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Cetoacidosis diabetica en pediatría COLOMBIA

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Cetoacidosis diabetica en pediatría COLOMBIA

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Cetoacidosis diabetica en pediatría COLOMBIA

  1. 1. Dra. Lucía Hernández Sómerson Residente de pediatría Universidad del Rosario
  2. 2. ¿POR QUÉ HABLAR DE ESTO? • INCIDENCIA :4,6-8,0/ 1.000 • DE CADA 100 NIÑOS MUEREN DE 4 A 10. Barrego, N. Epidemiologia de la diabetes en Colombia. Ministerio de Salud de Colombia. 08/01/2013
  3. 3. PANORAMA NACIONAL Barrego, N. Epidemiologia de la diabetes en Colombia. Ministerio de Salud de Colombia. 08/01/2013
  4. 4. PANORAMA NACIONAL Barrego, N. Epidemiologia de la diabetes en Colombia. Ministerio de Salud de Colombia. 08/01/2013
  5. 5. PANORAMA MUNDIAL Barrego, N. Epidemiologia de la diabetes en Colombia. Ministerio de Salud de Colombia. 08/01/2013
  6. 6. DEFINICIÓN DE CETOACIDOSIS DÉFICIT PROFUNDO DE INSULINA CARACTERIZADO POR : 1. HIPERGLICEMIA (250* mg/dL [11.1 mmol/L]) 2. ACIDOSIS(pH sérico 7.3, bicarbonato <15 mEq/L [15 mmol/L]) 3. EVIDENCIA DE ACUMULACIÓN DE CETOÁCIDOS (medición sérica o en orina de cetonas, aumento de anion gap). Wolfsdorg J, Glaser N, and Sperling M . Diabetic Ketoacidosis in Infants, Children, and Adolescents. .Diabetes Care, Vol 29, Num 5, May 2006. 35-40% de los niños y adolescentes al momento del diagnóstico de la diabetes Disbalance hidroelectrolítico : Potasio, fosforo y magnesio VÓMITO: Anion Gap: >10 DESHIDRATACIÓN Osm:300-330 mOsm/Kg
  7. 7. FISIOLOGÍA Guyton y Hall. Tratado de fisiología médica. Insulina, glucagón y Diabetes Mellitus. 11 Ed. Cap 78. Elsevier Health Sciences, 30/08/2011 ANABOLISMO CATABOLISMO Insulina testosterona Glucagón Cortisol- GH adrenalina β-oxidación Ácidos grasos catabolismo de proteínas Glucogénesis lipogénesis Síntesis proteica Glucólisis:aerobia o anaerobia
  8. 8. FISIOLOGÍA SÍNTESIS DE INSULINA SECRECIÓN DE INSULINA Guyton y Hall. Tratado de fisiología médica. Insulina, glucagón y Diabetes Mellitus. 11 Ed. Cap 78. Elsevier Health Sciences, 30/08/2011
  9. 9. Descargado de hospitalwebquest.wikispaces.com 21-5-13
  10. 10. FISIOLOGÍA LA INSULINA Y SU PAPEL Guyton y Hall. Tratado de fisiología médica. Insulina, glucagón y Diabetes Mellitus. 11 Ed. Cap 78. Elsevier Health Sciences, 30/08/2011 CAPTACIÓN DE GLUCOSA CAPTACIÓN DE AMINOACIDOS SÍNTESIS PROTÉICA SÍNTESIS DE GLUCÓGENO LIPOGÉNESIS GLUCONEOGÉNESIS LIPÓLISIS CETOGÉNESIS
  11. 11. FISIOPATOLOGÍA DE LA CETOACIDOSIS Wolfsdorg J, Glaser N, and Sperling M . Diabetic Ketoacidosis in Infants, Children, and Adolescents. .Diabetes Care, Vol 29, Num 5, May 2006. Absoluta Relativa Debut, interrupción omisión acetoace tato y β- hidroxibut irato);
  12. 12. FISIOPATOLOGÍA DE LA CETOACIDOSIS Descargado de http://www.scp.com.co/ArchivosSCP/27congreso/memorias/salon4/29/player.html 20-5-13 Clasificación de severidad
  13. 13. Y LLEGA EL PACIENTE A URGENCIAS…
  14. 14. MANIFESTACIÓN CLÍNICA Náuseas Vómito Dolor abdominal Disnea Mialgias Anorexia Cefalea Polidipsia Polifagia Poliuria Hipotermia Respiración de Kussmaul (hiperpnea) Aliento cetónico Hiporreflexia Hipotonía muscular Deshidratación Movimientos oculares descordinados, ¿CÓMO NOS LLEGA EL PACIENTE? Wolfsdorg J, Glaser N, and Sperling M . Diabetic Ketoacidosis in Infants, Children, and Adolescents. .Diabetes Care, Vol 29, Num 5, May 2006.
  15. 15. MANIFESTACIONES CLÍNICAS CEFALEA VÓMITO RECURRENTE BRADICARDIA HIPERTENSION DESATURACIÓN CAMBIOS EN EL EXAMEN NEUROLÓGICO Inquietud Irritabilidad Somnolencia incontinencia parálisis de los nervios craneales Respuestas pupilares anormales, Posturas anormales Wolfsdorg J, Glaser N, and Sperling M . Diabetic Ketoacidosis in Infants, Children, and Adolescents. .Diabetes Care, Vol 29, Num 5, May 2006.
  16. 16. DIAGNOSTICO • CLÍNICO • PARACLÍNICO -GLUCOMETRÍAS -GLICEMIA CENTRAL –HbA1C -ELECTROLITOS SÉRICOS COMPLETOS -FUNCIÓN RENAL-UROANÁLISIS -CUERPOS CETÓNICOS EN SANGRE Y ORINA -GASES ARTERIALES-VENOSOS -EKG -¿INFECCIÓN?: PEDIR LO NECESARIO PARA SU ESTUDIO
  17. 17. DIAGNOSTICOS DIFERENCIALES Hipoglicemia Sepsis Uremia Gastroenteritis con acidosis metabólica Acidosis láctica Intoxicación por salicilatos Ingesta de metanol Encefalitis Lesiones intracraneales Evento cerebrovascular
  18. 18. METAS DE TRATAMIENTO HIDRATAR CORREGIR HIPERGLICEMIA CORREGIR ACIDOSIS CORREGIR DISBALANCES ELECTROLÍTICOS
  19. 19. 1.TOMAR SIGNOS VITALES- PESO 2.ABCDE DE REANIMACIÓN 3.MONITORIA CONTINUA 4.EXAMEN FÍSICO GENERAL -ESTA DESHIDRATADO? -ESTA INFECTADO? -ESTADO NEUROLÓGICO? -HAY CETOSIS? 5.TOMAR PARACLÍNICOS 6.HIDRATAR
  20. 20. HIDRATACIÓN EN CETOACIDOSIS 1.BOLO SSN 20 cc/kg 2.HOLLIDAY-SEGAR 3. CÁLCULO DE DHT( MANEJAR COMO GII) • 1ª mitad en primeras 8-12 h, resto en • 24-48 h *Si el sodio es normal usar SSN 0,9%, si hay hipernatremia SS 0,45% *OJO : (se debe corregir el sodio,cada 100 mg/dl de glicemia por encima de 100 disminuye el Na en 1,6 mEq/lt). Coll , M y Durán P. Enfoque práctico de la cetoacidosis diabética en pediatría. CCAP Volumen 7 Número 3 NADA VIA ORAL
  21. 21. Completar examen físico : HAY INFECCIÓN? • Considerar antibióticos si es indicado. • Empezar balance de líquidos estricto Coll , M y Durán P. Enfoque práctico de la cetoacidosis diabética en pediatría. CCAP Volumen 7 Número 3
  22. 22. Signos vitales 2. Resultados de gases: si Ph < 7,25 alertar a UCI y endocrinología pediátrica. Uso de bicarbonato: manejo en UCIP o por Experto Coll , M y Durán P. Enfoque práctico de la cetoacidosis diabética en pediatría. CCAP Volumen 7 Número 3
  23. 23. • Bolo 0,1 u/kg IV de insulina cristalina y continuar con infusión de 0,05-0,1 u/kg/h. Si glicemia < 250, no dar bolo. • Empezar infusión a 0,05-0,1 u/kg/h (dilución: 100 cc SSN + 10 U insulina cristalina; 1 cc = 0,1 U) y cambiar líquidos a 50% SSN y 50% DAD 5% con electrolitos. • SOLO SE SUSPENDE LA INSULINA SI CESA LA CETONEMIA Y LA ACIDOSIS • Si glicemia < 250 o bajando más rápido de 100 mg/dl/h hay que aumentar la infusión de dextrosa pero no disminuir la insulina tan rápidamente y evitar edema cerebral. INICIAMOS LA INSULINA : GLUCOMETRÍA +SV 3 Coll , M y Durán P. Enfoque práctico de la cetoacidosis diabética en pediatría. CCAP Volumen 7 Número 3
  24. 24. – Si potasio > 5,5 no poner K y esperar nuevo control. – K 4,0-5,5 poner 30-40 mEq/lt (utilizar KCL o fosfato de potasio KPO4 para evitar hipercloremia o corregir hipofosfatemia). – K < 4,0 poner 20 mEq/l KCL y 20 mEq/l KPO4. * La CAD y el tratamiento con insulina disminuyen el K y el fosfato. *En las primeras ocho horas corregir mitad con KCL y mitad con KPO porque el fosfato mejora la liberación de O2 a los tejidos. * La hiperfosfatemia produce hipo Ca con tetania. HIDRATACIÓN CALCULADA +MANEJO DEL POTASIO Coll , M y Durán P. Enfoque práctico de la cetoacidosis diabética en pediatría. CCAP Volumen 7 Número 3
  25. 25. Tiempo 60 minutos: • Signos vitales 3. • Glucometría. • Repetir electrolitos. • Gases arteriales. • Cetonemia y cetonuria. Coll , M y Durán P. Enfoque práctico de la cetoacidosis diabética en pediatría. CCAP Volumen 7 Número 3
  26. 26. • Tiempo 90 minutos: • Signos vitales 4. • El paciente debe salir de urgencias ya sea para piso, si está estable, o para UCI. (Usualmente con goteo de insulina van a UCI). Coll , M y Durán P. Enfoque práctico de la cetoacidosis diabética en pediatría. CCAP Volumen 7 Número 3
  27. 27. PRIMERAS 6 HORAS Y CAMBIO DE INSULINA • Glucometría cada hora. • Gases venosos. • Glicemia central. • Electrolitos cada dos horas. • Cetonuria con cada orina o en UCI con sonda vesical cada hora (retirar sonda vesical a las 24 h). • Cetonemia cada cuatro horas. • Monitoreo cardíaco continuo. Coll , M y Durán P. Enfoque práctico de la cetoacidosis diabética en pediatría. CCAP Volumen 7 Número 3
  28. 28. Wolfsdorg J, Glaser N, and Sperling M . Diabetic Ketoacidosis in Infants, Children, and Adolescents. .Diabetes Care, Vol 29, Num 5, May 2006. INSULINOTERAPIA
  29. 29. CONSIDERACIONES ESPECIALES • HIPOFOSFATEMIA: SOLO SE REPONE CUANDO P <1mg/dl O MANIFESTACIONES CLÍNICAS - RIESGO DE HIPOCALCEMIA • BICARBONATO: PRODUCE ACIDOSIS PARADÓJICA EN LCR E HIPOKALEMIA - SOLO EN ACIDOSIS SEVERA 1–2 mmol/kg X60 min • ¿CUANDO INICIO LA DIETA?: PACIENTE HIDRATADO , pH > 7.3 , glicemia <200 mg/dl y HCO3 <18 Wolfsdorg J, Glaser N, and Sperling M . Diabetic Ketoacidosis in Infants, Children, and Adolescents. .Diabetes Care, Vol 29, Num 5, May 2006.
  30. 30. COMPLICACIONES • EDEMA CEREBRAL • 40% DE LAS TAC’S SON NORMALES AL INICIO POSTERIORMENTE MUESTRAN EDEMA , HEMORRAGIAS O INFARTOS • ¿QUIENES TIENEN MAS RIESGO? • ACIDOSIS SEVERA,NEUROLÓGICOS, HIPONATRÉMICOS. • TRATAMIENTO : MANITOL 0.25–1.0 g/kg, SS 3%5–10 ml/kg EN 30 min, , INTUBACIÓN NO HIPERVENTILACIÓN Muir, Andrews et. Al. Cerebral Edema in Childhood Diabetic Ketoacidosis. Diabetes care. Vol 27, Num 7, July 2004
  31. 31. PREVENCIÓN • EVITAR OMISIÓN DE TRATAMIENTO • ENSEÑANZA PSICOSOCIAL • EDUCACIÓN AL PACIENTE • CENTRO DE EMERGENCIA CERCANO • CONSECUCIÓN ANTICIPADA DEL MEDICAMENTO • MÉTODOS DE MEDICIÓN EN CASA • CONSIDERACIÓN ESPECIAL EN EL ADOLESCENTE, PSIQUIÁTRICO O NEUROLÓGICO. • LÍNEAS TELEFÓNICAS DE APOYO • SUPERVISIÓN DE LOS PADRES Wolfsdorg J, Glaser N, and Sperling M . Diabetic Ketoacidosis in Infants, Children, and Adolescents. .Diabetes Care, Vol 29, Num 5, May 2006.
  32. 32. POR ÚLTIMO… Natalicio Frederik Grant Banting Sede Principal: Diagonal 39A Bis No. 14 - 78, Teusaquillo, Bogotá, Colombia Tels: (+57) (1) 7 440888
  33. 33. BIBLIOGRAFÍA • Wolfsdorg J, Glaser N, and Sperling M . Diabetic Ketoacidosis in Infants, Children, and Adolescents. .Diabetes Care, Vol 29, Num 5, May 2006. • • Cooke D, and Plotnick L. Management of Diabetic Ketoacidosis in Children and Adolescents. Pediatr. Rev. 2008;29;431-436 • • Coll , M y Durán P. Enfoque práctico de la cetoacidosis diabética en pediatría. CCAP Volumen 7 Número 3 • • Barrego, N. Epidemiologia de la diabetes en Colombia. Ministerio de Salud de Colombia. 08/01/2013 • Muir, Andrews et. Al. Cerebral Edema in Childhood Diabetic Ketoacidosis. Diabetes care. Vol 27, Num 7, July 2004 • • Guyton y Hall. Tratado de fisiología médica. Insulina, glucagón y Diabetes Mellitus. 11 Ed. Cap 78. Elsevier Health Sciences, 30/08/2011

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