What Is Ketoacidosis?

Ketone bodies are intermediate metabolites of fatty breakdown in the liver, including acetoacetate, beta-hydroxybutyric acid, and acetone. Under normal circumstances, the body produces a small amount of ketones, which are used as energy sources as the blood is transported to the heart, kidneys and skeletal muscles. The concentration of ketones in the blood is very low, generally not exceeding 1.0 mg / dL, and also in the urine. No ketone bodies were detected. When there is insufficient insulin in the body or lack of sugar in the body, such as hunger, fasting, and severe pregnancy reactions, when the fat is decomposed too much, the ketone body concentration increases, and a part of the ketone body can be excreted through the urine to form ketonuria. When the amount of ketone bodies produced in the liver exceeds the utilization capacity of extrahepatic tissues, the blood ketone body concentration will be too high, leading to ketemia and ketonuria. The acetoacetic acid and -hydroxybutyric acid in the ketone body are both acidic substances. When too much is accumulated in the blood, the blood can become acidic and cause acidosis, which is called ketoacidosis.

Basic Information

English name: ketoacidosis
Visiting department: Department of Endocrinology, Emergency
Common causes: Diabetes, hunger, heavy drinking, etc.

Common symptoms: Drinking more urine and drinking, physical and weight loss, decreased appetite, nausea and vomiting, keto smell in the breath, dehydration symptoms and even changes

Causes of ketoacidosis

Diabetic ketoacidosis

The main causes of diabetic ketoacidosis are infection, improper diet or treatment, and various stress factors.

2. Starvation ketosis

When normal people and diabetic patients are severely hungry, the energy supply in the body mainly depends on lipolysis, and excessive fat decomposition can cause the accumulation of ketone bodies and cause ketosis.

3. Alcoholic ketosis

After heavy drinking, it can inhibit gluconeogenesis, accelerate ketone body production, and lead to ketosis.

Clinical manifestations of ketoacidosis

Ketoacidosis can be divided into mild, moderate and severe cases according to the degree. Mild pH <7.3 or bicarbonate <15mmol / L; moderate pH <7.2 or bicarbonate <10mmol / L; severe pH <7.1 or bicarbonate <5mmol / L, the latter can easily enter a coma. The clinical manifestations of heavier ketoacidosis include the following aspects:

1. Diabetes symptoms worsen

Symptoms of increased drinking and urine, physical strength, and weight loss worsened.

2. Gastrointestinal symptoms

This includes loss of appetite and nausea and vomiting.

3. Changes in breathing

Some patients may have a keto odor similar to the rotten apple smell in their breath.

4. Dehydration and shock symptoms

Patients with moderate and severe ketoacidosis often have symptoms of dehydration. Dehydration of up to 5% may show signs of dehydration, such as decreased urine output, dry skin, and sunken eyes. When dehydration exceeds 15% of body weight, circulatory failure may occur. Symptoms include increased heart rate, weak pulse, decreased blood pressure and body temperature, and severe cases can be life threatening.

5. Change of Mind

The clinical manifestations of conscious changes vary widely, with headache, dizziness, malaise followed by irritability, lethargy, and coma in the early stages. The causes of coma include too much acetoacetate, cerebral hypoxia, dehydration, elevated plasma osmotic pressure, and circulatory failure.

Ketoacidosis

Blood sugar

It is usually between 16.7 and 33.3 mmol / L, sometimes reaching 33.3 to 55.5 mmol / L.

2. Urine Ketone

Strong positive. When combined with renal dysfunction, ketone bodies cannot be excreted from the urine, so although ketoacidosis occurs, ketone bodies are negative or only in trace amounts.

3. Blood Ketone

The determination of blood ketones is mostly based on the nitroprusside method. At present, it is generally accepted that blood ketone L is normal, and blood ketones> 3mmol / L are of diagnostic significance.

4. Blood electrolytes and urea nitrogen (BUN)

Sodium and chlorine are often low due to blood concentration, which can be normal or elevated; blood potassium can be normal, low or high. However, the overall potassium, sodium, and chlorine decreased, and BUN increased, which was caused by decreased blood volume, insufficient renal perfusion, and increased protein breakdown. Those who did not decrease continuously had a poor prognosis.

5. Blood pH

The blood carbon dioxide binding power and pH value decreased, the remaining alkali level decreased, and the anion gap increased significantly.

6. Other

(1) Blood routine The levels of granulocytes and neutrophils can increase, reflecting blood concentration, infection or enhanced adrenal function.

(2) Urine routine There may be symptoms of urinary system infection.

(3) Serum lipids can be increased, and serum can be chyle in severe cases.

(4) Chest X-ray is helpful for finding induced or secondary diseases.

(5) ECG is helpful to find the cause (such as myocardial infarction) and can help understand the blood potassium level.

Diagnosis of ketoacidosis

According to the clinical manifestations and laboratory findings of diabetic ketoacidosis, it is not difficult to make a correct diagnosis in time.

Ketoacidosis treatment

Once diabetic ketoacidosis is diagnosed, it should be treated immediately. The purpose of treatment is to correct water and electrolyte imbalances, correct acidosis, supplement insulin to promote glucose utilization, and find and remove stress factors that induce ketoacidosis.

General processing

Monitor blood glucose, blood ketones, urine ketones, electrolytes, and arterial blood gas analysis.

2. Rehydration

It is very important for patients with severe ketoacidosis, which is not only conducive to the correction of dehydration, but also helps to reduce blood sugar and eliminate ketone bodies. The amount of fluid replacement should vary from person to person depending on the degree of dehydration in the patient.

3. Insulin

Low-dose insulin therapy can maximize the inhibition of ketone body production without causing hypoglycemia and hypokalemia. When the blood sugar drops to 13.9mmol / L, start to input 5% glucose solution. Increasing the heat card will help ketone body correction .

4. Correcting Electrolytic Disorders

Blood potassium changes should be closely monitored during treatment. ECG monitoring can sensitively reflect the level of blood potassium from T wave changes, which is helpful for timely adjustment of potassium concentration and speed.

5. Correct the acid-base balance disorder

The biochemical basis of diabetic ketoacidosis is the excessive production of ketone bodies, not the excessive loss of HCO _{3. The} treatment should mainly use insulin to inhibit ketone body production, promote the oxidation of ketone bodies, and oxidize ketone bodies to produce HCO ₃ . correct. Premature and excessive administration of NaHCO _{3 is} harmful and unhelpful.

6. Treatment incentives

In addition to actively correcting metabolic disorders, treatment of patients with ketoacidosis must also actively seek out predisposing factors and treat them accordingly, such as severe infections, myocardial infarction, surgical diseases, gastrointestinal disorders, and so on. Among them, infection is the most common cause, and sensitive antibiotics should be used early.

(1) Treatment of ketosis and ketoacidosis during pregnancy: Diabetic ketosis due to hunger, mainly to ensure that enough calories are taken daily, which must reach 2 100kcal. After the calories meet the needs of the body, diabetic ketosis will naturally ease. Metabolic diabetic ketosis caused by insufficient insulin dose is often associated with high blood sugar, which can be relieved mainly by rational adjustment of insulin dosage. Diabetic ketoacidosis should be performed in accordance with the principle of diabetic ketoacidosis in the general population.

(2) Geriatric ketosis treatment principles: It is roughly the same as adults, and correcting dehydration is still an important measure for rescue. Due to the multifunctional organ decline in the elderly, isotonic fluid or gastrointestinal fluid replacement is the first choice to correct dehydration. It is necessary to closely observe the condition and adjust the fluid replacement volume at any time. Pay close attention to the blood sugar falling rate, so as not to cause the blood sugar falling too fast to cause hypoglycemia, cerebral edema or even cerebral hernia, which is life-threatening. adjust the electrolyte level to prevent excessive fluctuations in blood potassium. Too low or too high blood potassium can induce various arrhythmias, cardiac events and the risk of sudden cardiac death in elderly patients. Elderly patients with diabetic ketosis often co-infect infections, and are prone to complicate or complicate many other organ diseases. During the treatment, comprehensive attention is paid to the protection of multiple organ functions and the prevention of important organ function failure.