Ketoacidosis diagnosis, Diabetic Ketoacidosis

Sample

1. Blood needed to prepare the serum.
2. The urine sample may also be used.

Indications

1. Ketone bodies are advised in patients with diabetes mellitus.
   1. The advice in case of uncontrolled diabetes mellitus.
   2. In ketoacidosis associated with alcoholism, starvation,  and a high protein diet.

Definition

• In ketoacidosis, there is inhibition of glycolysis while glycogenolysis and gluconeogenesis are stimulated.
• There are hyperglycemia and deranged acid balance and electrolyte imbalance.

Pathophysiology

1. Ketone bodies substrate is free fatty acids from the adipose.
2. Long-chain fatty acids are taken up by the liver.
   1. In the liver are reesterified to triglycerides and stored in the liver.
   2. Or these are converted to very-low-density lipoprotein and returns to the blood.
3. infants have earlier ketonuria than adults after decreased food intake.
4. In uncontrolled diabetes mellitus:
   1. low insulin level leads to:
      1. increased lipolysis.
      2. Decreased reesterification.
      3. There are increased plasma free fatty acids.
      4. Insulin and glucagon ratio changes.
         1. This ratio is changed and enhances fatty acids oxidation
         2. It leads to increased ketone bodies formation in the liver and decreased peripheral tissue metabolism gives rise to accumulation in the blood.
         3. There is an accumulation of acetoacetate ketone bodies in the blood.
            

            Ketone Bodies Ratio and relation to Diabetes Mellitus

            

            Ketone Bodies Formation

Signs and Symptoms:

There may be :

1. A cough.
2. Fever.
3. Chills.
4. Chest pain.
5. Arthralgia.
6. Dyspnoea.
7. Tachycardia.
8. Hypotension.
9. Hypothermia.

Causes of ketone bodies formation:

1. Starvation.
2. Frequent vomiting.
3. Diabetes mellitus.
4. Glycogen storage disease (von Gierke disease).
5. During pregnancy.

Lab findings are:

1. The glucose level may range from 300 to 500 mg/dL.
2. Ketones bodies are beta-hydroxybutyric acid, acetoacetic acid, and acetone is positive.
   • These are produced during gluconeogenesis, mainly due to increased fatty acid oxidation to acetyl CoA.
   • Excessive concentration of ketone bodies in the blood is called ketonemia.
   • When there is increased excretion in the urine is called ketonuria.
3. Electrolytes show :
   1. Decreased Sodium.
   2. Increased Potassium.
   3. The anion gap is increased.
   4. Total CO 2 decreased.
4. Blood gases  shows:
   1. pH decreased.
   2. Metabolic acidosis.
   3. Bicarbonates are decreased.

Ketoacidosis and Diabetic ketosis:

Test	Lab findings
Glucose	300 to 500 mg/dL
Ketones	Positive (Acetone, Beta-hydroxybutyric acid and acetoacetic acid)
Electrolytes	Sodium Decreased
	Potassium increased
	Total CO 2 decreased
	Anion gap increased
Blood gases	pH decreased
	Bicarbonate decreased

Method to detect ketone bodies

1. Sodium nitroprusside reaction gives lavender color.
   1. This is very sensitive 10 times for acetoacetate than with acetone.
   2. It does not react with beta-hydroxybutyrate.

2. Gerhardt’s ferric chloride test mainly measures the acetoacetate ketone body.

Treatment

1. 1. Start with saline for volume replacement.
   2. Insulin infusion (but delay if serum potassium level is low <_3.3 meq/L).
   3. Potassium replacement when the serum level is <5.5 meq/L.
   4. Glucose drip (5% dextrose with 0.45% saline when the plasma glucose level is <250 mg/dL.
   5. Continue glucose and insulin until the anion gap is <12 meq/L.
   6. Try to find the causative agent

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