Diabetic ketoacidosis in the elderly
Introduction
Introduction to diabetic ketoacidosis in the elderly Diabetic ketoacidosis means that under the influence of various incentives, the insulin does not increase significantly, the glycemic hormone is not properly elevated, causing sugar, protein, fat and even water, electrolyte, acid-base balance imbalance leading to high blood sugar High blood ketone, ketoneuria, dehydration, electrolyte imbalance, metabolic acidosis and other syndromes. basic knowledge The proportion of illness: 0.12% Susceptible people: the elderly Mode of infection: non-infectious Complications: cerebral edema, epilepsy
Cause
The cause of diabetic ketoacidosis in the elderly
High blood sugar (20%):
The blood glucose of patients with DKA is moderately elevated, often in the range of 300-500 mg/dl. Unless renal insufficiency occurs, it will not exceed 500 mg/dl. The causes of hyperglycemia in patients include decreased insulin secretion and body response to insulin. Reduced sex, increased secretion of glycosaminoglycans, as well as dehydration, blood concentration and other factors.
Ketoacidosis (15%):
The ketone body is an incomplete product of fat -oxide, including acetoacetic acid, -hydroxybutyric acid and acetone. Among them, acetoacetic acid is a strong organic acid, which can react with ketone body powder; -hydroxyl Butyric acid is a reduction product of acetoacetic acid, also a strong organic acid, which is the largest in the ketone body, accounting for 70% of the total ketone body; acetone is the decarboxylation product of acetoacetate, the amount is the least, neutral, no renal threshold, Can be discharged from the respiratory tract, normal human blood ketone body does not exceed 10mg / dl, ketoacidosis can increase 50 to 100 times, urine ketone positive.
Acidosis (10%):
When ketoacidosis occurs, organic acids such as keto acid, lactic acid, and inorganic acids such as sulfuric acid and phosphoric acid increase, and the acid and alkali in the kidneys are aggravated. In addition, dehydration and shock cause acid dysfunction in the body, which eventually leads to acidosis.
Dehydration (10%):
When ketoacidosis, blood sugar is significantly increased, and a large number of acid roots are produced, osmotic diuresis and acid loss, plus deep breathing loss and possibly accompanied by vomiting, gastrointestinal diarrhea caused by diarrhea, etc. Can cause dehydration to occur.
Electrolyte disturbance (10%):
Permeability diuresis, reduced intake and vomiting, intracellular and extracellular water transfer, blood concentration can lead to electrolyte imbalance, especially potassium loss, due to the simultaneous loss of electrolytes and blood concentration, the actual measured blood electrolyte level can be High, low, or in the normal range, when ketoacidosis occurs, due to increased blood lipid levels, water-soluble electrolyte components such as blood sodium can be pseudo-reduced, and phosphorus loss increases due to increased catabolism. Hypophosphatemia can occur clinically.
Prevention
Elderly people with diabetes ketoacidosis prevention
The specific preventive measures are as follows:
1. Actively control diabetes.
2. Carefully avoid induced factors, including:
1 infection.
2 trauma.
3 vomiting, diarrhea and other gastrointestinal diseases.
4 acute myocardial infarction and heart failure.
5 trauma;
6 surgery and anesthesia.
3. In case of infection, even if it is non-insulin-dependent diabetes, insulin should be supplemented as an emergency measure.
Complication
Complications of diabetic ketoacidosis in the elderly Complications, brain edema, epilepsy
Mainly complicated by increased intracranial pressure, cerebral edema, epilepsy, circulatory failure and so on.
1. Normal adult intracranial pressure is 0.8 to 1.8 kPa, and children are 0.5 to 1 kPa. Increased intracranial pressure means that the pressure generated by the contents of the cranial cavity on the cranial wall exceeds the normal range, that is, the patient's lateral position is used for lumbar puncture, and the cerebrospinal fluid hydrostatic pressure exceeds 2 kPa.
2. Cerebral edema refers to the pathological phenomenon that the water in the brain increases and the volume of the brain increases, which is the response of brain tissue to various pathogenic factors. Can cause intracranial hypertension, damage brain tissue, clinically common in nervous system diseases, such as craniocerebral trauma, intracranial infection (encephalitis, meningitis, etc.), cerebrovascular disease, intracranial space-occupying diseases (such as tumors), Seizures and systemic diseases such as toxic dysentery, severe pneumonia.
3. Epilepsy is commonly known as "sheep epilepsy", "shofar wind", "lamb mad" or "sexual epilepsy", which is a paroxysmal movement caused by paroxysmal abnormal discharge of brain neurons in various ways. A disease of consciousness, spirit, and autonomic dysfunction. As early as 2,200 years ago, the "Yellow Emperor's Internal Classic" was recorded. I believe that people will not be familiar with this disease, and they are often referred to as exhaustion by people.
4. Systemic pathological processes in which metabolic dysfunction occurs due to severe disease or severe physical damage caused by trauma or poisoning, resulting in a decrease in blood volume or acute cardiac dysfunction.
Symptom
Symptoms of diabetic ketoacidosis in the elderly Common symptoms Diabetic ketoacidosis, polyuria, polydipsia, urinary coma, shock, nausea, gastrointestinal symptoms, appetite, abdominal pain
Ketoacidosis can be divided into mild, moderate and severe according to its degree. Mildness refers to simple ketosis, no acidosis, mild to moderate acidosis can be classified as moderate; severe It refers to ketoacidosis accompanied by coma, or although there is no coma, but the carbon dioxide binding is less than 10mmol / L, the latter is easy to enter a coma, the clinical manifestations of heavier ketoacidosis include the following aspects:
1. Diabetes symptoms worsen
Drink more urine, the symptoms of physical strength and weight loss worsened.
2. Gastrointestinal symptoms
Including appetite loss, nausea and vomiting, some patients, especially type 1 diabetes patients may have abdominal pain symptoms, and sometimes even mistaken for acute abdomen, the cause of abdominal pain is still unclear, some people think that may be caused by dehydration and hypokalemia Gastrointestinal dilatation is associated with paralytic ileus.
3. Respiratory changes
Caused by acidosis, when the blood pH < 7.2, the breathing is fast, in order to facilitate acid discharge; when the pH is <7.0, the respiratory center is inhibited, and some patients may have a ketone odor similar to the smell of rotten apple.
4. Dehydration and shock symptoms
Middle and severe ketoacidosis patients often have dehydration symptoms, dehydration up to 5% may have dehydration performance, such as reduced urine output, dry skin, eyeball subsidence, etc., dehydration over 15% of body weight may have circulatory failure, symptoms including heart rate Accelerate, pulse is weak, blood pressure and body temperature drop, etc., in severe cases can be life-threatening.
5. Mind change
The clinical manifestations of conscious changes vary greatly. Early headaches, dizziness, euphemism, and then irritability, lethargy, and coma, causing coma include excessive acetoacetate, cerebral hypoxia, dehydration, elevated plasma osmotic pressure, and circulatory failure.
6. Induced disease performance
All kinds of induced diseases have special manifestations, should be noted, so as not to cover up with ketoacidosis, delay the disease.
Examine
Examination of diabetic ketoacidosis in the elderly
Blood pH
The blood carbon dioxide binding force and pH value decreased, the residual alkali level decreased, and the anion gap increased significantly (normal 12~16mmol/L). According to the difference of various indexes, acidosis can be divided into three levels: light, medium and heavy. (Table 1) Individuals may be accompanied by respiratory alkalosis.
Clinically, it can be seen that the pH is not low, and even ketoacidosis of alkalemia, patients with multiple metabolic alkalosis, severe vomiting, excessive intake of diuretics or excessive alkaline substances should be identified.
2. Other
1 blood routine: granulocyte and neutrophil levels can be increased, reaction blood concentration, infection or enhanced adrenal function.
2 urine routine: may have urinary tract infection performance.
3 blood lipids: can be elevated, heavy serum can be chyle-like.
4 chest penetration, is conducive to the search for induced or secondary diseases.
5 ECG: It is helpful to find the cause (such as myocardial infarction), which can help to understand the blood potassium level.
Electrocardiogram: Temporary high-point P wave can occur due to temporary aggravation of right atrial pressure load. When hypokalemia occurs, T wave is generally low.
Diagnosis
Diagnosis and diagnosis of diabetic ketoacidosis in the elderly
diagnosis
According to the clinical manifestations and laboratory tests of diabetic ketoacidosis, it is not difficult to make a correct diagnosis in time.
Differential diagnosis
However, it is necessary to identify acidosis and coma caused by other causes.
1. Other acute complications of diabetes, including hyperosmolar coma, lactic acidosis and hypoglycemia.
2. Cerebrovascular accident
Can induce ketoacidosis, causing both to coexist.
3. Other causes of ketoacidosis, such as hunger ketosis and alcoholic ketoacidosis, but blood sugar is generally normal or low, or only slightly higher than normal.
4. A variety of acute abdomen, such as acute pancreatitis, cholecystitis can be complicated by ketoacidosis.
