Diabetes Mellitus is a chronic metabolic disease, characterized by high levels of glucose in the blood, as a result of alterations in the production and action of the hormone known as insulin.
Insulin is responsible for facilitating the passage of glucose to the tissues, therefore, reducing blood glucose levels (glycemia), thus avoiding the repercussions of the rise in blood glucose. Among the complications of the alterations are: diabetic retinopathy, renal alterations, hyperglycemic hyperosmolar state, diabetic ketoacidosis, among others.
The DKA, is one of the most severe complications of diabetes, because their impact can endanger life within hours. The DKA is a secondary metabolic state end to insulin deficiency, leading to a metabolic pathway of fatty acid degradation that produces metabolites side called ketones, that the accumulated decreases blood pH and creates a state of metabolic acidosis and multi-organ failure.
Symptoms of diabetic ketoacidosis.
The signs and symptoms include clinical manifestations that occur with diabetes but that are mostly accentuated and generate a greater state of dehydration, such as:
- Increased frequency of urination.
- Increase in fluid intake, secondary to the feeling of thirst.
- Increase in food intake.
- Weight loss.
Once a state of decompensation of diabetes has been reached, symptoms such as the following may occur:
- Nausea and vomiting, which rapidly increase the state of dehydration and acidosis.
- General weakness.
- Altered mental state (confusion, lethargy, drowsiness, stupor, coma, depending on the severity of ketoacidosis).
- Ketone breath (characteristic apple-like odor).
- Hyperventilation with Kussmaul breathing.
- Abdominal pain can be caused by ketosis itself, but it must be borne in mind that an abdominal pathology can be the main cause of ketoacidosis. Therefore, it is necessary to determine and rule out whether the true cause of the alteration is of gastrointestinal origin, after hydrating the patient and correcting the metabolic alteration.
- Signs of dehydration (dry oral mucosa, decreased or absent urine volume in 24 hours, hypotension, etc.).
Treatment of diabetic ketoacidosis.
Treatment, first of all, will depend on the timing of the diagnosis and the capacity of the healthcare center; in addition to the specialized expertise of the doctor, which allows efficient management of diabetic ketoacidosis.
By means of the questioning, physical examination and the pertinent complementary studies that the patient is requested, the ketoacidosis must be determined (especially in the case of patients who are debuting as diabetics), the degree of severity, differential diagnoses and causes of ketoacidosis diabetes such as a severe infection or sepsis, causes of traumatic or immunological origin, among others, which must also be corrected in order to eliminate the underlying cause that generates the clinical picture.
The treatment of diabetic ketoacidosis, once the aforementioned has been taken into account, is based mainly on the correction of the internal environment through the administration of intravenous fluids and insulin.
With regard to insulin, it is used for its suppressive effect on ketone production, and for the reduction of hyperglycemia, which is its main objective in the correction treatment of the existing acid-base balance alteration.
It is managed by continuous infusion pumps or flow regulators based on formulas that are established according to weight and blood glucose levels, thus requiring individualized management according to the requirements of each patient
In the case of fluid replacement, it is important to be clear that patients with diabetic ketoacidosis are severely dehydrated, so initially fluid therapy should be rapid and abundant, as long as there are no mainly cardiovascular contraindications, following a scheme defined according to the weight and in the first hours, allowing adequate maintenance of hydration in later stages.
In the case of pediatric patients, fluid therapy will be dosed using special formulas and hydrations according to the weight and age of the patient. The infusion or replacement of fluids in maintenance will be adjusted depending on the state of recovery of urine production, blood pressure and hydration status of the patient
All conditions that generate an increase in blood sugar should be avoided, including diet, until the hyperglycemic imbalance can be regulated, and the patient improves general conditions and is allowed to start a diet. Likewise, potassium replacement is necessary, because insulin management constitutes a measure that will indirectly decrease potassium blood levels, with the risk of generating cardiovascular risks such as arrhythmias.
Another measure used is the use of bicarbonate, in the case of patients with a pH lower than 7. However, in some treatment guides the use of bicarbonate is controversial, so it will be up to the treating physician to omit or indicate this drug.