Ketoacidosis

Introduction Most patients with ketoacidosis have polyuria, polydipsia, polydipsia and fatigue several days before the disturbance of consciousness, followed by loss of appetite, nausea, vomiting, often accompanied by headache, lethargy, irritability, rapid breathing, and bad breath. Apple flavor (acetone) is characteristic of its typical onset. As the disease progresses further, severe water loss occurs, the amount of urine decreases, the skin elasticity is poor, the eyeball sinks, the pulse speeds, and the blood pressure drops. In the advanced period, various reflexes are dull or even disappear, so sleepiness and even coma.

Cause

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 been taking phenformin for a long time, especially when liver and kidney function are poor. DKA is also induced. High-dose thiazide diuretics are also 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.

an examination

Related inspection

Blood test glycine buffer buffer plasma ketone body

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.

2. Blood test

(1) Blood sugar: Most of the blood sugar is increased from 16.65 to 27.76 mmol/L (300 to 500 mg/dl), sometimes up to 36.1 to 55.5 mmol/L (600 to 1000 mg/dl) or more, and blood glucose is >36.1 mmol/L. May be accompanied by hyperosmolar coma.

(2) blood ketone: qualitative and strong positive. 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.

Differential diagnosis

1. lactic acidosis: These patients have acute onset, infection, shock, history of hypoxia, acidosis, rapid breathing and dehydration. Although blood glucose is normal or elevated, blood lactate is significantly elevated. (more than 5 mmol/L), the anion gap exceeded 18 mmol/L.

2. Alcoholic acidosis: There are alcohol abuse habits, which are often caused by heavy drinking. The patient's blood -hydroxybutyrate is elevated due to hyperemesis, and blood ketone may be positive, but at the same time as acidosis and anion gap increase. Its osmotic pressure also increases.

3. Hunger ketosis: Due to insufficient eating, the patient's fat is decomposed and blood ketone is positive, but urine sugar is negative and blood sugar is not high.

4. Hypoglycemia coma: The patient had had too little food, the onset was acute, and he was sick and coma, but he was negative for urine sugar and urine ketone, and had low blood sugar. He had excessive history of insulin injection or excessive hypoglycemic medication.

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