MMPAD Munich Meeting Report

MEETING REPORT 7 European Roadshow - Friday 25 th May, 2018 Munich, Germany Klemens Raile began his presentation by explaining that despite all efforts, DKA occurs in 16–67% of newly-diagnosed diabetic patients in most countries. If DKA is suspected, emergency assessment is based on clinical examination, including; body weight, hydration status, heart rate, state of consciousness and signs of infection. Clinical signs of DKA include abdominal pain, nausea, vomiting, deep (Kussmaul) breathing, confusion and unconsciousness. Raile demonstrated the symptoms by presenting case studies, one example being of a 16-year-old boy (46 kilograms, Glasgow Coma Scale = CGS 14), who was conscious with slowed reactions, had deep (Kussmaul) breathing, dark circles under the eyes and extremely cold hands. His skin turgor was reduced, his pulse at the radial artery was weak, his blood pressure was low (105/45 mmHg) and his heart rate was elevated (120 beats per minute). The lab results were indicative of ketonuria and glucosuria. Mild DKA is biochemically defined as hyperglycaemia (blood glucose levels above 200 mg/dL), venous pH value below 7.3 or serum bicarbonate below 15 mmol/L, ketonemia (ß-hydroxybutyrate [BOHB] > 3 mmol/L) or ketonuria. Possible sources of error are artificial ventilation (CO 2 elimination), perfusion (lactic acidosis) and vomiting (alkalosis). What has changed in the management of DKA? Current guidelines are based on data from 2004. However, the definitions of DKA, metabolic ketone monitoring, optimisation of insulin therapy and fluid replacement have since been revised. Raile thinks it is appropriate to use levels of the predominant ketone (BOHB) in DKA for monitoring purposes instead of checking pH values to diagnose acidosis. Recommendations for fluid management have been modified on the basis of the results of randomised trials with different study protocols which revealed no differences among low and rapid rehydration rates or between rehydration with alternative saline concentrations (0.45% or 0.9% saline solution) . 4 Treatment goals and therapy guidance for DKA Treatment goals for DKA include the resolution of dehydration and acidosis as well as inhibition of unrestricted ketogenesis . 2, 5 However, does one have to intravenously substitute fluids and insulin in DKA? The speaker agreed that one should in cases of severe abdominal pain, vomiting, reduced consciousness and serious dehydration. Fluids and insulin are required if moderate to severe acidosis is present (pH value <7.2), irrespective of physical symptoms . 6 Fluid and saline replacement should be initiated, after the extent of dehydration has been evaluated, as an acute compensation in cases of hypovolemia or shock (10 mL per kg); and thereafter continuous infusion should be used for maintenance. Infusion rate is based on fluid deficit assessment (as a general rule 10% of bodyweight is assumed) and bodyweight. ACUTE COMPLICATIONS – DIABETIC KETOACIDOSIS Presented by Professor Klemens Raile - Charité University Medicine An extract from Professor Raile's presentation is available here