acute effects of diabetes mellitus
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Acute Effects of Diabetes
Mellitus
Hao Xie
01/08/2010
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Causes of Diabetes Mellitus
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Causes of Diabetes Mellitus
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Causes of Diabetes Mellitus
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Acute Effects: Fatty Liver
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Acute Effects: Acidosis/Coma
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Late Complications of Prolonged Hyperglycemia
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DKA
A collection of severe and potentially life-threatening metabolic disturbances:
Hyperglycemia Osmotic diuresis
Urinary loss of fluids & electrolytes
Extracellular fluid volume contraction
Depletion of total body K+ stores
(even though may be hyperkalemic 2 to cell shift)
Ketone productionMetabolic acidosis
Compensatory Respiratory alkalosis (hopefully!)
Uncontrolled lipolysis severe TG
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DKA: Pathophysiology
Glucose
Pyruvate
Acetyl-CoA
Ketoacids
Krebs
+ PFKInsulin
fat cell
TG
FFA
HSL
Liver Cell
Fatty
Acyl-CoA
Insulin -
VLDL (TG)
Glucagon
Insulin
+
+
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DKA: Pathophysiology
Glucose
Pyruvate
Acetyl-CoA
Ketoacids
Krebs
+ PFKInsulin
fat cell
TG
FFA
HSL
Liver Cell
Fatty
Acyl-CoA
Insulin -
VLDL (TG)
Glucagon
Insulin
+
+
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DKA: Potassium
K+ defecit: 3-5 mEq/Kg (350 mEq for 70Kg)
Normal to high serum K+
K+
K+
H+ H+
Ketoacidosis
Insulin
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DKA: Potassium K+ deficit 3-5 mEq/kg (350 mEq 70kg)
Need K+ with initial IV fluid & insulin Rxunless: (normal serum K+: 3.5-5.0 mEq/L)
Anuric
K+
> 5.5 mEq/L or hyperkalemic ECG changes
Initial [K] Replacement
> 5.5 mEq/L nil (initially)
5.2-5.5 mEq/L 10 mEq/h4-5.2 mEq/L 20 mEq/h
3-4 mEq/L 30 mEq/h
< 3 mEq/L 40 mEq/h
> 20 mEq/h:
Cardiac monitor
> 60 mEq/L:Central line
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HONCHyperosmolar Non-Ketotic Coma
T2DM, elderly (mean age 60-73), F > M
Pathogenesis poorly understood
Mild extracellular fluid volume instigatingfactor
Insulin/Glucagon ratio sufficient to limit DKA
Diminished thirst or access to water Vicious cycle develops
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Hyperglycemia
Osmotic Diuresis
Volume Contraction
Pre-renal azotemia
HONC
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HONC: Insulin?
Patients can be treated successfully without insulin
If IV fluids inadequate, blood sugar and serum OSM
will not drop despite insulin
Majority of studies used insulin
Hi-dose Insulin: severe hypokalemia, shock
Therefore if going to use insulin, use low doses:
Bolus 0.1 U/kg, Rate 1-2 U/h (or 0.1 U/kg/h)
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Pathogenesis of DKA & HONC
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References
Silbernagl and Lang, Color Atlas of
Pathophysiology 2000
Kumar, Abbas et al. Robbins and Cotran
Pathologic Basis of Disease
William Harper, M.D. Endocrinology &
Metabolism, McMaster University
Kitabchi et al. Endocrinol Metab Clin N Am 35
(2006) 725751