ketoacidosis - a very very short overview (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
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1 ketoacidosis - a very very short overview (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
2 Outline 1 pathophysiology ketoacid generation 2 clinical presentations acetonaemic vomiting diabetic ketoacidosis, typical course alcoholic ketoacidosis 3 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
3 Outline 1 pathophysiology ketoacid generation 2 clinical presentations acetonaemic vomiting diabetic ketoacidosis, typical course alcoholic ketoacidosis 3 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
4 Outline 1 pathophysiology ketoacid generation 2 clinical presentations acetonaemic vomiting diabetic ketoacidosis, typical course alcoholic ketoacidosis 3 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
5 pathophysiology ketoacid generation Outline 1 pathophysiology ketoacid generation 2 clinical presentations acetonaemic vomiting diabetic ketoacidosis, typical course alcoholic ketoacidosis 3 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
6 pathophysiology ketoacid generation pathophysiology 0 ketone bodies source: (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
7 acetonaemic vomiting Outline 1 pathophysiology ketoacid generation 2 clinical presentations acetonaemic vomiting diabetic ketoacidosis, typical course alcoholic ketoacidosis 3 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
8 acetonaemic vomiting acetonaemic vomiting 1 when your small child simply will not stop vomiting Brandel, Das acetonämische Erbrechen in der Praxis MunchMedWochenschr 1968, 110(45) (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
9 acetonaemic vomiting acetonaemic vomiting 2 when your small child simply will not stop vomiting In a susceptible child anything from a common respiratory infection or even psychological alterations to genetic metabolic illnesses can initiate a vicious cycle of vomiting, starvation metabolism, consequent ketoacidosis and more vomiting. In modern terminology this is better known as cyclic vomiting. (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
10 acetonaemic vomiting acetonaemic vomiting 3 when your small child simply will not stop vomiting Treatment is simple - give glucose and fluids! (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
11 diabetic ketoacidosis, typical course Outline 1 pathophysiology ketoacid generation 2 clinical presentations acetonaemic vomiting diabetic ketoacidosis, typical course alcoholic ketoacidosis 3 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
12 diabetic ketoacidosis, typical course diabetic ketoacidosis 1 a young person in severe distress, the common presentation (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
13 diabetic ketoacidosis, typical course diabetic ketoacidosis 1 a young person in severe distress, the common presentation - polyuria, polydipsia - general weakness - nausea and vomiting - abdominal pain (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
14 diabetic ketoacidosis, typical course diabetic ketoacidosis 2 a young person in severe distress, the common presentation (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
15 diabetic ketoacidosis, typical course diabetic ketoacidosis 2 a young person in severe distress, the common presentation - severe dehydration - circulatory compromise - somnolence, stupor, coma - acetone smell - Kußmaul breathing - pseudoperitonitis - signs and symptoms pointing to another illness triggering ketoacidosis, especially an infection (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
16 diabetic ketoacidosis, typical course diabetic ketoacidosis 3 a young person in severe distress, the common presentation (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
17 diabetic ketoacidosis, typical course diabetic ketoacidosis 3 a young person in severe distress, the common presentation - hyperglycaemia - fluid loss of 10% of body weight - severe losses of Na + and K +, 500 to 1000mmol - hyperosmolarity: 2 ([Na + ] + [K + ]) + [glucose] + [urea] - severe metabolic, unknown anion acidosis - initially often low serum-na and high serum-k values - moderate leukocytosis (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
18 diabetic ketoacidosis, typical course diabetic ketoacidosis 4 typical treatment recommendations (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
19 diabetic ketoacidosis, typical course diabetic ketoacidosis 4 typical treatment recommendations - as ever: ABC - if necessary, secure the airway! - replace fluid losses, typically 2l isotonic crystalloid during the first two hours - be prepared to replace [K + ]-losses, eventually [Mg 2+ ] - continuous insulinadministration - shift to half strength electrolyte fluids and glucose administraton with serum-glucose falling to below 15mmol/l (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
20 diabetic ketoacidosis, typical course diabetic ketoacidosis 5 a typical course in a young adult (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
21 diabetic ketoacidosis, typical course diabetic ketoacidosis 5 a typical course in a young adult (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
22 diabetic ketoacidosis, typical course diabetic ketoacidosis 6 DKA cases during one year at Central Hospital Skaraborg, Skövde, 2004/2005 (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
23 diabetic ketoacidosis, typical course diabetic ketoacidosis 7 DKA cases during one year at Central Hospital Skaraborg, Skövde, 2004/2005 (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
24 Outline 1 pathophysiology ketoacid generation 2 clinical presentations acetonaemic vomiting diabetic ketoacidosis, typical course alcoholic ketoacidosis 3 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
25 diabetic ketoacidosis 14 when all goes wrong in a young adult (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
26 diabetic ketoacidosis 14 when all goes wrong in a young adult a young adult with known type 1 diabetes mellitus impulsive behaviour, in an angry fit just ignores her insulin needs admitted with severe diabetic ketoacidosis (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
27 diabetic ketoacidosis 14 when all goes wrong in a young adult a young adult with known type 1 diabetes mellitus impulsive behaviour, in an angry fit just ignores her insulin needs admitted with severe diabetic ketoacidosis (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
28 diabetic ketoacidosis 15 when all goes wrong in a young adult (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
29 diabetic ketoacidosis 15 when all goes wrong in a young adult slow resolution of the ketoacidotic derangement no resolution of the hyperchloraemic component increasingly inadequate respiratory response 10 hours after admission to ICU severe vomiting, aspiration, respiratory and cardiac arrest severe persistent central nervous damage inspite of CPR in an ICU environment (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
30 diabetic ketoacidosis 16 comorbidity and atypical presentations in the ageing diabetic patient (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
31 diabetic ketoacidosis 16 comorbidity and atypical presentations in the ageing diabetic patient a 57 year old lady at six in the morning (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
32 diabetic ketoacidosis 16 comorbidity and atypical presentations in the ageing diabetic patient a 57 year old lady at six in the morning 40 years of type 1 diabetes mellitus injects insulin only once daily nausea and vomiting for a whole day refuses to get medical attention, her husband finally manages to drive her to hospital walks through the door, becomes restless anaesthesiologist immediately contacted and present (me... ) 15 minutes after walking in, severe bradacardia and circulatory arrest (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
33 diabetic ketoacidosis 17 comorbidity and atypical presentations in the ageing diabetic patient (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
34 diabetic ketoacidosis 17 comorbidity and atypical presentations in the ageing diabetic patient ABC! - intubation, ventilation, adrenalin, fluids first blood gas analysis: ph 6.86, SBE -27mEq/l, PCO 2 5kPa (38mmHg) Ringerś solution and trometamol- Na-bicarbonate given (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
35 diabetic ketoacidosis 22 a dreaded complication in paediatric cases: cerebral oedema (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
36 diabetic ketoacidosis 22 a dreaded complication in paediatric cases: cerebral oedema Cerebral oedema is reported to be the leading cause of paediatric mortality due to diabetic ketoacidosis, affecting about 1% of all cases 61 of 6977 hospital patients with DKA had clinically apparent cerebral oedema, with 13 of 15 deaths occuring in this group. Glaser N, Barnet P, Mccaslin I, Nelson D, Trainor J, Louie J, Kaufman F, Quayle K, Roback M, Malley R, Kuppermann N Risk factors for cerebral edema in children with diabetic ketoacidosis, NEnglJMed 2001, 344:264-9 (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
37 diabetic ketoacidosis 23 a dreaded complication in paediatric cases: cerebral oedema (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
38 diabetic ketoacidosis 23 a dreaded complication in paediatric cases: cerebral oedema Risk factors associated with cerebral edema would be: age inferior to 5, recent DM diagnosis, long-standing symptoms, hypocapnia, severe acidosis, bicarbonate treatment for acidosis, excessive volume replacement in the first 4 hours and insulin administration in the first hour of fluid replacement Wolfsdorf JI, Craig ME, Daneman D, Dunger D, Edge JA, Lee WRW, Rosenbloom A, Sperling MA, Hanas R ISPAD Clinical Practice Consensus Guidelines Diabetic Ketoacidosis Pediatric Diabetes 2007, 8:28-43 (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
39 diabetic ketoacidosis 24 a dreaded complication in paediatric cases: cerebral oedema MRI imageing, though, suggests vasogenic oedema due to ischaemia as the pathogenetic mechanism initiating cerebral oedema. (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
40 alcoholic ketoacidosis Outline 1 pathophysiology ketoacid generation 2 clinical presentations acetonaemic vomiting diabetic ketoacidosis, typical course alcoholic ketoacidosis 3 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
41 alcoholic ketoacidosis alcoholic ketoacidosis 1 when the stomach just will not take more ethanol (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
42 alcoholic ketoacidosis alcoholic ketoacidosis 1 when the stomach just will not take more ethanol (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
43 alcoholic ketoacidosis alcoholic ketoacidosis 2 when the stomach just will not take more ethanol As in the small child with cyclic vomiting, these patients are caught in a vicious circle of vomiting, starvation metabolism and more vomiting. As with the paediatric patients, the decisive point is recognising this clinical presentation. (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
44 good bye conflicts of interest Outline 1 pathophysiology ketoacid generation 2 clinical presentations acetonaemic vomiting diabetic ketoacidosis, typical course alcoholic ketoacidosis 3 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
45 good bye conflicts of interest conflicts of interest my two conflicts of interest! (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
46 good bye conflicts of interest conflicts of interest my two conflicts of interest! (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
47 good bye conflicts of interest conflicts of interest my two conflicts of interest! (ICU, Herlev Hospital, Copenhagen) ketoacidosis Fem Minutter uge / 29
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