Ministry of health protection of ukraine

MINISTRY OF HEALTH PROTECTION OF UKRAINE

Vynnitsa national medical university named after M.I.Pyrogov

«CONFIRM» on methodical meeting of endocrinology department A chief of endocrinology department, prof. Vlasenko M.V. _________________ “_31_”_august___ 2012 y

METHODOLOGICAL RECOMMENDATIONS

for independent work of students

by preparation for practical classes

Scientific discipline	Internal medicine
Мodule № 4	Urgent conditions in the clinic of internal medicine
substantial module №5	Urgent conditions in endocrinology
Topic	Management the patient with ketoacidotic coma
Course	6
Faculty	Medical № 1

Vynnitsa – 2012

Subject: Supervision of a patient with hiperhlikemichnoyu (ketoatsydotychnoyu) point
Relevance: Diabetes mellitus as "non-infectious epidemic, which swept the beginning of XXI century more than 170 million people, which leads to as acute and chronic complications of diabetes. The basis of the origin and development of acute complications of diabetes are severe disorders of vital functions: homeostasis of respiratory, circulatory, etc.. These disorders are directly threatening the lives and require immediate assistance. Therefore the study of coma in diabetes mellitus is extremely important in training future doctors.
Goal training: to teach students the example of the clinical analysis of patients diagnosed with ketoacidosis and who hiperhlikemichnu ketoatsydotychnu prekomu, to the differential diagnosis of lactic hiperosmolyarnoyu and commas, to apply modern standards of diagnosis and treatment of diabetic coma ketoatsydotychnoyi.
The student must know:
1. The main clinical signs of ketoacidosis and coma ketoatsydotychnoyi.
2. Pathogenesis of the main symptoms of keto acidosis and coma ketoatsydotychnoyi.
3. Modern methods of diagnosis and differential diagnosis of ketoacidosis and coma ketoatsydotychnoyi.
4. Pharmacological drugs used in treatment of coma in diabetes mellitus.
The student should be able to:
1. Identify symptoms of ketoacidosis and coma ketoatsydotychnoyi.
2. Perform a differential diagnosis ketoatsydotychnoyi and hypoglycemic coma and lactic hiperosmolyarnoyi coma.
3. Assign treatment keto acidosis and coma ketoatsydotychnoyi according to the protocols of care in "Endocrinology" (Order MZ of Ukraine № 574 of 08.05.2009 town).
4. Carry out measures to prevent ketoatsydotychnoyi coma.
Timing practice (5,5 hrs.):
1. Morning medical conference - 30 min.;
2. Supervision of patients in the department - 2hod.;
3. Clinical analysis of medical history (seminar) - 1,5 hour.;
4. Independent work (study of literature, articles from the past 2 years, design blog, solving problems with step 2) - 1.5 hours.

Minutes examination, diagnosis, treatment and prevention

PART OF MANAGEMENT TO ACTION
Getting sick patient find out passport details (name, sex, age, residence, occupation and profession. Find out relatives and install cause of ketoacidosis or coma, which were provocative factors.
The main reason for the emergence of state-ketoatsydotychnyh absolute and relative insulin deficiency
Provoking factors:
- Concomitant diseases (acute inflammation, exacerbation of chronic diseases, infectious diseases).
- Violations of treatment regimen (omission or cancellation of insulin, errors in prescribing or administration of insulin dose, the introduction of waste for a period of, or in terms of storage and insulin. Etc.).
- Lack of control over blood glucose.
- Surgery and trauma.
- Pregnancy.
- Late diagnosis of diabetes.
- Late appointment of insulin therapy in type 2 TsTs.
- Chronic insulin therapy antagonists (glucocorticoids, diuretynamy etc.)..
- Stress.
Find out the dynamics of the disease.
Complaints Define and refine the patient (according to relatives) to patient complaints of loss of consciousness:
- Thirst;
- Polyuria;
- Increasing dryness of skin;
- Weakness, adynamia;
- Headache;
- Lack of appetite;
- Nausea, vomiting;
- Difficulty breathing.
When examining the physical examination of the patient rate:
1. The state of consciousness:
 And art. - Anxiety or drowsiness (mild - keto acidosis)
II art. stupor (prekoma)
III. coma
2. Respiratory rate and character of breathing - like Kussmaul
3. Smell of acetone in the presence of mu exhale air.
4. Assess the tone of eyeballs - lowered.
5. Muscle tone, tendon reflexes - lowered.
6. Skin turgor of skin - dry, turgor decreased.
7. Pulse - rapid, arrhythmic, SC - lows, can not be determined.
8. Weakened heart tones.
9. Abdomen - swollen, listen peri stalku.
10. Perkutornoho size of the liver - increased.
11. Diuresis - oliguria, anuria.
12. The mass of the patient's body.
Plan survey of glycemia in blood every hour, total protein, K, Na, urea, creatinine, bilirubin, transaminase, ketonemiya, pH of blood, serum bicarbonate, serum osmolarity, blood lipids, hematocrit, complete blood count, acetone in the urine, the overall analysis urine, ECG, ophthalmologic consultation (eyeground), neurologist (rating on a scale of Glasgow)
Laboratory and instrumental investigations Evaluate level:
Diagnostic criteria DK
DK
Stage II and stage III stage
Plasma Glucose (mg / dl)> 250> 250> 250
Arterial pH 7,30-7,25 7,24-7,10 <7.10
Bicarbonate serum (mekv / l) (NSO3) 15.10 18-15 <10
* Positive urine Ketones. Positive. Positive.
Ketones * Positive serum. Positive. P
zytyv.
Effective osmolarity (my / l) ** various different different
*** Anion gap> 10> 12> 12
The state of consciousness alarming alarming-ness-ness or drowsiness stupor or coma
   * Method of nitroprusydom
** Calculated as 2 [Na (mmol / l)] + glucose (mmol / l)
   *** Calculated as 2 (Na +) - (CL-- NSO3) - (mekv / l)
Differential diagnosis of hypoglycemic point differential diagnosis com
Clinical and laboratory features Hiperhlikemichna (ketoatsydotychna) hypoglycemic
various different age
Family history of diabetes first discovered, the violation of diet, insulin therapy regime, infection, stress excess insulin, oral hypoglycemic drugs, excessive physical work, hunger
Predecessors weakness, nausea, thirst, vomiting, dry mouth, polyuria hunger, sweating, trembling
Gradual development of coma (2 3 days) against the background of concurrent disease - 1 day fast (minutes)
Features peredkoma-toznoho gradual loss of consciousness of the excitement that goes into a coma
The temperature is normal, normal subfebrylna
The skin is dry, hyperemia, reduced turgor humidity, normal turgor
Muscle tone decreased reflexes increased tone
Tongue dry wet
Eyeballs are soft, low tone tone normal
Pupils narrowed advanced
Kussmaul breathing, acetone odor
normal
AT reduced rate
Pulse frequent frequent
Signs of dehydration expressed no
Diuresis polyuria, oliguria then the standard
High glycemic low
No high glucosuria
There is no ketonuria
Natriyemiya rate, increased rate
Kaliyemiya reduced rate
Azotemiya increased rate
Moderately elevated blood lactate standard
Blood pH decreased rate
Normal blood osmolarity increased
Other criteria

Formulation Examples diagnosis diagnosis

Diabetes mellitus type 1, severe form in the stage of decompensation. Diabetic ketoacidosis stage.
Diabetes mellitus type 1, severe form in the stage of decompensation. Diabetic coma ketoatsydotychna, psevdoperytonialna form.
Diabetes mellitus type 1, severe form in the stage of decompensation. Diabetic ketoacidosis third stage kolaptoyidna form.
Treatment Plan
Drug therapy
Make a plan for treatment of the patient:
1. Catheterization of the subclavian vein.
2. Bladder catheterization (leave catheter in the bladder).
3. Intraneazalnyy probe.
Drug therapy
1. Elimination of insulin and normalization of carbohydrate metabolism
Performed by "small" short-acting insulin: 0,05-0,1 units / kg / hr fluid / v, then i / v drip considering the level of blood glucose:
- When glycemia> 39 mmol / l - 0.1 units / kg / h / in jet;
- When glycemia 39-17 mmol / l - 0.1 units / kg / h / to drip;
- When glycemia 17.11 mmol / l - 0.05 units / kg / h / to drip; mounting 5% glucose solution (prevention of "rykoshetnoyi" hypoglycemia);
- With glycemia <11 mmol / l - go for 4-6 OD subcutaneously every 3-4 hours.
Necessary to maintain glycemia at 8.10 mmol / liter. Optimal speed decrease glycemia 5.3 mmol / l / hr. The sharp decrease of blood glucose lead to the strengthening of hypokalaemia and metabolic brain edema.
2. Rehydration, disintoxication therapy, fight collapse
It is necessary to calculate the fluid deficit in a particular patient.
Volume of fluid (water) in the human body is 60% of body mass (0,6 × kg (body weight)).
Actual calculated by the formula:

140 mmol / l (average blood Na)

× 0,6 × patient weight (kg)
Na patient blood (mmol / l) + patient's blood glucose (mmol / l) × 0,5

The deficit is fluid: fluid volume - actual volume.

Example: patient weight 60 kg, sodium 155 mmol / L, glycemia 26 mmol / liter.
Volume of liquid = 0,6 × 60 kg = 36 liters.

                                             140

Actual = × 0,6 × 60 = 29.9 liters.
                                        155 +26 × 0,5
Fluid deficit = 36 l - 29,9 l = 6.1 liters. This volume should be restored for 2 3 days.
In a rehydration therapy should be considered more supportive fluids, which depends on body weight.
Volume of daily maintenance fluid based on body weight:
Weighing from 0 to 10 kg 100 ml / kg / day
10-20 kg (1000 ml + 50 ml / kg) / day
> 20 kg (1500 ml + 20 ml / kg) / day (or 1500 ml/m2)
- 1 degree of dehydration (fluid loss <10% of body weight, clinical hemodynamic no violation, dry mucous membranes, reduced skin turgor) - during the day 1-1,5 poured deficit amount plus hourly daily maintenance infusion at a speed of infusion double volume of hourly support for one hour.
- 2 degrees of dehydration (fluid loss 10-20% of body weight, characterized by signs of unstable hemodynamics, hypovolemia, dropped his eyes, poor capillary filling), saline fluid is injected at a rate of 5-20 ml / kg per hour and then double hourly volume maintenance infusion.
- 3 degrees of dehydration (loss of fluid over 20% of body weight, characterized by clinical signs of shock at the periphery of the pulse is weak or absent) injected 2 x 10-20 ml / kg / per jet, and then - double capacity hour maintenance infusion.
Gipergidratatsiya not life threatening the patient, if poured liquid on average 10% of body weight for 12 hours infusion. For children over the risk gipergidratatsii in the first 4 hours - the amount of fluid less than 50 ml / kg, and for the first day not more than 4 l / m 2 body surface of the child.
More rapid rehydration therapy can lead to complications: acute left ventricular failure, pulmonary edema, a sharp decrease of glycemia, which will cause metabolic brain edema.
3. Restoring electrolyte balance
To restore the level of potassium in the blood injected 2% solution of potassium chloride / v glucose with insulin (1 unit of transfused 4 g glucose) at a rate:
- At the level of potassium in the blood of <3 mmol / l - 3 grams of potassium, which corresponds to 150 ml of 2% solution of potassium chloride;
- At the level of potassium from 3 to 4 mmol / l - 2 g of potassium, which corresponds to 100 ml of 2% solution of potassium chloride;
- At the level of potassium in the blood of 4 to 5 mmol / l - 1.5 g of potassium, which corresponds to 75 ml of 2% solution of potassium chloride;
- At the level of potassium in the blood from 5 to 6 mmol / l - 1 g of potassium, which corresponds to 50 ml of 2% solution of potassium chloride;
- At the level of potassium in the blood of more than 6 mmol / L - potassium preparations are not entered.
Kaliopenia can lead to cardiac arrhythmias, weakness and paralysis of the intercostal muscles, atony of the stomach and intestines of hipokaliyemichnoyi coma.
Phosphate deficiency may restore the introduction of potassium phosphate, magnesium deficiency is restored by the introduction of 10% magnesium sulfate solution 6.8 ml every 3 hours under the control of blood pressure.
4. Restoration of normal acid-alkaline balance
The indications for the introduction of soda is to maintain low blood pH, low bicarbonate content of blood with 5 mmol / l (with normal 20-24 mmol / l), presence of pathological breathing Kussmaul, hyperkalaemia, cardiovascular collapse. Number of 4% sodium hydrogen carbonate, that you must enter the patient using the following formula:
Body weight (kg) × 0,4 × [25-HNCO3-]
On average, this number is 2 ml / kg. You can enter trysamin 1,5 g / kg (up to 500 ml per day).
To prevent hypokalaemia transfused per 100 mg of sodium hydrogen carbonate additionally injected 50-75 ml 2% potassium chloride.
To reduce acidosis Kokarboksilazy prescribed 100 mg every 6 hours, oxygen inhalation.
5. Normalization of the cardiovascular system
In the process of combined treatment ketoatsydotychnoyi prekomy coma and made permanent in combination with oxygen in / on unitiol infusion (2 ml/10 kg body weight 3-4 times a day) that restores the activity of intracellular enzyme system, increases oxygen delivery and utilization of tissues. If necessary, enter the heart and vascular preparations. To increase the contractility of the myocardium in the IV is added 0,5 ml 0,05% strofantynu (1-2 times a day) in the presence of arterial hypotension is shown in / on the introduction of 10% solution 1-2 ml of caffeine in / 0.5 m % solution Doxa 1-2 ml, with the collapse designate / m administration of 1% solution mezaton 1-2 ml (children - 0.1 ml / year) or 30-60 mg prednisolone, or hydrocortisone 75-150 mg in saline , 150-200 ml of blood plasma.
6. Elimination of the pathological condition which vyzvav hiperketonemichnyy management
In order to prevent infectious diseases hostrozapalnyh genesis using antibiotics.
Due to the hypercoagulation and to prevent the syndrome of disseminated intravascular coagulation of blood in the first 6:00 of the patient withdrawal from ketoatsydotychnoyi commas injected heparin on ED in 5000 / 4 times a day, then / m under the control parameters of the coagulation system. When olihouriyi / v jet 40-80 mg furosemide.
Unrestrained vomiting may be a sign of cerebral edema that occurs with the rapid and excessive fluid type, forced reduction of glucose in the blood. Early manifestations of brain edema is a headache, somnolence, urinary incontinence, seizures, anizokoriya, bradycardia, increased blood pressure. See treatment of cerebral edema.

Independent work

1. The study of literature
- Endocrinology. Edited. Sci. PM Bodnar. New book. - Vinnytsya. - 2010s - 464p.
- Endocrinological. Ed. Prof. PN Bodnar. New book. - Vinnitsa, 2007s - 236s.
- Training manuals departments.
- Order MZ of Ukraine from 08.05.2009 № 574 "On approval of protocols of care in" Endocrinology ".
- Current recommendations and standards of treatment of common diseases of internal organs / by red.prof. YM Mostovoy - Kiev - 2008 - 487 sec.
MORE
1. State of emergency in medicine / Ed. Prof. Little VP - Kiev - 2000 - 346 sec.
2. Zielinski BA Pharmacotherapy of emergency conditions in endocrine disorders - Kiev - 1995 - 63 sec.
3. Vlasenko NV, Palamarchuk AV Vernyhorodskyy VS, Sokurov SO, Fischuk AA, VV Skomarovsky State of emergency in Endocrinology / teaching aids / - Kiev - 2006 - 112 sec.
Preparation of abstract classes on the topic from the article:
- Endocrinology. Ed. MD Tronko (Kyiv)
- Problems of endocrine disorders. Ed. YI Karachentsev (Kharkiv)
- International Journal of Endocrinology. Ed. VI Pankiv (Donetsk)
- Problems of Endocrinology and Endocrine Surgery Ed. OS Larin (Kyiv)
- Journals therapeutic profile.
3. Solution tests and situational problems Step 2.
4. Writing reports of clinical analysis of patients.
 
Protocol analysis of clinical patient

Name _____________________________________________ patient __________________________________________________________________________________________________________________

Profession _______________________________ Age ______________
Complaints patient ___________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Anambes morbid ___________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Anamnes _____________________________________________ vitae ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Results of physical examination of the patient: _________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Previous diagnosis: _______________________________________
___________________________________________________________________________________________________________________________________________________________________________
Which diseases should conduct a differential diagnosis:
1. ______________________________________________________
2. ______________________________________________________
3. ______________________________________________________
4. ______________________________________________________
5. ______________________________________________________
Test Plan: _________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Results of laboratory and instrumental examinations:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

_________________________________________________________

_________________________________________________________
__________________________________________________________________________________________________________________
Justification of clinical diagnosis: _________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Clinical diagnosis: ________________________________________
The main diseases: ___________________________________
___________________________________________________________________________________________________________________________________________________________________________
Complications: ____________________________________________
__________________________________________________________________________________________________________________
Diseases: ____________________________________
___________________________________________________________________________________________________________________________________________________________________________
 Prediction: ________________________________________________
__________________________________________________________________________________________________________________
Able to work: __________________________________________
___________________________________________________________________________________________________________________________________________________________________________
Treatment: _______________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Drug therapy: __________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Glycemic control: ________________________________________
Marks on learning practical skills
Number p / p and manipulation skills Signature
student / manager
1. Practical skills
1.1. Be able to conduct interviews, physical examination of patients with diabetic ketoacidosis and ketoatsydotychnu coma.
1.2. Be able to analyze laboratory testing
1.3. Be able to assign therapy and intensified insulin therapy scheme ketoatsydotychnoyi point various options
2. State of emergency
2.1. Be able to assist with state ketoatsydotychnomu
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 
TESTS baseline KNOWLEDGE

1. L. 1928 The patient arrived in hospital unconscious. It is known that he was suffering from diabetes for 8 years, receiving insulin Protofan NM 20 units morning and 14 OD evening.
OBJECTIVE: dry skin. Ps - 112/hv., Rhythmic, small. AT - 90/60 mmHg Tongue dry, crimson. The smell of acetone breath. RR - 28/hv., Noisy breathing. Abdomen soft, participates in the act of breathing. The liver is palpated 4 cm below the costal arch.
Blood glucose 39 mmol / L, urine acetone reaction sharply positive. What is the approximate initial and subsequent doses of insulin?
1 .* short-acting insulin 0.1 units / kg intravenous fluid, and then to 0.1 units / kg body weight every hour.
2. Short-acting insulin 50 units intravenously and 50 units intramuscularly every 4 hours.
3. Short-acting insulin by 20 units intramuscularly three times a day.
4. Short-acting insulin 50 units intramuscularly, and then to 10 units intravenously every 2 hours.
5. Increase dose Protofanu NM twice, continue to enter 2 times a day.

2. Patient K, 23, suffers from diabetes 6 years. Gets insulin Humodar K25 16 units morning and 10 units in the evening, will be compensated. Five days ago ill angina. Deteriorated. Intensified thirst, increased diuresis (up to 5 liters per day), escape appetite, nausea appeared. OBJECTIVE: height 174 cm, weight 69 kg. The skin is dry. The smell of acetone breath. Ps -92/hv., Rhythmic. AT - 115/70 mmHg The liver is palpated 2 cm from the costal arch. Blood glucose 19 mmol / L, urine acetone reaction is positive. What special diets in this patient?

1 .* Delete fat-free, allow easily digestible carbohydrates.
2. Limit fats and carbohydrates.
3. Limit fats and proteins, carbohydrates increase.
4. Zoom proteins, limit fats.
5. Zoom proteins restrict carbohydrates.

3. Patients 49 years. Diabetes mellitus 10 years, received insulin Humodar R 6 units in the morning, Humodar B 22 OD OD in the morning and 14 evening. Three days ago, after consuming substandard food appeared vomiting, frequent, liquid emptying in 10 - 12 times a day. In connection with denial of food did not receive insulin. Condition deteriorated sharply in the morning, craving intensified, there was drowsiness, muscle cramps appeared limbs in 16 hours. lost consciousness. OBJECTIVE: consciousness is absent, the skin dry. Tone eyeballs reduced. Shallow breathing, accelerated. Acetone smell from mouth there. Pulse 116/hv. Little. AT - 80/50 mm Hg. Art. Weakened heart tones. Vesicular breathing weakened. Tongue dry. Abdomen soft, not painful. Liver is the land from under the costal arch to 3 cm plasma sodium - 160 mmol / liter. Blood Glucose - 45 mg / l, urine glucose - 6%, daily diuresis 0,5 L, urine acetone reaction negative. For the rehydration therapy which solution do I enter?

1 .* 0,45% solution of sodium chloride intravenous drip
2. 10% glucose solution by intravenous drip
3. 5% glucose solution by intravenous drip
4. 0.9% sodium chloride intravenous drip
5. 4% solution of sodium bicarbonate intravenous drip

4. Patient 28 years old, suffering from diabetes for 7 years. Gets 30-34 OD insulin a day, will be compensated. Once transferred two weeks ago of pneumonia worsened.

2.
3.

4.
5.

5.

2.
3.
4.
5.

6.
1.

2.
3.

5.

7.

2.
3.

4.
5.

8.
1.

3.
4.
5.

9.
1.

2.
3.

5.

10.
1.

3.
4.

5.

11.
1.

3.
4.
5.

12.
1.

3.
4.
5.

13.
1.

2.

4.
5.

14.
1.
2.
3.

5.

15.

2.
3.

4.
5.

16. Art. What preliminary diagnosis?

1.
2.

4.
5.

17. The skin is dry, pale. Art.
1.

3.
4.

5.

18. Art.

2.
3.
4.
5.

19.
1.

3.
4.
5.

 
Clinical problem for self-

Art.
1.
2.
3.

1.
2.

3.
4.
5.

Art.

1.
2.
3.
4.
5.
6.

Art.

1.
2.
3.
4.
5.

Art.

1.
2.
3.
4.
5.

Art.

1.
2.

3.
4.

Art.

1.
2.

3.
     4.
5.
 

Art.

1.
2.
3.
4.
5.
1.
2.
3.
4.
     5.