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Abstract
Diabetic ketoacidosis (DKA) is a common, serious acute complication in children with diabetes mellitus (DM). DKA can accompany new-onset type 1 insulin-dependent DM, or it can occur with established type 1 DM, during the increased demands of an acute illness or with decreased insulin delivery due to omitted doses or insulin pump failure. In addition, DKA episodes in children with type 2 DM are being reported with greater frequency. Although the diagnosis is usually straightforward in a known diabetes patient with expected findings, a sizable proportion of patients with new-onset DM present with DKA. The purpose of this comprehensive review is to acquaint clinicians with details regarding the pathophysiology, treatment caveats, and potential complications of DKA.
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Glaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, Wolfsdorf JI, Codner E. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022; 23:835-856. [PMID: 36250645 DOI: 10.1111/pedi.13406] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/01/2023] Open
Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Austria Medical University of Graz, Graz, Austria
| | - Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Valentino Cherubini
- Department of Women's and Children's Health, G. Salesi Hospital, Ancona, Italy
| | - Sylvia Estrada
- Department of Pediatrics, Division of Endocrinology and Metabolism, University of the Philippines, College of Medicine, Manila, Philippines
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Agwu JC, Ng SM. Fluid and electrolyte therapy in childhood diabetic ketoacidosis management: A rationale for new national guideline. Diabet Med 2021; 38:e14595. [PMID: 33963601 DOI: 10.1111/dme.14595] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 05/04/2021] [Indexed: 12/13/2022]
Abstract
Fluid and electrolyte therapy in childhood diabetic ketoacidosis (DKA) management has been controversial. Previous National Institute for Health and Care Excellence (NICE) 2015 guidance advocated a restricted fluid regimen while more recent guidelines have advocated a more liberal approach to fluid replacement in DKA. At the core of the debate is the need to avoid developing cerebral oedema as a complication. Although subtle asymptomatic cerebral oedema is common in children presenting in DKA, clinically apparent cerebral oedema is rare and has been reported in approximately 0.5%-1% of DKA cases in children. Recent research evidence has shown that there was no clear evidence of a difference in rates of clinically apparent cerebral injury in children in DKA managed with a range of fluid volumes and rates of rehydration. In view of this, NICE has updated its guideline. In this paper, we review literature evidence underpinning the current understanding of the pathophysiology of cerebral oedema in children and discuss the rationale for the new NICE guidance.
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Affiliation(s)
- Juliana Chizo Agwu
- Department of Paediatrics, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Institute of Clinical Sciences, College of Medicine and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sze M Ng
- Paediatric Department, Southport and Ormskirk NHS Trust, Ormskirk, UK
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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Long B, Lentz S, Koyfman A, Gottlieb M. Euglycemic diabetic ketoacidosis: Etiologies, evaluation, and management. Am J Emerg Med 2021; 44:157-160. [PMID: 33626481 DOI: 10.1016/j.ajem.2021.02.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Diabetic ketoacidosis is an endocrine emergency. A subset of diabetic patients may present with relative euglycemia with acidosis, known as euglycemic diabetic ketoacidosis (EDKA), which is often misdiagnosed due to a serum glucose <250 mg/dL. OBJECTIVE This narrative review evaluates the pathogenesis, diagnosis, and management of EDKA for emergency clinicians. DISCUSSION EDKA is comprised of serum glucose <250 mg/dL with an anion gap metabolic acidosis and ketosis. It most commonly occurs in patients with a history of low glucose states such as starvation, chronic liver disease, pregnancy, infection, and alcohol use. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, which result in increased urinary glucose excretion, are also associated with EDKA. The underlying pathophysiology involves insulin deficiency or resistance with glucagon release, poor glucose availability, ketone body production, and urinary glucose excretion. Patients typically present with nausea, vomiting, malaise, or fatigue. The physician must determine and treat the underlying etiology of EDKA. Laboratory assessment includes venous blood gas for serum pH, bicarbonate, and ketones. Management includes resuscitation with intravenous fluids, insulin, and glucose, with treatment of the underlying etiology. CONCLUSIONS Clinician knowledge of this condition can improve the evaluation and management of patients with EDKA.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States of America.
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, VT, United States of America
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States of America
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL 60612, United States of America
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Long B, Willis GC, Lentz S, Koyfman A, Gottlieb M. Evaluation and Management of the Critically Ill Adult With Diabetic Ketoacidosis. J Emerg Med 2020; 59:371-383. [DOI: 10.1016/j.jemermed.2020.06.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/24/2020] [Accepted: 06/11/2020] [Indexed: 12/19/2022]
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 344] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Tan JN, Haroon SWP, Mukhopadhyay A, Lau T, Murali TM, Phua J, Tan ZY, Lee N, Chua HR. Hyperlactatemia Predicts Citrate Intolerance With Regional Citrate Anticoagulation During Continuous Renal Replacement Therapy. J Intensive Care Med 2017; 34:418-425. [PMID: 28372501 DOI: 10.1177/0885066617701068] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE: We aim to determine whether hyperlactatemia, which suggests multi-organ dysfunction and impaired organic substrate metabolism, may predict intolerance to regional citrate anticoagulation (RCA) during continuous venovenous hemofiltration (CVVH). METHODS: We performed a single-center, retrospective observational study in critically ill patients with acute kidney injury or end-stage renal disease and evaluated the association of peak serum lactate levels with citrate intolerance (CI) during the initial 72 hours of RCA-CVVH, defined by serum total-to-ionized calcium >2.5 plus systemic hypocalcemia. RESULTS: Eighty-eight patients were studied (aged 59 ± 14 years, 66% males, Acute Physiology and Chronic Health Evaluation II: 31 ± 8). Citrate was dosed at median 2.1 mmol/L of blood flow, with citrate load of 30 mmol/h, and CVVH effluent of 43 mL/kg/h. Twenty patients developed CI. Comparing patients with CI versus none, peak lactate levels were 8 (5-11) versus 3 (2-6) mmol/L, calcium replacement was 13 (10-17) versus 11 (8-12) mmol/h, and standard base excess was -4 (-12 to 1) versus 2(-4 to 7) mmol/L, respectively ( P < .05). Citrate intolerance developed in 38%, 44%, and 55%, in patients with peak lactate >4, >6, >7 mmol/L, respectively, versus 7% in those with peak lactate ≤4 mmol/L ( P ≤ .001), despite comparable citrate load and effluent rates across all categories. On multivariate analysis, hyperlactatemia and hyperbilirubinemia predicted CI ( P ≤ .01), which was associated with increasing calcium infusion requirement. Higher peak lactate from >4 to >7 mmol/L predicted CI with graded increase in odds ratio and specificity from 59% to 87%, but the corresponding negative predictive value from 93% to 87%. Area under nonparametric receiver operating characteristic curve for peak lactate and CI was 0.78. CONCLUSION: Hyperlactatemia predicts CI during RCA-CVVH with reasonable discriminatory performance in critically ill patients. Serum lactate surveillance may help preempt issues with citrate toxicity.
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Affiliation(s)
- Jia-Neng Tan
- 1 Division of Nephrology, University Medicine Cluster, National University Hospital, Republic of Singapore.,2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore
| | - Sabrina Wong Peixin Haroon
- 1 Division of Nephrology, University Medicine Cluster, National University Hospital, Republic of Singapore.,2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore
| | - Amartya Mukhopadhyay
- 2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore.,3 Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, Republic of Singapore
| | - Titus Lau
- 1 Division of Nephrology, University Medicine Cluster, National University Hospital, Republic of Singapore.,2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore
| | - Tanusya M Murali
- 1 Division of Nephrology, University Medicine Cluster, National University Hospital, Republic of Singapore.,2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore
| | - Jason Phua
- 2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore.,3 Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, Republic of Singapore
| | - Zong-Yao Tan
- 4 National University of Singapore High School of Mathematics and Science, Republic of Singapore
| | - Nicholas Lee
- 4 National University of Singapore High School of Mathematics and Science, Republic of Singapore
| | - Horng-Ruey Chua
- 1 Division of Nephrology, University Medicine Cluster, National University Hospital, Republic of Singapore.,2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore
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Konstantinov NK, Rohrscheib M, Agaba EI, Dorin RI, Murata GH, Tzamaloukas AH. Respiratory failure in diabetic ketoacidosis. World J Diabetes 2015; 6:1009-1023. [PMID: 26240698 PMCID: PMC4515441 DOI: 10.4239/wjd.v6.i8.1009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 01/08/2015] [Accepted: 05/27/2015] [Indexed: 02/05/2023] Open
Abstract
Respiratory failure complicating the course of diabetic ketoacidosis (DKA) is a source of increased morbidity and mortality. Detection of respiratory failure in DKA requires focused clinical monitoring, careful interpretation of arterial blood gases, and investigation for conditions that can affect adversely the respiration. Conditions that compromise respiratory function caused by DKA can be detected at presentation but are usually more prevalent during treatment. These conditions include deficits of potassium, magnesium and phosphate and hydrostatic or non-hydrostatic pulmonary edema. Conditions not caused by DKA that can worsen respiratory function under the added stress of DKA include infections of the respiratory system, pre-existing respiratory or neuromuscular disease and miscellaneous other conditions. Prompt recognition and management of the conditions that can lead to respiratory failure in DKA may prevent respiratory failure and improve mortality from DKA.
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Adeva-Andany MM, Fernández-Fernández C, Mouriño-Bayolo D, Castro-Quintela E, Domínguez-Montero A. Sodium bicarbonate therapy in patients with metabolic acidosis. ScientificWorldJournal 2014; 2014:627673. [PMID: 25405229 PMCID: PMC4227445 DOI: 10.1155/2014/627673] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 09/05/2014] [Accepted: 09/19/2014] [Indexed: 01/18/2023] Open
Abstract
Metabolic acidosis occurs when a relative accumulation of plasma anions in excess of cations reduces plasma pH. Replacement of sodium bicarbonate to patients with sodium bicarbonate loss due to diarrhea or renal proximal tubular acidosis is useful, but there is no definite evidence that sodium bicarbonate administration to patients with acute metabolic acidosis, including diabetic ketoacidosis, lactic acidosis, septic shock, intraoperative metabolic acidosis, or cardiac arrest, is beneficial regarding clinical outcomes or mortality rate. Patients with advanced chronic kidney disease usually show metabolic acidosis due to increased unmeasured anions and hyperchloremia. It has been suggested that metabolic acidosis might have a negative impact on progression of kidney dysfunction and that sodium bicarbonate administration might attenuate this effect, but further evaluation is required to validate such a renoprotective strategy. Sodium bicarbonate is the predominant buffer used in dialysis fluids and patients on maintenance dialysis are subjected to a load of sodium bicarbonate during the sessions, suffering a transient metabolic alkalosis of variable severity. Side effects associated with sodium bicarbonate therapy include hypercapnia, hypokalemia, ionized hypocalcemia, and QTc interval prolongation. The potential impact of regular sodium bicarbonate therapy on worsening vascular calcifications in patients with chronic kidney disease has been insufficiently investigated.
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Affiliation(s)
- María M. Adeva-Andany
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - Carlos Fernández-Fernández
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - David Mouriño-Bayolo
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - Elvira Castro-Quintela
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - Alberto Domínguez-Montero
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
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Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WWR, Mungai LNW, Rosenbloom AL, Sperling MA, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014; 15 Suppl 20:154-79. [PMID: 25041509 DOI: 10.1111/pedi.12165] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 12/16/2022] Open
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12
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Goguen J, Gilbert J. Urgences hyperglycémiques chez l’adulte. Can J Diabetes 2013. [DOI: 10.1016/j.jcjd.2013.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Koves IH, Pihoker C. Pediatric diabetic ketoacidosis management in the era of standardization. Expert Rev Endocrinol Metab 2012; 7:433-443. [PMID: 30754163 DOI: 10.1586/eem.12.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Up to 70% of children with new-onset Type 1 diabetes mellitus (T1DM) present with diabetic ketoacidosis (DKA), with most cases initially assessed by their primary care provider. DKA is the most common cause of death in children with T1DM, mainly related to cerebral edema that occurs at a frequency of 0.15-4.6%. Early recognition of DKA can be improved by increasing the awareness of early clinical symptoms such as enuresis, polyuria and polydipsia. Clinical acumen paired with early assessment of patients with suspected T1DM and known T1DM, particularly if risk factors for DKA are present, can prevent serious complications and fatal outcomes. Urgent referral to specialist centers for suspected new-onset T1DM/DKA is required. A standardized approach is recommended to be followed to ensure successful initial management of DKA, both in the nonspecialist setting before transfer and in the more specialized hospital setting. This article outlines such a management approach.
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Affiliation(s)
- Ildiko H Koves
- b Seattle Children's Hospital, Division of Endocrinology and Diabetes, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
| | - Catherine Pihoker
- a Seattle Children's Hospital, Division of Endocrinology and Diabetes, 4800 Sand Point Way NE, Seattle, WA 98105, USA
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Abstract
Objective This study was designed to examine the efficacy and risk of bicarbonate administration in the emergent treatment of severe acidemia in diabetic ketoacidosis (DKA). Methods PUBMED database was used to identify potentially relevant articles in the pediatric and adult DKA populations. DKA intervention studies on bicarbonate administration versus no bicarbonate in the emergent therapy, acid-base studies, studies on risk association with cerebral edema, and related case reports, were selected for review. Two reviewers independently conducted data extraction and assessed the citation relevance for inclusion. Results From 508 potentially relevant articles, 44 were included in the systematic review, including three adult randomized controlled trials (RCT) on bicarbonate administration versus no bicarbonate in DKA. We observed a marked heterogeneity in pH threshold, concentration, amount, and timing for bicarbonate administration in various studies. Two RCTs demonstrated transient improvement in metabolic acidosis with bicarbonate treatment within the initial 2 hours. There was no evidence of improved glycemic control or clinical efficacy. There was retrospective evidence of increased risk for cerebral edema and prolonged hospitalization in children who received bicarbonate, and weak evidence of transient paradoxical worsening of ketosis, and increased need for potassium supplementation. No studies involved patients with an initial pH < 6.85. Conclusions The evidence to date does not justify the administration of bicarbonate for the emergent treatment of DKA, especially in the pediatric population, in view of possible clinical harm and lack of sustained benefits.
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Affiliation(s)
- Horng Ruey Chua
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia.
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Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee W, Rosenbloom A, Sperling M, Hanas R. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes 2009; 10 Suppl 12:118-33. [PMID: 19754623 DOI: 10.1111/j.1399-5448.2009.00569.x] [Citation(s) in RCA: 172] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Joseph Wolfsdorf
- Division of Endocrinology, Children's Hospital Boston, MA 02115, USA.
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Barone B, Rodacki M, Cenci MCP, Zajdenverg L, Milech A, Oliveira JEPD. [Diabetic ketoacidosis in adults--update of an old complication]. ACTA ACUST UNITED AC 2009; 51:1434-47. [PMID: 18209885 DOI: 10.1590/s0004-27302007000900005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2007] [Accepted: 06/22/2007] [Indexed: 12/21/2022]
Abstract
Diabetic ketoacidosis is an acute complication of Diabetes Mellitus characterized by hyperglycemia, metabolic acidosis, dehydration, and ketosis, in patients with profound insulin deficiency. It occurs predominantly in patients with type 1 diabetes and is frequently precipitated by infections, insulin withdrawal or undiagnosed type 1 diabetes. The authors review its pathophysiology, diagnostic criteria and treatment options in adults, as well as its complications.
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Affiliation(s)
- Bianca Barone
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, Instituto Estadual de Diabetes, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ
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Affiliation(s)
- Joseph Wolfsdorf
- Division of Endocrinology, Children's Hospital Boston, Boston, MA, USA
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Affiliation(s)
- Joseph Wolfsdorf
- Division of Endocrinology, Children's Hospital Boston, Boston, Massachusetts, USA
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Abstract
Diabetic ketoacidosis is an important complication of diabetes in children and is the most frequent diabetes-related cause of death in childhood. The pathophysiology of this condition can be viewed as an exaggeration of the normal physiologic mechanisms responsible for maintaining an adequate fuel supply to the brain and other tissues during periods of fasting and physiologic stress. The optimal therapy has been a subject of controversy, particularly because the most frequent serious complication of diabetic ketoacidosis-cerebral edema-and the relationship of this complication to treatment are incompletely understood. In this article, the author reviews the pathophysiology of diabetic ketoacidosis and its complications and presents an evidence-based approach to the management of this condition.
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Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, School of Medicine, University of California-Davis, 2516 Stockton Boulevard, Sacramento, CA 95817, USA.
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Abstract
Diabetic ketoacidosis (DKA) is the most common hyperglycemic emergency in patients with diabetes mellitus. DKA most often occurs in patients with type 1 diabetes, but patients with type 2 diabetes are susceptible to DKA under stressful conditions, such as trauma, surgery, or infections. DKA is reported to be responsible for more than 100 000 hospital admissions per year in the US, and accounts for 4-9% of all hospital discharge summaries among patients with diabetes. Treatment of patients with DKA uses significant healthcare resources and accounts for 1 out of every 4 healthcare dollars spent on direct medical care for adult patients with type 1 diabetes in the US. Recent studies using standardized written guidelines for therapy have demonstrated a mortality rate of less than 5%, with higher mortality rates observed in elderly patients and those with concomitant life-threatening illnesses. Worldwide, infection is the most common precipitating cause for DKA, occurring in 30-50% of cases. Urinary tract infection and pneumonia account for the majority of infections. Other precipitating causes are intercurrent illnesses (i.e., surgery, trauma, myocardial ischemia, pancreatitis), psychological stress, and non-compliance with insulin therapy. The triad of uncontrolled hyperglycemia, metabolic acidosis and increased total body ketone concentration characterizes DKA. These metabolic derangements result from the combination of absolute or relative insulin deficiency and increased levels of counter-regulatory hormones (glucagon, catecholamines, cortisol, and growth hormone). Successful treatment of DKA requires frequent monitoring of patients, correction of hypovolemia and hyperglycemia, replacement of electrolyte losses, and careful search for the precipitating cause. Since the majority of DKA cases occur in patients with a known history of diabetes, this acute metabolic complication should be largely preventable through early detection, and by the education of patients, healthcare professionals, and the general public. The frequency of hospitalizations for DKA has been reduced following diabetes education programs, improved follow-up care, and access to medical advice. Novel approaches to patient education incorporating a variety of healthcare beliefs and socioeconomic issues are critical to an effective prevention program.
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Affiliation(s)
- Guillermo E Umpierrez
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA.
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Abstract
Diabetic ketoacidosis, hyperglycaemic hyperosmolar state, and lactic acidosis represent three of the most serious acute complications of diabetes. There have been some advances in our understanding of the pathogenesis of these conditions over the last three decades, together with more uniform agreement on their treatment and innovations in technology. Accordingly their incidence, morbidity, and mortality are decreasing, but at rates that fall short of our aspirations. Hyperglycaemic crises in particular remain an important cause of morbidity and mortality in diabetic populations around the world. In this article, understanding of these conditions and advances in their management, and the available guidelines for their treatment, are reviewed. As far as is possible, the recommendations are based on clear published evidence; failing that, what is considered to be a common sense synthesis of consensus guidelines and recommendations is provided.
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Affiliation(s)
- P English
- Diabetes and Endocrinology Research Group, Clinical Sciences Centre, University Hospital Aintree, Liverpool, UK.
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Dunger DB, Sperling MA, Acerini CL, Bohn DJ, Daneman D, Danne TPA, Glaser NS, Hanas R, Hintz RL, Levitsky LL, Savage MO, Tasker RC, Wolfsdorf JI. ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents. Arch Dis Child 2004; 89:188-94. [PMID: 14736641 PMCID: PMC1719805 DOI: 10.1136/adc.2003.044875] [Citation(s) in RCA: 215] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (TIDM). Mortality is predominantly related to the occurrence of cerebral oedema; only a minority of deaths in DKA are attributed to other causes. Cerebral oedema occurs in about 0.3-1% of all episodes of DKA, and its aetiology, pathophysiology, and ideal method of treatment are poorly understood. There is debate as to whether physicians treating DKA can prevent or predict the occurrence of cerebral oedema, and the appropriate site(s) for children with DKA to be managed. There is agreement that prevention of DKA and reduction of its incidence should be a goal in managing children with diabetes.
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Affiliation(s)
- D B Dunger
- University of Cambridge, Department of Paediatrics, Addenbrooke's Hospital, Level 8, Box 116, Cambridge CB2 2QQ, UK.
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Dunger DB, Sperling MA, Acerini CL, Bohn DJ, Daneman D, Danne TPA, Glaser NS, Hanas R, Hintz RL, Levitsky LL, Savage MO, Tasker RC, Wolfsdorf JI. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics 2004; 113:e133-40. [PMID: 14754983 DOI: 10.1542/peds.113.2.e133] [Citation(s) in RCA: 172] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- David B Dunger
- European Society for Paediatric Endocrinology, West Smithfield, London, United Kingdom.
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Abstract
Severe acidemia (blood pH < 7.1 to 7.2) suppresses myocardial contractility, predisposes to cardiac arrhythmias, causes venoconstriction, and can decrease total peripheral vascular resistance and blood pressure, reduce hepatic blood flow, and impair oxygen delivery. These alterations in organ function can contribute to increased morbidity and mortality. Although it seemed logical to administer sodium bicarbonate to attenuate acidemia and therefore lessen the impact on cardiac function, the routine use of bicarbonate in the treatment of the most common causes of severe acidemia, diabetic ketoacidosis, lactic acidosis, and cardiac arrest, has been an issue of great controversy. Studies of animals and patients with these disorders have reported conflicting data on the benefits of bicarbonate, showing both beneficial and detrimental effects. Alternative alkalinizing agents, tris-hydroxymethyl aminomethane and Carbicarb, have shown some promise in studies of animals and humans, and reevaluation of these buffers in the treatment of severe acidemic states seems warranted. The potential value of base therapy in the treatment of severe acidemia remains an important issue, and further studies are required to determine which patients should be administered base therapy and what base should be used.
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Affiliation(s)
- J A Kraut
- Division of Nephrology, Veterans Administration Greater Los Angeles Health Care System, Los Angeles, CA 90073, USA.
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Abstract
OBJECTIVE The use of bicarbonates in the treatment of severe diabetic ketoacidosis remains controversial, especially regarding the benefit/risk ratio. The aim of this study was to assess the efficacy of bicarbonate therapy during severe diabetic ketoacidosis (pH <7.10). DESIGN Retrospective study. SETTING The emergency unit of a teaching hospital. PATIENTS The records of 39 patients consecutively admitted for severe diabetic ketoacidosis were analyzed (pH <7.10). The patients were divided into two groups: group 1 (n = 24; patients with bicarbonate treatment) and group 2 (n = 15; patients without bicarbonate treatment). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We compared two groups of patients presenting with severe diabetic ketoacidosis (pH values between 6.83 and 7.08) treated with or without bicarbonate. A group of 24 patients received 120+/-40 mmol sodium bicarbonate. The two groups were similar at admission with regard to clinical and biological parameters. No difference could be demonstrated between the two groups concerning the clinical parameters or the normalization time of biochemical parameters. If the number of patients with hypokalemia was comparable between the two groups, the potassium supply was significantly more important in group 1 compared with group 2 (366+/-74 mmol/L vs. 188+/-109 mmol/L, respectively; p < .001). CONCLUSIONS Data from the literature and this study are not in favor of the use of bicarbonate in the treatment of diabetic ketoacidosis with pH values between 6.90 and 7.10.
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Affiliation(s)
- A Viallon
- Emergency and Intensive Care Units, Hôpital Bellevue, Centre Hospitalo-Universitaire, Saint-Etienne, France
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Green SM, Rothrock SG, Ho JD, Gallant RD, Borger R, Thomas TL, Zimmerman GJ. Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis. Ann Emerg Med 1998; 31:41-8. [PMID: 9437340 DOI: 10.1016/s0196-0644(98)70279-3] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVE Although adjunctive intravenous bicarbonate therapy is commonly recommended for children with severe diabetic ketoacidosis (DKA), no studies assessing clinical outcome with this therapy have ever been performed. Our objective was to determine whether bicarbonate therapy influenced outcome for pediatric DKA. METHODS The study was a retrospective consecutive case series of 147 admissions for severe DKA (initial pH < or = 7.15 and glucose concentration > or = 300 mg/dL [16.7 mmol/L]) in 106 children during a 16-year period at a tertiary university medical center. Descriptive statistics were applied to the 147 admissions. The first patient admitted with DKA was then selected for each of the 106 children, and clinical and laboratory data were compared between subjects who did and did not receive bicarbonate. Multivariate and matched pair analyses were performed to control potentially confounding variables. RESULTS Fifty-seven of the 147 patients admitted with DKA (39%) were successfully treated without bicarbonate, including 9 with a pH of 7.00 or less and one with a pH of 6.73. The frequency of complications was comparable between bicarbonate and nonbicarbonate groups (4% versus 2%, P = 1.00). The mean duration of hospitalization for children receiving bicarbonate was 23% (16 hours) longer than children who did not receive bicarbonate in the multivariate analysis (P = .07) and 37% (22 hours) longer in the matched pair analysis (P = .01). The mean rate of metabolic recovery by three distinct measures was similar between groups, and the sample had 80% power to detect differences of 14% to 29% in these measures. CONCLUSION We found no evidence that adjunctive bicarbonate improved clinical outcome in children with severe DKA. The rate of metabolic recovery and complications were similar in patients treated with and without bicarbonate, and prolonged hospitalizations were noted in the bicarbonate group. We conclude that adjunctive bicarbonate is unnecessary and potentially disadvantageous in severe pediatric DKA.
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Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University School of Medicine, CA, USA
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Affiliation(s)
- G E Umpierrez
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303, USA
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Affiliation(s)
- H E Lebovitz
- Department of Medicine, State University of New York Health Science Center at Brooklyn, 11203-2098
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31
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Riley LJ, Cooper M, Narins RG. Alkali therapy of diabetic ketoacidosis: biochemical, physiologic, and clinical perspectives. Diabetes Metab Rev 1989; 5:627-36. [PMID: 2558864 DOI: 10.1002/dmr.5610050801] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- L J Riley
- Section of Nephrology, Temple University Health Sciences Center, Philadelphia, Pennsylvania 19140
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Affiliation(s)
- M Walker
- Department of Medicine, Medical School, Newcastle Upon Tyne, England
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Oster JR, Alpert HC, Rodriguez GR, Vaamonde CA. Effect of acute reversal of experimentally-induced ketoacidosis with sodium bicarbonate on the plasma concentrations of phosphorus and potassium. Life Sci 1988; 42:811-9. [PMID: 2828806 DOI: 10.1016/0024-3205(88)90655-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
To determine if ketoacidosis per se, or its reversal with NaHCO3, predisposes to hypophosphatemia, six conditioned dogs were infused for two hours with 3.0 mmol/kg body wt/hour of beta-hydroxybutyric acid, followed by 1.5 mmol/kg/hour of NaHCO3 for two hours. Acid infusion caused moderate decrements in blood pH and [HCO3], a 23 +/- 4% increase in plasma [P] (p less than 0.005), and a 15 +/- 3% decrease in plasma [K] (p less than 0.005). NaHCO3 administration returned blood pH and [HCO3] levels to or slightly greater than baseline. Plasma [P] decreased, but not below baseline, whereas plasma [K] remained below baseline, and underwent an additional small decline (p less than 0.01). We conclude that acute correction of experimental ketoacidosis with NaHCO3 reverses the characteristic hyperphosphatemia but does not induce hypophosphatemia. On the other hand, NaHCO3 administration appeared to contribute to the perpetuation of hypokalemia.
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Affiliation(s)
- J R Oster
- Medical Service, Veterans Administration, Miami, Florida
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35
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36
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Abstract
We report the biochemical data of 22 hospital admissions because of untreated diabetic ketoacidosis. Fifty percent of admitted patients showed an initial serum potassium between 4.6 and 6.0 mEq/l whereas severe hyperkalemia (value greater than 6.1 mEq/l) occurred in 32%. Initial potassium levels show a slight negative correlation with pH but a stronger correlation (p less than 0.001) was found between the initial serum potassium and glucose values. We suggest that hyperglycemia due to insulinopenia must be one of the factors in the pathogenesis of this hyperkalemia.
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37
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Patel DG, Kalhan SC. Diabetic ketoacidosis. Indian J Pediatr 1986; 53:559-72. [PMID: 3102368 DOI: 10.1007/bf02748659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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38
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Abstract
The effect of intravenous bicarbonate on the changes in intermediary metabolites during the initial treatment of diabetic ketoacidosis was examined in 16 patients. The results were compared with the changes seen in 16 patients receiving intravenous saline. Infusion of 150 mmol (mEq) bicarbonate significantly delayed the fall in blood lactate, lactate:pyruvate ratio, and total ketone bodies observed in the saline treated group. No difference in the rate of fall of blood glucose concentration was found. There is no metabolic indication for the use of intravenous bicarbonate in the treatment of diabetic ketoacidosis.
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39
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Abstract
Rates of recovery of plasma glucose and bicarbonate levels, arterial pH, and level of consciousness were determined in a retrospective analysis of 95 episodes of severe diabetic ketoacidosis in patients treated with conventional regimens including low-dose insulin, saline, and potassium administration. No significant differences were found between 73 episodes in 52 patients treated with sodium bicarbonate and 22 episodes in 21 patients not undergoing such treatment. In view of these observations, the potential hazards of sodium bicarbonate replacement therapy, and the fact that sodium bicarbonate is still frequently given, the use of intravenous sodium bicarbonate treatment in patients with severe diabetic ketoacidosis requires reevaluation.
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42
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Abstract
A brief review of some therapy results in 763 episodes of diabetic coma from 1960 to 1973 reveals a significant decrease in lethality after institution of an intensive care unit. Present aspects of management are: intensification of shock therapy, potassium substitution and treatment of cerebral edema. The possibly dangerous role of hypotonic solutions is discussed. The lowering of the as yet high lethality of diabetic coma is an urgent necessity.
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Abstract
A review if presented of the use of low-dose insulin infusion in the management of 58 episodes of severe diabetic hyperglycaemia. Neutral insulin in a dosage of 2-4 units per hour is infused via a paediatric giving set to achieve a sustained physiological elevation of insulin levels. This method is safe, simple and rapidly effective in lowering the blood glucose level, the mean rate of fall (62 mg/100 ml/hr, or 11% per hour) being unaffected by prior insulin therapy, acidosis or ketonuria. Classification of the hyperglycaemia as ketoacidotic or hyperosmolar is unnecessary before insulin therapy is instituted, as the relative decline in glucose level is the same in the hyperosmolar non-ketotic group as in the others. Proven infection significantly lowers the rate of fall of glucose level. Hypoglycaemia and hypokalaemia are rare during low-dose infusion. Early and adequate replacement with potassium phosphate is recommended, oral potassium supplements being continued for several days. Bicarbonate therapy is rarely indicated in the management of acidosis. No patient had cerebral oedema during treatment, and one elderly patient with extensive pneumonia and empyema died during the infusion. It is suggested that continuation of low-dose insulin infusion, together with 5% dextrose solution, after the plasma glucose level reaches 200 mg/100 ml, may hasten the clearance of ketones, preventing relapse.
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44
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Abstract
The diagnosis of diabetic ketoacidosis must be suspected and the initiation of treatment should be prompt to provide a satisfactory outcome in the treatment of diabetic ketoacidosis. Corrections of fluid and electrolyte deficiencies should be made slowly; rapid "push"injections or large infusions of sodium bicarbonate should avoided and ample amounts of potassium should be given early. Precautions should be taken so that blood glucose concentrations do not fall rapidly, and so that blood glucose levels of 250-300 mg/100 ml are maintained by the administration of 5-10% glucose solutions. Bicarbonate therapy is indicated only in severe acidosis (pH less than or equal to 7.1). Physicians who are trained in the care of diabetes mellitus should supervise the treatment. In our hospital the same staff physicians and fellows attend all patients with diabetes. In addition the efforts of our house staff and nurses have contributed significantly to the care of these patients.
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45
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Abstract
36 patients in severe diabetic ketoacidosis were studied prospectively. All patients were treated with small doses of insulin, the first 18 by the intramuscular route and the remainder by continuous intravenous infusion. These patients were compared with 25 ketoacidotic patients who were treated with large intravenous boluses of insulin. With the intramuscular regimen there was a slower fall of blood-sugar than with intravenous insulin administered either in boluses or as a continuous infusion. The acidosis took longer to correct when small doses of insulin were used. In practice a long time interval between correction of the hyperglycaemia and correction of the acidosis may be a problem when the continuous infusion of insulin is used. Potassium requirements during treatment were identical (30-40 mmol/l fluid infused) and independent of the insulin regimen. However, small doses of insulin led to a poor retention of potassium. In the management of diabetic ketoacidosis the mode of administration of insulin is of limited significance, and small doses, although effective in most cases, are not clearly superior to conventional treatment with large doses.
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Keller U, Berger W, Ritz R, Truog P. Course and prognosis of 86 episodes of diabetic coma. A five year experience with a uniform schedule of treatment. Diabetologia. 1975;11:93-100. [PMID: 238893 DOI: 10.1007/bf00429380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The admission data and the course of 58 episodes of severe diabetic ketoacidotic coma and of 28 episodes of non-ketotic coma are compared. The non-ketotic patients were older; initial blood glucose, osmolarity, blood urea and serum sodium concentration were higher than in the ketotic patients. Treatment in the first 24 hrs consisted of similar amounts of insulin in both coma forms, the presence of acidaemia did not increase the insulin needs. Acidaemia was corrected only when pH was below 7.20. The disadvantages of alkali therapy are emphasized. A comparison of the age groups of survivors and those patients who died within 72 hrs showed an increase in mortality with age. However, the mortality rates from ketotic and non-ketotic coma were similar in the age groups above 50 years. On admission, blood glucose, osmolarity and blood urea were higher in the fatal cases. Blood urea was the most important indicator of a fatal outcome. The response of blood glucose to insulin was impaired in the subsequently fatal cases. Insulin was given in "moderate" doses by constant infusion. The use of "small" doses is discussed. Early mortality was 14% in the ketotic and 29% in the non-ketotic cases. The most frequent causes of death were circulatory failure of undetermined origin, infections and thromboembolic complications.
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Keller U, Berger W, Ritz R, Truog P. Course and prognosis of 86 episodes of diabetic coma. A five year experience with a uniform schedule of treatment. Diabetologia 1975; 11:93-100. [PMID: 238893 DOI: 10.1007/bf00429830] [Citation(s) in RCA: 65] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The admission data and the course of 58 episodes of severe diabetic ketoacidotic coma and of 28 episodes of non-ketotic coma are compared. The non-ketotic patients were older; initial blood glucose, osmolarity, blood urea and serum sodium concentration were higher than in the ketotic patients. Treatment in the first 24 hrs consisted of similar amounts of insulin in both coma forms, the presence of acidaemia did not increase the insulin needs. Acidaemia was corrected only when pH was below 7.20. The disadvantages of alkali therapy are emphasized. A comparison of the age groups of survivors and those patients who died within 72 hrs showed an increase in mortality with age. However, the mortality rates from ketotic and non-ketotic coma were similar in the age groups above 50 years. On admission, blood glucose, osmolarity and blood urea were higher in the fatal cases. Blood urea was the most important indicator of a fatal outcome. The response of blood glucose to insulin was impaired in the subsequently fatal cases. Insulin was given in "moderate" doses by constant infusion. The use of "small" doses is discussed. Early mortality was 14% in the ketotic and 29% in the non-ketotic cases. The most frequent causes of death were circulatory failure of undetermined origin, infections and thromboembolic complications.
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48
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49
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Walsh CH, Soler NG, James H, Fitzgerald MG, Malins JM. Studies on whole-body potassium in non-ketoacidotic diabetics before and after treatment. Br Med J 1974; 4:738-40. [PMID: 4216389 PMCID: PMC1612802 DOI: 10.1136/bmj.4.5947.738] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Serial measurements of whole-body potassium were carried out in 28 diabetic patients, in 23 of whom diabetes had only recently been diagnosed. Eleven patients were treated with insulin, 12 with oral hypoglycaemic agents, and the rest were already on oral hypoglycaemic agents and had developed poor diabetic control; four of these required insulin. Whole-body potassium was measured before treatment was begun (or altered) and again one and six weeks later. Whole-body potassium (ratio of observed to expected) was initially reduced in most of the patients requiring insulin. After control of diabetes whole-body potassium increased significantly in the three groups. The increase in whole-body potassium in the individual patients varied over a wide range, and in patients who were treated with insulin it was often of a similar magnitude to that observed in patients in diabetic ketoacidosis.
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