Diabetic ketoacidosis (DKA) is characterized by an acute onset, dangerous condition, rapid progression, and high misdiagnosis rate, and untimely and irregular treatment may increase the occurrence of cerebral edema, permanent neurological damage, and death.
There are many clinical cases of delayed and inappropriate treatment due to negligence, so let’s talk about the details that need extra attention in the diagnosis and treatment of DKA.
The details of DKA diagnosis should be noted
1. Ask carefully about past medical history and pre-onset conditions
DKA can occur in either type 1 or type 2 diabetes. In type 2 diabetes, DKA is mostly caused by acute infection, inappropriate reduction of insulin or sudden interruption of treatment, improper diet, gastrointestinal disease, stroke, myocardial infarction, trauma, surgery, pregnancy, childbirth, overexertion, mental stimulation, etc.
Therefore, the possibility of DKA should be considered in patients with known diabetes or those who have recently experienced diabetes-like symptoms upon inquiry, especially in patients with recent irregularities, lifestyle changes or stressful conditions.
2. Pay attention to whether there is a rotten apple smell in the breath
The main manifestations of DKA are “three more and one less” symptoms, i.e. increased thirst, excessive drinking, excessive urination, and increased fatigue;
Loss of appetite, nausea, vomiting, often accompanied by headache, irritability, drowsiness and other symptoms, deep and rapid breathing, the smell of rotten apples in the breath (acetone smell);
In the further development of the disease, there is severe water loss, decreased urine output, sunken eyes, dry skin mucosa, decreased blood pressure, rapid and weak pulse, and cold extremities;
In the advanced stage, various reflexes are dulled or even disappeared, and the consciousness is impaired to different degrees, ending in coma.
Among them, the smell of rotten apple in the breath is the characteristic performance of DKA.
3. Pay attention to patients with gastrointestinal symptoms, acute abdomen and other symptoms to avoid misdiagnosis
It is easy to misdiagnose as acute gastroenteritis, intestinal obstruction, acute pancreatitis and other digestive system diseases.
To avoid misdiagnosis, it is recommended to check blood glucose and urine ketone bodies to identify patients with gastrointestinal symptoms and acute abdomen, especially those with combined diabetes mellitus.
4.Think of some special cases of DKA
Some diabetic patients (especially young type 1 diabetic patients) may have DKA as their first manifestation. In order to avoid missing the diagnosis, patients with unexplained nausea, vomiting, acidosis, water loss, shock, coma, especially those with ketone odor (rotten apple smell) in their breath, low blood pressure and high urine output, should think of the possibility of DKA, regardless of their history of diabetes.
5. Know the test contents and diagnostic criteria of DKA
Patients with suspected DKA should immediately check terminal blood glucose, blood gas analysis, urine routine, and blood ketones if available, for early detection of ketosis or DKA.
If urine glucose and ketone bodies are positive with increased blood glucose and decreased blood pH and/or carbon dioxide binding capacity, DKA can be diagnosed regardless of the history of diabetes mellitus.
The increase in blood ketone bodies in DKA is more than 3 mmol/L, and the increase in blood glucose is usually between 16.7 and 33.3 mmol/L, with hyperglycemic hyperosmolarity syndrome or renal dysfunction in excess of 33.3 mmol/L.
The details of DKA treatment should be paid attention to
The standard treatment of DKA includes rehydration, insulin, potassium supplementation, alkaline supplementation and other treatments.
1. Rehydration
The total amount of rehydration fluid is usually estimated at 10% of the body weight before the onset of the disease, and oral rehydration fluid can be given to those with mild dehydration without acidosis.
The rehydration rate should be fast and then slow, with 1000-2000 mL in the first 2 h, 1/3 of the calculated water loss in the first 4 h, and 500-1000 mL every 4-6 h. The total amount of fluid infusion in the first 24 h should be 4000-5000 mL, and up to 6000-8000 mL in severe water loss.
If hypotension or shock exists before treatment and rapid rehydration cannot effectively raise blood pressure, colloid solution should be administered and other anti-shock measures should be used. Encourage drinking water (or saline) to reduce the amount of intravenous rehydration.
Several details of rehydration should be noted.
①The total amount of rehydration fluid should be estimated according to the weight before the onset of the disease;
②Rehydration should be “adequate”, “fast first, then slow”, “salt first, then sugar, crystal first, then colloid”, “oral and intravenous together”;
③Several key values: 10%, 13.9, 1/3;
④Encourage oral rehydration and reduce the amount of intravenous rehydration;
⑤ When blood glucose drops to 13.9 mmol/L, stop using saline and decide to switch to glucose solution or glucose saline solution according to the blood sodium situation.
2.Insulin therapy
Several details of insulin therapy should be noted.
①It is advocated that small doses of continuous intravenous insulin drip, and it is not recommended to push insulin intravenously in one large dose;
②Short-acting human insulin or fast-acting insulin analogues (such as menthol insulin and lypro insulin) should be used, and medium-acting human insulin or long-acting insulin analogues should not be used;
③In severe hypokalemia (<3.3 mmol/L), potassium should be supplemented first, and insulin therapy should be started when the blood potassium rises to 3.5 mmol/L;
④Measure blood glucose regularly and adjust insulin dosage according to the decrease of blood glucose;
⑤ One subcutaneous injection of insulin should be given 1 hour before stopping insulin drip, or the drip should be stopped 1-2 hours after insulin injection before meal;
⑥After the ketone body disappears, blood glucose drops to less than 13.9 mmol/L and the patient can eat regularly, subcutaneous insulin injection can be changed.
3. Potassium supplementation
Several details of potassium supplementation should be noted.
①If the blood potassium is normal and the urine volume is <30 mL/h, potassium supplementation should be suspended and started again after the urine volume increases;
②If blood potassium is higher than normal, potassium supplementation should be withheld;
③Monitoring of blood potassium and urine volume, preferably with cardiac monitoring, to reflect the change of T wave to adjust the concentration and speed of potassium supplementation;
④Potassium enters into the cells slowly, so you should continue to take potassium salt orally for several days after recovery.
4.Alkaline supplementation
Several details of alkaline supplementation should be noted.
① Not all DKA should be supplemented with alkali, only when pH <7.0 should be considered;
②Alkaline supplementation should be less and slower, not too early or too fast;
③If alkaline supplementation is indicated, alkaline supplementation should be stopped when pH>7.0, and excessive supplementation is not recommended to avoid increasing urinary potassium loss, aggravating cerebral edema and tissue hypoxia;
④The solution medium for alkaline supplementation should be water for injection, and saline and glucose (salt) solution should not be used.
5.Other
Including strengthening nursing care, removing causative factors (such as shock, infection, heart failure, cerebral edema, etc.), prevention and treatment of complications and symptomatic support, etc.
It should be noted that.
①Infection is often the cause of DKA, but its clinical manifestations are often masked by the manifestations of DKA, so it cannot be judged by the presence or absence of fever or blood picture alone, and should be actively managed;
(2) DKA is often accompanied by a mild to moderate increase in blood urea nitrogen and creatinine, which is usually prerenal in nature and can decrease with recovery from treatment, and cannot be blindly assumed to have renal impairment;
③Some patients with DKA may have elevated serum amylase and lipase even without pancreatitis, which may decrease to normal within a few days after treatment and do not require special treatment;
④Some patients with DKA may have a transient increase in serum glutamic oxalacetic transaminase and glutamic alanine transaminase, which usually return to normal 2-3 days after treatment and do not require treatment.
Finally, in the clinical diagnosis and treatment of DKA, attention should be paid to avoid some common misunderstandings, such as insufficient rehydration, inappropriate types of infusion, insufficient or excessive insulin, inattention to potassium supplementation, blind alkaline supplementation, failure to control triggers, and neglect of glucose supplementation.