)yp-- Arial |w|wgw - .2 EShona. .2  McIntyre $  . .2 @ December 2003# .--"Systemwf  -&TNPP &՜.+,D՜.+,h   On-screen ShowDj ArialTimes New Roman Wingdings WatermarkA patient with flu The Patient Presenting complainton examinationWhat happened next: and then:Venous blood gas managementDiabetic KetoacidosisEuglycaemic ketoacidosis!What happens in euglycaemic DKA?Management of DKALiterature usedFluid ReplacementInsulin therapy LiteratureElectrolyte replacement BicarbonateAnticoagulationFinding a Cause MonitoringSummary  Fonts UsedDesign Template Slide Titles 6> _PID_GUIDAN{59D703EC-6783-11D8-B226-004081094556}(_ paul illingworth  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEGHIJKLMOPQRSTUWXYZ[\]`Root EntrydO)Current UserVSummaryInformation(FPowerPoint Document(DDocumentSummaryInformation8N