Diabetic ketoacidosis

Introduction Diabetic ketoacidosis refers to the obvious deficiency of insulin under the influence of various incentives in diabetic patients, and the abnormal growth of raw sugar hormones, resulting in hyperglycemia, high blood ketone, ketonuria, dehydration, electrolyte imbalance, metabolic acidosis, etc. Symptoms of pathological changes are one of the common emergencies in internal medicine. This disease is mainly caused by disorder of glucose metabolism, excessive production of ketone bodies in the body, resulting in a decrease in the concentration of HCO3- in the blood. When decompensation, the blood pH drops, causing acidosis. The clinical manifestations are characterized by acute onset, serious illness and rapid changes.

Cause

The main causes of DKA are infection, improper diet or treatment, and various stress factors. DKA can be used as a first-episode patient in patients with type 1 diabetes who are untreated and whose condition progresses rapidly, especially in children or adolescents.

Acute infection

It is an important cause of DKA, including respiratory, urinary and skin infections, and has a high incidence in winter and spring. Acute infection can be a complication of DKA, which is a cause and effect with DKA, forming a vicious circle and increasing the complexity of diagnosis and treatment.

2. Improper treatment

Such as discontinuation of drugs (especially insulin) treatment, insufficient drug and drug resistance. In particular, patients with type 1 diabetes who discontinue or reduce the dose of insulin therapy often cause DKA. Patients with type 2 diabetes have long-term large doses of phenformin, especially when liver and kidney function are poor, and DKA is also induced. High-dose thiazide diuretics have also been reported. In recent years, some patients have convinced that there is no definitive treatment or "drug", and they have given up the scientifically recognized regular treatment plan, especially in patients with type 1 diabetes, and even discontinued insulin, which is more likely to induce DKA.

3. Eating out of control and / or gastrointestinal diseases

Such as excessive diet, too sweet (too much sugar) or insufficient, alcohol, or vomiting, diarrhea, etc., can aggravate metabolic disorders and induce DKA.

4. Other stress

Such as severe trauma, anesthesia, surgery, pregnancy, childbirth, mental stimulation, and myocardial infarction or cerebrovascular accidents. The increase in the level of glucosamine caused by stress, the increase in excitability of the sympathetic nervous system, combined with eating disorders, are all likely to induce ketoacidosis.

an examination

Related inspection

Urine glycemic blood glucose anti-insulin antibody anti-insulin receptor antibody pancreatic exocrine function test

Urine check

(1) Urine sugar: often strong positive, but urine sugar decreased or even disappeared when severe renal function decreased.

(2) Urine ketone body: When the kidney function is normal, the ketone body is often strongly positive, but when the renal function is obviously impaired, the ketone body is reduced or even disappears. The reagent for qualitative determination of ketone body is reacted only with acetoacetic acid, weakly reacted with acetone, and has no reaction with -hydroxybutyric acid, so it is easy to miss the diagnosis when -hydroxybutyric acid is dominant in urine.

(3) Sometimes there may be proteinuria and tubular urine, and excretion of sodium, potassium, calcium, magnesium, phosphorus, chlorine, ammonium and HCO-3 in the urine increases.

blood test

(1) blood sugar and blood sugar increase, most of which is 16.65 ~ 27.76mmol / L (300 ~ 500mg / dl), sometimes up to 36.1 ~ 55.5mmol / L (600 ~ 1000mg / dl) or more, blood glucose > 36.1mmol / L often Accompanied by hyperosmolar coma.

(2) Blood ketone is often positive and strong. However, since the ketone body in blood is mainly -hydroxybutyric acid, the blood concentration is 3 to 30 times that of acetoacetic acid, and is parallel to the ratio of NADH/NAD. For example, blood is characterized by -hydroxybutyric acid. When the test is negative, a specific enzyme test should be further carried out to directly measure the level of -hydroxybutyrate. In DKA, the blood ketone body is generally more than 5 mmoL / L (50 mg / dl), sometimes up to 30 mmol / L, more than 5 mmol.

(3) Acidosis is mainly related to the formation of ketone bodies. The ketone bodies include -hydroxybutyric acid, acetoacetic acid and acetone, and acetoacetic acid and acetone react with sodium nitroprusside, while -hydroxybutyric acid does not react with sodium nitroprusside. In most cases, in DKA, a large amount of acetoacetate in the serum reacts with sodium nitroprusside. Metabolic acidosis of this disease, the pH of the compensation period can be within the normal range, when decompensated, the pH is often lower than 7.35, and sometimes less than 7.0. The CO2 binding force is often lower than 13.38 mmol/L (30% volume), and when it is severe, it is lower than 8.98 mmol/L (20% volume), and HCO3- can be reduced to 10-15 mmol/L. Blood gas analysis showed an increase in alkali residue, and the buffer base was significantly reduced (<45mmol/L=, SB and BB also decreased.

Differential diagnosis

Hyperosmolar non-ketotic diabetic coma can also have dehydration, shock, coma and other manifestations, more common in the elderly, but blood glucose often exceeds 33.3mmol / L, blood sodium exceeds 155mmol / L, plasma osmotic pressure exceeds 330mmol / L , blood ketone body.

1. Clinically, patients with coma, dehydration and acidosis, and shock, especially those with unexplained causes, ketone odor, low blood pressure and still high urine volume, should be alert to the possibility of the disease. Some have diabetes alone with DKA alone, some are complicated by diabetes, such as uremia, cerebrovascular accident and other diseases caused by coma, and some or other coma after coma induced ketoacidosis, etc., should be carefully identified . Generally, by asking about medical history, physical examination, testing urine sugar, urinary ketone, blood sugar, blood ketone and carbon dioxide binding force, blood gas analysis, etc., most of the diagnosis can be confirmed.

2. Identification of DKA, HNDC and LA caused by acute metabolic disorder of diabetes and acute complication of diabetes mellitus with hypoglycemia and coma.

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