Cetoacidosis Diabtica

Milagros Blancarte
R1MI
28 abril 2017
Complicaciones Agudas de la Diabetes

Cetoacidosis
Estado hiperosmolar Hiperglucmico
Diabetes Mellitus .

8.5% de la poblacin mundial

1.5 Millones Muertes 43% antes de los 70 aos
Encuesta Nacional de Salud y Nutrcin 2016
Prevalencia pas de 9.2% en 2012 a 9.4% en 2016

ENSANUT 2016
 Mujeres: 10.3% Hombres 8.4%
87.7% Tratamiento
Uso de insulina aumento de 6.5% a 11.1%
Hb glicosilada solo en 15.2%
ENSANUT 2016
 Cetoacidosis Diabtica
Epidemiologa

34% DB II, 66% DBM1

Edades entre 18 y 44 aos 56%
45 a 65 aos 24%
Menores de 20 aos 18%

Diabtes Care 24:131-153,2001

Clinical Diabetes 15:236-239, 1997
1.Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care
2009; 32:1335.
 Factores desencadenantes

1.- Kitabchi AE, Razavi L.Hyperglycemic Crises: Diabetic Ketoacidosis (DKA), And Hyperglycemic Hyperosmolar State (HHS). In:
2.-Randall L, Begovic J, Hudson M, et al. Recurrent diabetic ketoacidosis in inner-city minority patients: behavioral, socioeconomic, and psychosocial factors. Diabetes Care 2011; 34:1891.
3.- Wachtel TJ, Tetu-Mouradjian LM, Goldman DL, et al. Hyperosmolarity and acidosis in diabetes mellitus: a three-year experience in Rhode Island. J Gen Intern Med 1991; 6:495.
4,.Taylor SI, Blau JE, Rother KI. SGLT2 Inhibitors May Predispose to Ketoacidosis. J Clin Endocrinol Metab 2015; 100:2849.
6.- Wachtel TJ, Silliman RA, Lamberton P. Prognostic factors in the diabetic hyperosmolar state. J Am Geriatr Soc 1987; 35:737.
 Cuadro Clnico

Desarrollo rpido, 24 horas.

Nusea vomito.
leo
Exploracin fsica

1.-Lorber D. Nonketotic hypertonicity in diabetes mellitus. Med Clin North Am 1995; 79:39.
2.-Malone ML, Gennis V, Goodwin JS. Characteristics of diabetic ketoacidosis in older versus younger adults. J Am Geriatr Soc 1992; 40:1100.
3.-Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care 2009; 32:1335.
 Diagnstico

1.Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care
2009; 32:1335.
 Glucosa Srica

350-500 mg/dl
Pacientes Euglucmicos

1.-Munro JF, Campbell IW, McCuish AC, Duncan LJ. Euglycaemic diabetic ketoacidosis. Br Med J 1973; 2:578.
2.-Burge MR, Hardy KJ, Schade DS. Short-term fasting is a mechanism for the development of euglycemic ketoacidosis during periods of insulin deficiency. J Clin Endocrinol Metab 1993;
76:1192.
3.-Eisenbarth GS, Polonsky KS, Buse JB. Type 1 diabetes mellitus: Acute diabetic emergencies: Diabetic ketoacidosis. In: Williams Textbook of Endocrinology, Larsen PR, Kronenberg HM,
Melmed S, Polonsky KS (Eds), Elsevier Science, Philadelphia 2003. p.1500 .
 D
Cetonas
R

Falsos negativos: Betahidroxibutirico: Acetona 10:1

Nitroprusiato acetoacetato , - con acetona no beta hidroxibutirato. (Predominante en

Cetoacidosis severa, o Acidosis lctica

Falso positivo: Captopril, peniciliamina, mesna

Determinacin directa de B hidroxibutirato

1.-Laffel L. Ketone bodies: a review of physiology, pathophysiology and application of monitoring to diabetes. Diabetes Metab Res Rev 1999; 15:412.
2.-Sheikh-Ali M, Karon BS, Basu A, et al. Can serum beta-hydroxybutyrate be used to diagnose diabetic ketoacidosis? Diabetes Care 2008; 31:643.
3.-Wiggam MI, O'Kane MJ, Harper R, et al. Treatment of diabetic ketoacidosis using normalization of blood 3-hydroxybutyrate concentration as the endpoint of emergency management. A
randomized controlled study. Diabetes Care 1997; 20:1347.
 Hallazgos Laboratorio
Acidosis metablica

Anion GAP
Na srico - (Cl srico+ HCO3) nl 8
a 12
Sin correccin

Osmolaridad plasmtica
Osmolaridad efectiva
Effective Posm = [2 x Na(mEq/L)]+
[glucose(mg/dL) 18]

1.-Emmett M, Narins RG. Clinical use of the anion gap. Medicine (Baltimore) 1977; 56:38.
2,.Adrogu HJ, Eknoyan G, Suki WK. Diabetic ketoacidosis: role of the kidney in the acid-base homeostasis re-evaluated. Kidney Int 1984; 25:591.
 Otras Anormalidades
Leve Hiponatremia
Sodio Corregido Pseudohiponatremia:
K: 1/3 pacientes
artefactos
Hipercalemia, Efecto
electrolticos al
Sodio medido + Insulina ( K Celula)
medir
(glucosa
100/100)*1.6

1.-Arora S, Cheng D, Wyler B, Menchine M. Prevalence of hypokalemia in ED patients with diabetic ketoacidosis. Am J Emerg Med 2012; 30:481.
2.-Atchley DW, Loeb RF, Richards DW, et al. ON DIABETIC ACIDOSIS: A Detailed Study of Electrolyte Balances Following the Withdrawal and Reestablishment of Insulin
 Fsforo Normal o elevado

Creatinina: BUN y creatinina

Creatinina elevados por hipovolemia

Lipasa Pancreatitis

Hipercortisolemia y catecolaminas elevadas.

Leucocitosis Ms de 25000 o mas del 10% bandas
Infeccin

1.- Kemperman FA, Weber JA, Gorgels J, et al. The influence of ketoacids on plasma creatinine assays in diabetic ketoacidosis. J Intern Med 2000; 248:511.
2.-Yadav D, Nair S, Norkus EP, Pitchumoni CS. Nonspecific hyperamylasemia and hyperlipasemia in diabetic ketoacidosis: incidence and correlation with biochemical
abnormalities. Am J Gastroenterol 2000; 95:3123.
Eisenbarth GS, Polonsky KS, Buse JB. Type 1 diabetes mellitus: Acute diabetic emergencies: Diabetic ketoacidosis. In:
Williams Textbook of Endocrinology, Larsen PR, Kronenberg HM,
Eisenbarth GS, Polonsky KS, Buse JB. Type 1 diabetes mellitus: Acute diabetic emergencies: Diabetic ketoacidosis.
In: Williams Textbook of Endocrinology, Larsen PR, Kronenberg HM,
 Tratamiento:

1.Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care
2009; 32:1335.
1.Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care
2009; 32:1335.
1.Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care
2009; 32:1335.
1.Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care
2009; 32:1335.
1.Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care
2009; 32:1335.
1.Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care
2009; 32:1335.
1.Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care
2009; 32:1335.
 Cambio a Insulina SC

MENOR DE 200 MG/DL Y AL MENOS DOS DE

LOS SIGUIENTES
ANION GAP <12 MEQ/L
BICARBONATO >15 MEQ/l
PH > 7.30

1.Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care
2009; 32:1335.
 Criterios de resolucin

Anion Gap <12

Paciente Tolera va oral

1.Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care
2009; 32:1335.
 Complicaciones

Hipocalemia
Hipoglucemia
Edema cerebral
Edema pulmonar

1.Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care
2009; 32:1335.