一世n this first part of our 2-part podcast on DKA and HHS, DrsMelanie Baile..那Bourke Tillmann.和Leeor Sommer讨论鉴定鉴定DKA患者的潜在原因或触发的重要性，抑制DKA患者患者正常pH或正常血清葡萄糖，如何有效地缩小差距，为什么停止胰岛素输注几乎从未表明过，如何避免心脏塌陷当DKA患者需要气管插管时，气管中塑料中最好的替代品，为什么使用协议改善患者结果，如何避免低血糖和低钾血症的常见并发症，还有更多...
Podcast voice editing by Raymond Cho. Production, sound design & editing by Anton Helman.
Written Summary and blog post by Lorraine Lau & Winny Li, edited by Anton Helman September, 2020.
引用这个播客是：Helman, A. Baimel, M. Sommer, L. Tillmann, B. Episode 146 – DKA Recognition and ED Management. Emergency Medicine Cases. September, 2020. //www.mp3valve.com/dka-recognition-ed-management。访问[日期]。
The Difficulty in Diagnosing Diabetic Ketoacidosis (DKA)
There are no definitive criteria for the diagnosis of DKA according to the 2018 Canadian DKA Guidelines. As such, it is important to have a low threshold to consider the diagnosis in any diabetic patient who presents with polyuria, polydipsia, hyperpnea, abdominal pain/nausea/vomiting or altered level of awareness. While most patients with DKA will have the三合会高血糖，阴离子间隙代谢酸中毒和酮血症那there are important例外：
DKA.patients can have a没有rmalglucose (euglycemic DKA – see below)
DKA.patients can have a没有rmalpH和A.没有rmalbicarbonate (normal VBG) in the context of ketoacidosis plus metabolic alkalosis as a result of vomiting and/or the triggering illness
Negative urine ketones should not be used to rule out DKA, as urine tests measure the presence of acetoacetate, but not β-hydroxybutyrate
临床珍珠：Many patients with DKA present with some degree of abdominal pain. Severe abdominal pain with only mild ketoacidosis argues一种gainstDKA作为原因。当有疑问，对腹部成像的需要，首先复苏，并进行串行腹部检查。如果酮症中毒改善，则对图像具有低阈值，但患者继续存在症状或临床恶化。
Severity categorization of DKA
Evaluation for precipitating cause of DKA is paramount as it is often the cause of of death in patients with DKA
DKA.can be the initial manifestation of diabetes, but it often occurs in the context of known diabetes plus a trigger. Most often, it is due to medication non-adherence, incorrect dosing or infection. However, any physiologic stress can trigger DKA.
一世nfant on board (pregnancy)
一世ndiscretion (dietary nonadherence)
一世nsulin deficiency (insulin pump failure or nonadherence)
一世n addition, common可以触发DKA的药物include glucocorticoids, diuretics and atypical antipsychotics.
DKA.work-up should include CBC, electrolytes, extended electrolytes, creatinine, BUN, albumin, VBG, lactate, serum ketones, as well as consideration for:
Maintain a high index of suspicion for DKA in the following patients who present with nausea, vomiting, shortness of breath and/or metabolic acidosis, and evaluate for DKA with serum ketones and/or β-hydroxybutyrate:
T1/T2DM Patients taking SGLT-2 inhibitors (the “zins”)
Pregnant patients – due to transplacental glucose transport, will have relative euglycemia (more common in second or third trimester)
Add dextrose (D5W) to the IV fluid if/when blood glucose approaches normal to allow continued insulin infusion at a rate sufficient to resolve DKA while avoiding hypoglycemia OR when glucose <15 (250-300mg/DL) switch to D5-1/2NS NS at an initial rate of 150 to 250 mL/h
Our experts recommend starting with NS or RL and consider ongoing fluid resuscitation with RL to avoid the hyperchloremic acidosis associated with large volumes of NS
关键点：Volume resuscitationmustprecede insulin therapyin order to adequately restore intravascular volume and tonicity. Early insulin therapy has the added risk of hypoglycemia and hypokalemia.
The literature does not support replacing bicarb in adult DKA patients with pH ≥6.9. There is retrospective evidence of transient paradoxical worsening of ketosis and an increased need for potassium supplementation in patients who received bicarb. Our experts caution against the routine use of bicarbonate therapy in DKA. The decision to give bicarb should be tailored to the individual patient, their hemodynamics and their acid/base status.
Evaluate fluid status (e.g. with ultrasonography), provide additional crystalloid if necessary
分析了患者生理上的挑战patients to intubate for several reasons. Their respiratory dynamics of hyperpnea to correct their underlying metabolic acidosis means the ventilator must equally match their large tidal volume and respiratory rate. This intrinsically puts the patient at risk for ventilator induced lung injury and subsequent development of ARDS. Furthermore, these patients with profound metabolic acidosis are at risk of circulatory collapse peri-intubation as periods of apnea during intubation will cause their pCO2水平迅速上升，恶化酸中毒。
一世f you must intubate:
Resuscitate before you intubate
Consider ketamine +/- paralytic; continue to bag if paralytic used to avoid any period of apnea
Consider an antiemetic
考虑给予IV BOLUS BICARB，特别是如果血清BICARB <10
高潮量（8CC / kg）和RR（24-28）过度通气
Consider asking for additional help from your anesthesiology colleagues
The Role of NIPPV in DKA
Oxygenation is rarely an issue in DKA, but rather work of breathing and respiratory fatigue may occur. Our experts do没有trecommend the routine use of BiPAP in DKA patients given the risk of aspiration and emesis in these patients, as they often concurrently have gastroparesis. Only consider NIPPV if the patient is in a highly monitored setting with one-to-one nursing care.
Avoiding Cerebral Edema in DKA
The key to avoiding cerebral edema in the management of DKA is togo slowwith resuscitation.
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Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.