学术讨论—糖尿病酮症酸中毒-英文PPT.ppt

Diabetic ketoacidosis(DKA)emergency department of shengjing hospital zhang hong lei第一页，共三十一页。case Mr wang，M，52 years oldchief complaint：polydipsia,polyuria,weakness for1week，vomiting for 10 hourphysical 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/LBUN:15.9mmol/L,Cr:147mmol/LK+:8mmol/L,Na+:118mmol/L,Cl-:80mmol/L,Glu:33mmol/Lurinalysis:ketone:3+,gravity:1.024,glu:4+第二页，共三十一页。problem what is the diagnosiswhat is the reason of hyperkalemia and hyponatremiawhat is the reason of Metabolic acidosishow to dispose the disease if you are the ER doctor on call第三页，共三十一页。Introduction DKA is a syndrome in which insulin deficiency and glucagonexcess combine to produce a hyperglycemic,dehydrated,acidotic patient with profound electrolyte imbalance第四页，共三十一页。PathophysiologyLiverMuscleAdiposetissueGluconeogenesisKetogenesisGlucose UtilizationLipolysisInsulinGlucagonEpinephrineCortisolGrownth hormone第五页，共三十一页。Pathophysiology第六页，共三十一页。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.第七页，共三十一页。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.第八页，共三十一页。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第九页，共三十一页。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第十页，共三十一页。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.第十一页，共三十一页。Diagnostic StrategiesPhysical Examination Typical findings include tachypnea with Kussmauls respiration,tachycardia,frank hypotension,the odor of acetone on the breath,and signs of dehydration第十二页，共三十一页。Diagnostic StrategiesLaboratory 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 orphysical stressors.Treatment is aimed at fluid replacement over the first 24 to 48 hours,insulin replacement,and potassium replacement.第二十八页，共三十一页。keywhat is the diagnosis DKAwhat is the reason of hyperkalemia 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 losseswhat is the reason of Metabolic acidosis Metabolic acidosis with an anion gap is primarily the result of elevated plasma levels of acetoacetate and-hydroxybutyrate,how to dispose the disease if you are the ER doctor on call Treatment is aimed at fluid replacement over the first 24 to 48 hours,insulin replacement,and potassium replacement第二十九页，共三十一页。thanks for attention thanks for attention第三十页，共三十一页。内容(nirng)总结Diabetic ketoacidosis(DKA)。ABG:PH:7.06,PaCO2:12mmHg,PaO2:117mmmHg,HCO3-:3.4mmol/L,Lactate:3.1mmol/L,BE:-24.7mmol/L，AG:34.6mmol/L。K+:8mmol/L,Na+:118mmol/L,Cl-:80mmol/L,Glu:33mmol/L第三十一页，共三十一页。