Diabetic ketoacidosis and hyperosmolar hyperglycemic nonketotic coma

Sudden adult death

In the investigation of sudden death in adults, channelopathies, such as long QT syndrome, have risen to the fore in the minds of forensic pathologists in recent years. Examples of these disorders are touched upon in this review as an absence of abnormal findings at postmortem examination is characteristic and the importance of considering the diagnosis lies in the heritable nature of these conditions. Typically, a diagnosis of a possible channelopathy is evoked as an explanation for a 'negative autopsy' in a case of apparent sudden natural death. However, the one potential adverse effect of this approach is that subtle causes of sudden death may be overlooked. The intention of this article is to review and discuss potential causes of sudden adult death (mostly natural) that should be considered before resorting to a diagnosis of possible channelopathy. Nonetheless, it becomes apparent that many of the potential causes of sudden death can have a genetic basis. Thus, it becomes an important consideration that there may be a genetic basis to sudden death that extends beyond the negative autopsy.

Diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) are life-threatening acute metabolic complications of diabetes mellitus. Although there are some important differences, the pathophysiology, the presenting clinical challenge, and the treatment of these metabolic derangements are similar. Each of these complications can be seen in type 1 or type 2 diabetes, although DKA is usually seen in patients with type 1 diabetes and HHNS in patients with type 2 disease. The clinical management of these syndromes involves careful evaluation and correction of the metabolic and volume status of the patient, identification and treatment of precipitating and comorbid conditions, a smooth transition to a long-term treatment regimen, and a plan to prevent recurrence.

Diabetic emergencies: Part 2. Hyperglycaemia

Part 2 of this series explores the pathophysiology and clinical management of diabetic emergencies involving hyperglycaemia, including both diabetic ketoacidosis and the rarer hypernatremic, non-ketotic coma. Part 1 (Hypoglycaemia) was published in Accident and Emergency Nursing 7(4): 190-196.

Ketone bodies: a review of physiology, pathophysiology and application of monitoring to diabetes

Ketone bodies are produced by the liver and used peripherally as an energy source when glucose is not readily available. The two main ketone bodies are acetoacetate (AcAc) and 3-beta-hydroxybutyrate (3HB), while acetone is the third, and least abundant, ketone body. Ketones are always present in the blood and their levels increase during fasting and prolonged exercise. They are also found in the blood of neonates and pregnant women. Diabetes is the most common pathological cause of elevated blood ketones. In diabetic ketoacidosis (DKA), high levels of ketones are produced in response to low insulin levels and high levels of counterregulatory hormones. In acute DKA, the ketone body ratio (3HB:AcAc) rises from normal (1:1) to as high as 10:1. In response to insulin therapy, 3HB levels commonly decrease long before AcAc levels. The frequently employed nitroprusside test only detects AcAc in blood and urine. This test is inconvenient, does not assess the best indicator of ketone body levels (3HB), provides only a semiquantitative assessment of ketone levels and is associated with false-positive results. Recently, inexpensive quantitative tests of 3HB levels have become available for use with small blood samples (5-25 microl). These tests offer new options for monitoring and treating diabetes and other states characterized by the abnormal metabolism of ketone bodies.

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a complex and potentially fatal metabolic disorder in patients with diabetes mellitus. An understanding of the pathophysiology of DKA is essential in order to optimize patient management. A combination of insulin deficiency, increased stress hormone levels, and volume depletion account for the laboratory abnormalities and clinical signs observed in these patients. Successful therapy depends upon correction of hyperglycemia, dehydration, and electrolyte and blood gas abnormalities.

Complications and concurrent disease associated with diabetes mellitus

Many animals with diabetes mellitus are severely ill on clinical presentation. The spectrum of disease is quite variable and includes diabetic ketoacidosis (DKA), ketosis without acidosis, hyperosmolar nonketotic syndrome (HNKS), and other nonketotic variants (negative urine ketones, serum osmolality < 340 mOsm/kg with or without acidosis). These more severe forms of diabetes are often precipitated by concurrent diseases such as pyelonephritis, pancreatitis, pyometra, hyperadrenocorticism, renal failure, and heart failure. To make matters worse, in-hospital treatment of diabetic dogs and cats is commonly associated with serious complications, including hypoglycemia, hypokalemia, and hypophosphatemia.

Renal tubular handling of potassium in children with insulin-dependent diabetes mellitus

To clarify the mechanism by which renal potassium (K) excretion is reduced in children with insulin-dependent diabetes mellitus, we studied two groups of patients: (A) at diagnosis and (B) after at least 1 year of follow-up. Group A (15 children) was studied twice: on the day of admission and after 1 month of insulin therapy. On admission, urinary K excretion, fractional K excretion, and transtubular K concentration gradient (TTKG) were significantly decreased, but became normal after extended insulin therapy. TTKG was inversely correlated with blood glucose (P < 0.001) and hemoglobin A1c (HbA1c, P < 0.001). Group B (73 children with a mean follow-up of 54 +/- 36 months) was subdivided according to the TTKG: 30 patients had a low TTKG < 4.0 (median 3.2) and 43 patients had a normal TTKG > or = 4.0 (median 5.2). Patients had a low TTKG and those with a normal TTKG had an identical duration of follow-up and similar values for plasma renin activity, aldosterone concentration, calciuria, magnesiuria, albumin excretion rate, and creatinine clearance. However, those with a low TTKG had significantly higher blood HbA1c levels, urine volume, and glucosuria. Logistic regression analysis showed that the only independent variables predicting a low TTKG were blood HbA1c and glucosuria (P < 0.001). These data confirm that a reduced renal K excretion is a characteristic feature of diabetic children; this is reversible with appropriate insulin therapy, largely depends on the metabolic control of the disease, and, specifically, on the degree of hyperglycemia and/or glucosuria.

Complications and concurrent disease associated with diabetic ketoacidosis and other severe forms of diabetes mellitus

The more serious forms of diabetes mellitus such as diabetic ketoacidosis (DKA) and hyperosmolar nonketotic syndrome (HNKS) are precipitated commonly by other underlying disease processes. In addition, the treatment of these severe forms of diabetes mellitus are often complicated by therapy. This article discusses common concurrent disorders and therapeutic complications seen in both canine and feline diabetes mellitus.

Diabetic ketoacidosis

This article reviews the pathogenesis of diabetic ketoacidosis (DKA) and provides a rational approach to the management of patients with DKA. The therapeutic discussion includes the use of low-dose insulin, no bicarbonate, or phosphate therapy on the majority of DKA patients, based on numerous prospective randomized studies. The article also discusses controversial subjects such as the use of hypotonic versus isotonic saline with and without colloids, hydration of subjects before insulin therapy, and admission of DKA patients to the general ward versus emergency ward versus intensive care unit. A concise, simple protocol is also presented as a suitable reference for management of patients with DKA.

The use of vitreous humor levels of glucose, lactic acid and blood levels of acetone to establish antemortem hyperglycemia in diabetics

Glucose and lactic acid concentrations were measured in 328 autopsy cases. Glucose and lactic acid in vitreous humor and blood levels of acetone were found to be valuable indicators of antemortem hyperglycemia in diabetics. Resuscitation significantly increased glucose concentrations in vitreous humor whereas blood levels of acetone were not significant (< 1 mg/dl: detection limit). Values encountered in postmortem cases are presented and case results are discussed.

Resource utilization in treatment of diabetic ketoacidosis in adults

This study defines determinants of cost of treatment of diabetic ketoacidosis. A chart review for 92 cases of ketoacidosis from 1988 to 1992 in 40 females and 25 males (age range 18 to 81) showed a length of stay of 5.7 +/- 4.9 d. Length of stay did not correlate with the level of nursing care or any other component of the initial order set. Length of stay was shorter in cases managed by diabetologists. Length of stay was inversely proportional to the interval from arrival to the first shot of intermediate or long-acting insulin. Length of stay was longer in subjects with a positive bacterial culture (mean, 9.1 d) and was longer in subjects who arrived in the evening. There was a female predominance in total and recurrent cases of ketoacidosis. Female patients received fewer educational sessions than males. The grade of acidosis affected the duration of acidemia, but the grade of acidosis, APACHE scores, and admission lab values did not correlate with length of stay. The use of an intensive care unit (ICU) included more testing and expense without uniform clear benefit. Optimal transition from intensive to routine management includes resumption of long-acting insulins as soon as possible. Optimization of hospital care and reduction of incidence of ketoacidosis in females would have a marked effect on health care costs.

Pseudonormoglycemia in diabetic ketoacidosis with elevated triglycerides

A 24-year-old newly diagnosed male patient with diabetes presented with diabetic ketoacidosis (DKA) (pH 7.16, HCO3 6.0) and extreme hypertriglyceridemia (239.35 mmol/L). The diagnosis of DKA was delayed because of the apparent depression of the true serum glucose (to 11 mmol/L). He was treated with intravenous (IV) insulin and rehydration, which normalized his pH, HCO3, and triglyceride levels. To the authors' knowledge, this is both the highest triglyceride level recorded and the first report of a high triglyceride level as the apparent cause of a factitiously low glucose level.

Concepts of fluid therapy in diabetic ketoacidosis and hyperosmolar hyperglycemic nonketotic coma

Despite many advances in the overall treatment of type I diabetes mellitus during the last few years, no major advance has been made in decreasing the mortality rate of diabetic ketoacidosis or hyperosmolar hyperglycemic nonketotic coma. A major concern in both of these disease states is the development of cerebral edema during treatment. The guiding principles of therapy in both disease states are rehydration, electrolyte replacement, insulin therapy, and treatment of any underlying illnesses. If the patient is hypotensive, therapy begins with colloid or normal saline administration to support blood pressure. Fluid and electrolyte deficits should be calculated and replaced during 48 hours. Low-dose insulin therapy is employed for treatment of hyperglycemia. Neurologic function should be carefully monitored and mannitol administered if a change in neurologic function occurs.