Diabetic ketoacidosis – the dekompensirovanny form of diabetes proceeding with increase in level of glucose and ketone bodies in blood. It is characterized by thirst, the strengthened urination, dryness of skin, an acetone smell from a mouth, belly-aches. From TsNS emergence of headaches, block, irritability, drowsiness, slackness is noted. Ketoacidosis is diagnosed according to biochemical blood test and urine (glucose, electrolytes, ketone bodies, BRAIDS). A basis of treatment are insulin therapy, rehydration actions and correction of pathological changes in electrolytic exchange.
Diabetic ketoacidosis (DKA) – the sharp failure of mechanisms of regulation of a metabolism at patients with diabetes which is followed by a hyperglycemia and a ketonemiya. Is one of the complications of the diabetes (D) which are most often met in endocrinology. Is registered approximately in 5-8 cases on 1000 patients with SD of 1 type in a year, it is directly connected with quality of delivery of health care by sick diabetes. Mortality from a ketoatsidotichesky coma fluctuates within 0,5-5% and depends on the present of hospitalization of the patient in a hospital. Generally this complication occurs at people up to 30 years.
Reasons of diabetic ketoacidosis
Acts as the reason of development of a sharp decompensation absolute (at diabetes of 1 type) or expressed relative (at diabetes 2 types) insulin insufficiency. Ketoacidosis can be one of options of a demonstration of SD of 1 type at the patients who are not knowing about the diagnosis and not receiving therapy. If the patient already receives treatment concerning SD, the reasons for development of ketoacidosis can become:
- Inadequate therapy. Includes cases of the wrong selection of an optimum dosage of insulin, the untimely translation of the patient from the tableted antihyperglycemic medicines on hormone injections, malfunction of an insulin pomp or the syringe handle.
- Non-compliance with recommendations of the doctor. Diabetic ketoacidosis can arise if the patient incorrectly corrects an insulin dosage depending on glycemia level. Pathology develops when using the expired medicines which lost the medicinal properties, independent decrease in a dosage, unauthorized replacement of injections with tablets or full refusal of antihyperglycemic therapy.
- Sharp increase of need for insulin. Usually accompanies such states as pregnancy, a stress (especially at teenagers), the injuries, infectious and inflammatory diseases, heart attacks and strokes accompanying pathology of an endocrine origin (an akromegaliya, Cushing's syndrome, etc.), surgical interventions. Use of some medicines because of which glucose level increases in blood can be the cause of ketoacidosis (for example, glucocorticosteroids).
In a quarter of cases authentically it is not possible to establish the reason. Development of a complication does not manage to be connected with one of provocative factors.
The main role in pathogenesis of diabetic ketoacidosis is assigned to a lack of insulin. Without it glucose cannot be utilized owing to what there is a situation called by "hunger among abundance". That is glucose in an organism is enough, but its use is impossible. In parallel there is an emission in blood of such hormones as adrenaline, cortisol, STG, a glucagon, AKTG which only strengthen gluconeogenesis, increasing concentration of carbohydrates in blood even stronger. As soon as there is excess of a kidney threshold, glucose comes to urine and begins to be removed from an organism, and together with it a considerable part of liquid and electrolytes is removed.
Because of a condensation of blood the fabric hypoxia develops. It provokes activation of glycolysis on an anaerobic way because of what the maintenance of a lactate increases in blood. Because of impossibility of its utilization lactateacidosis is formed. Kontrinsulyarny hormones start process of a lipoliz. A large amount of the fatty acids acting as an alternative power source comes to a liver. Ketone bodies are formed of them. At dissociation of ketone bodies acidosis of metabolic type develops.
On weight of a current diabetic ketoacidosis is divided into three degrees. As evaluation criteria serve laboratory indicators and existence or lack of consciousness at the patient.
- Easy degree. Glucose of plasma of 13-15 mmol/l, pH of arterial blood ranging from 7,25 to 7,3. Serumal bicarbonate from 15 to 18 ¼Ý¬ó/l. Existence of ketone bodies in the analysis of urine and serum of blood +. Anionny difference higher than 10. There are no violations of consciousness.
- Average degree. Plasma glucose within 16-19 mmol/l. Range of acidity of arterial blood from 7,0 to 7,24. Serumal bicarbonate - 10-15 ¼Ý¬ó/l. Ketone bodies in urine, blood serum ++. Violations of consciousness are absent or drowsiness is noted. Anionny difference of more than 12.
- Heavy degree. Glucose of plasma is higher than 20 mmol/l. Indicator of acidity of arterial blood less than 7,0. Serumal bicarbonate of less than 10 ¼Ý¬ó/l. Ketone bodies in urine and serum of blood +++. The Anionny difference exceeds 14. There are violations of consciousness in the form of a sopor or a coma.
Symptoms of diabetic ketoacidosis
Sudden development is not characteristic of DKA. Symptoms of pathology are usually formed within several days, their development during the period is in exceptional cases possible till 24 o'clock. Ketoacidosis at diabetes passes stages of a prekoma, the beginning ketoatsidotichesky coma and a full ketoatsidotichesky coma.
The first complaints of the patient confirming a condition of a prekoma are unquenchable thirst, a frequent urination. The patient is disturbed by dryness of integuments, their peeling, unpleasant feeling of tightness of skin. When drying mucous membranes complaints to burning and an itch in a nose appear. If ketoacidosis is formed for a long time, strong loss of weight is possible. Weakness, fatigue, loss of working capacity and appetite are characteristic complaints for the patients who are in a condition of a prekoma.
The beginning ketoatsidotichesky coma is followed by nausea and attacks of vomiting which do not give relief. Emergence of belly-aches is possible (pseudo-peritonitis). The headache, irritability, drowsiness, block demonstrate involvement in pathological process of TsNS. Survey of the patient allows to establish existence of an acetone smell from a mouth and a specific respiratory rhythm (Kussmaul's breath). Tachycardia and arterial hypotension are noted. The full ketoatsidotichesky coma is accompanied by consciousness loss, decrease or total absence of reflexes, the expressed dehydration.
Diabetic ketoacidosis can lead to development of hypostasis of lungs (generally owing to incorrectly picked up infusional therapy). Arterial thromboses of various localization as a result of excessive loss of liquid and increase in viscosity of blood are possible. In rare instances brain hypostasis develops (generally occurs at children, often terminates letalno). Because of decrease in volume of the circulating blood shock reactions are formed (their development is promoted by the acidosis accompanying a myocardial infarction). At long stay in a coma it is impossible to exclude accession of a secondary infection, most often in the form of pneumonia.
Diagnosis of ketoacidosis at SD can present to complexity. Patients with peritonitis symptoms, nausea and vomiting often get not in endocrinological, and to surgical offices. To avoid non-core hospitalization of the patient, the following diagnostic events are held:
- Consultation of the endocrinologist or diabetolog. On reception the expert estimates the general condition of the patient if consciousness is kept, specifies complaints. Primary survey gives information on dehydration of integuments and visible mucous, decrease in turgor of soft fabrics, existence of an abdominal syndrome. At survey hypotonia, consciousness violation signs (drowsiness, block, complaints to headaches), an acetone smell, Kussmaul's breath comes to light.
- Laboratory researches. At ketoacidosis concentration of glucose in blood plasma is higher than 13 mmol/l. In urine of the patient existence of ketone bodies and a glucosuria is defined (diagnostics is carried out with use of special test strips). At blood test decrease in an acid indicator (less than 7,25), a giponatriyemiya (less than 135 mmol/l) and a gipokaliyemiya (less than 3,5 mmol/l), a hypercholesterolemia (more than 5,2 mmol/l), increase in osmolarity of plasma (more than 300 ¼«ß¼/kg), increase in an anion difference comes to light.
The ECG is important for an exception of a myocardial infarction to which they can lead electrolytic violations. The X-ray analysis of a thorax is necessary for an exception of secondary infectious damage of airways. Differential diagnostics of a diabetic ketoatsidotichesky coma is carried out with a lactic coma, a hypoglycemic coma, uraemia. Difdiagnostika with a giperosmolyarny coma seldom has clinical value as the principles of treatment of patients are similar. If bystry establishment of the reason of loss of consciousness at patients with diabetes is impossible, glucose introduction is recommended to stop a hypoglycemia which meets much more often. Bystry improvement or deterioration in a condition of the person against the background of introduction of glucose allows to establish the consciousness loss reason.
Treatment of diabetic ketoacidosis
Treatment of a ketoatsidotichesky state is carried out only in the conditions of a hospital, at development of a coma - in the conditions of chamber of intensive therapy. The bed rest is recommended. Therapy consists of the following components:
- Insulin therapy. Correction of a dose of hormone or selection of an optimum dosage at initially revealed diabetes is obligatory. Treatment has to be followed by constant control of level of a glycemia and a ketonemiya.
- Infusional therapy. About three main directions are carried out: regidratation, correction of BRAIDS and electrolytic violations. Use intravenous administration of chloride of sodium, medicines of potassium, a sodium hydrocarbonate. The early beginning is recommended. The amount of the entered solution calculates taking into account age and the general condition of the patient.
- Treatment of the accompanying pathologies. Can aggravate a condition of the patient with DKA the accompanying heart attack, a stroke, infectious diseases. For treatment of infectious complications antibiotic treatment is shown, at suspicion on vascular accidents – thrombolytic therapy.
- Monitoring of the vital indicators. The constant electrocardiography, a pulsoksimetriya, assessment of level of glucose and ketone bodies is carried out. Originally monitoring each 30-60 minutes, and after improvement of a condition of the patient spend each 2-4 hours within the next days.
Today the developments directed to decrease in probability of development of DKA in patients with diabetes are conducted (insulin medicines in the tableted forms are developed, ways of delivery of medicine in an organism are improved, search of methods which would allow to restore own production of hormone is conducted).
Forecast and prevention
At timely and effective therapy in the conditions of a hospital ketoacidosis manages to be stopped, the forecast favorable. At a delay of delivery of health care pathology quickly passes into a coma. The lethality makes 5%, and at patients 60 years - to 20% are aged more senior.
The basis of prevention of ketoacidosis is a training of the patients suffering from diabetes. Patients have to be acquainted with complication symptomatology, are informed on need of the correct use of insulin and devices for its introduction, trained in bases of control over glucose level in blood. The person has to be most informed on the disease. Maintaining a healthy lifestyle and observance of the diet which is picked up by the endocrinologist is recommended. If the symptomatology inherent in diabetic ketoacidosis develops, it is necessary to see doctors to avoid negative consequences.