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Liu A, Hou X, Nie J, Wen Q, Pan Z. Decompression sickness followed by diabetic ketoacidosis and sepsis shock: an unusual case report. Undersea Hyperb Med 2024; 51:41-46. [PMID: 38615352] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Decompression sickness (DCS) is caused by abrupt changes in extracorporeal pressure with varying severity. Symptoms range from mild musculoskeletal pain to severe organ dysfunction and death, especially among patients with chronic underlying disease. Here, we report an unusual case of a 49-year-old man who experienced DCS after a dive to a depth of 38 meters. The patient's symptoms progressed, starting with mild physical discomfort that progressed to disturbance of consciousness on the second morning. During hospitalization, we identified that in addition to DCS, he had also developed diabetic ketoacidosis, septic shock, and rhabdomyolysis. After carefully balancing the benefits and risks, we decided to provide supportive treatment to sustain vital signs, including ventilation support, sugar-reducing therapy, fluid replacement, and anti-infection medications. We then administered delayed hyperbaric oxygen (HBO2) when his condition was stable. Ultimately, the patient recovered without any sequelae. This is the first case report of a diver suffering from DCS followed by diabetic ketoacidosis and septic shock. We have learned that when DCS and other critical illnesses are highly suspected, it is essential to assess the condition comprehensively and focus on the principal contradiction.
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Affiliation(s)
- Anwei Liu
- Department of Intensive Care Unit, the General Hospital of Southern Theater Command, the Chinese People's Liberation Army, Guangzhou 510000, China
| | - Xiaogan Hou
- Department of Intensive Care Unit, the General Hospital of Southern Theater Command, the Chinese People's Liberation Army, Guangzhou 510000, China
| | - Jing Nie
- Department of Medicine Intensive Care Unit, the General Hospital of Southern Theater Command, the Chinese People's Liberation Army, Guangzhou 510000, China
| | - Qiang Wen
- Department of Intensive Care Unit, the General Hospital of Southern Theater Command, the Chinese People's Liberation Army, Guangzhou 510000, China
| | - Zhiguo Pan
- Department of Intensive Care Unit, the General Hospital of Southern Theater Command, the Chinese People's Liberation Army, Guangzhou 510000, China
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Meoli M, Lava SAG, Bronz G, Goeggel-Simonetti B, Simonetti GD, Alberti I, Agostoni C, Bianchetti MG, Scoglio M, Vismara SA, Milani GP. Eu- or hypoglycemic ketosis and ketoacidosis in children: a review. Pediatr Nephrol 2024; 39:1033-1040. [PMID: 37584686 PMCID: PMC10899420 DOI: 10.1007/s00467-023-06115-5] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/17/2023]
Abstract
The last decade has been characterized by exciting findings on eu- or hypoglycemic ketosis and ketoacidosis. This review emphasizes the following five key points: 1. Since the traditional nitroprusside-glycine dipstick test for urinary ketones is often falsely negative, the blood determination of β-hydroxybutyrate, the predominant ketone body, is currently advised for a comprehensive assessment of ketone body status; 2. Fasting and infections predispose to relevant ketosis and ketoacidosis especially in newborns, infants, children 7 years or less of age, and pregnant, parturient, or lactating women; 3. Several forms of carbohydrate restriction (typically less than 20% of the daily caloric intake) are employed to induce ketosis. These ketogenic diets have achieved great interest as antiepileptic treatment, in the management of excessive body weight, diabetes mellitus, and in sport training; 4. Intermittent fasting is more and more popular because it might benefit against cardiovascular diseases, cancers, neurologic disorders, and aging; 5. Gliflozins, a new group of oral antidiabetics inhibiting the renal sodium-glucose transporter 2, are an emerging cause of eu- or hypoglycemic ketosis and ketoacidosis. In conclusion, the role of ketone bodies is increasingly recognized in several clinical conditions. In the context of acid-base balance evaluation, it is advisable to routinely integrate both the assessment of lactic acid and β-hydroxybutyrate.
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Affiliation(s)
- Martina Meoli
- Family Medicine Institute, Università Della Svizzera Italiana, 6900, Lugano, Switzerland
| | - Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Gabriel Bronz
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Barbara Goeggel-Simonetti
- Family Medicine Institute, Università Della Svizzera Italiana, 6900, Lugano, Switzerland
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Giacomo D Simonetti
- Family Medicine Institute, Università Della Svizzera Italiana, 6900, Lugano, Switzerland
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Ilaria Alberti
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlo Agostoni
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Mario G Bianchetti
- Family Medicine Institute, Università Della Svizzera Italiana, 6900, Lugano, Switzerland.
| | - Martin Scoglio
- Family Medicine Institute, Università Della Svizzera Italiana, 6900, Lugano, Switzerland
| | - Stefano A Vismara
- Family Medicine Institute, Università Della Svizzera Italiana, 6900, Lugano, Switzerland
| | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
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3
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Hay RE, Parsons SJ, Wade AW. The effect of dehydration, hyperchloremia and volume of fluid resuscitation on acute kidney injury in children admitted to hospital with diabetic ketoacidosis. Pediatr Nephrol 2024; 39:889-896. [PMID: 37733096 DOI: 10.1007/s00467-023-06152-0] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a recognized comorbidity in pediatric diabetic ketoacidosis (DKA), although the exact etiology is unclear. The unique physiology of DKA makes dehydration assessments challenging, and these patients potentially receive excessive amounts of intravenous fluids (IVF). We hypothesized that dehydration is over-estimated in pediatric DKA, leading to over-administration of IVF and hyperchloremia that worsens AKI. METHODS Retrospective cohort of all DKA inpatients at a tertiary pediatric hospital from 2014 to 2019. A total of 145 children were included; reasons for exclusion were pre-existing kidney disease or incomplete medical records. AKI was determined by change in creatinine during admission, and comparison to a calculated baseline value. Linear regression multivariable analysis was used to identify factors associated with AKI. True dehydration was calculated from patients' change in weight, as previously validated. Fluid over-resuscitation was defined as total fluids given above the true dehydration. RESULTS A total of 19% of patients met KDIGO serum creatinine criteria for AKI on admission. Only 2% had AKI on hospital discharge. True dehydration and high serum urea levels were associated with high serum creatinine levels on admission (p = 0.042; p < 0.001, respectively). Fluid over-resuscitation and hyperchloremia were associated with delayed kidney recovery (p < 0.001). Severity of initial AKI was associated with cerebral edema (p = 0.018). CONCLUSIONS Dehydration was associated with initial AKI in children with DKA. Persistent AKI and delay to recovery was associated with hyperchloremia and over-resuscitation with IVF, potentially modifiable clinical variables for earlier AKI recovery and reduction in long-term morbidity. This highlights the need to re-address fluid protocols in pediatric DKA.
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Affiliation(s)
- Rebecca E Hay
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Canada.
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada.
| | - Simon J Parsons
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Canada
- Section of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Calgary, Alberta Children's Hospital, Calgary, Canada
| | - Andrew W Wade
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Canada
- Section of Nephrology, Department of Pediatrics, Faculty of Medicine, University of Calgary, Alberta Children's Hospital, Calgary, Canada
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Ramanan M, Delaney A, Venkatesh B. Fluid therapy in diabetic ketoacidosis. Curr Opin Clin Nutr Metab Care 2024; 27:178-183. [PMID: 38126191 DOI: 10.1097/mco.0000000000001005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 12/23/2023]
Abstract
PURPOSE OF REVIEW To evaluate recent evidence (2021-2023) on fluid therapy in diabetic ketoacidosis. Key evidence gaps which require generation of new evidence are discussed. RECENT FINDINGS Balanced crystalloid solutions, compared to the commonly recommended and used 0.9% sodium chloride solution (saline), may result in better outcomes for patients with diabetic ketoacidosis, including faster resolution of acidosis, less hyperchloremia and shorter hospital length of stay. Upcoming results from randomized trials may provide definitive evidence on the use of balanced crystalloid solutions in diabetic ketoacidosis. Evidence remains scarce or conflicting for the use of "two-bag" compared to conventional "one-bag" fluid, and rates of fluid administration, especially for adult patients. In children, concerns about cerebral oedema from faster fluid administration rates have not been demonstrated in cohort studies nor randomized trials. SUMMARY Fluid therapy is a key aspect of diabetic ketoacidosis management, with important evidence gaps persisting for several aspects of management despite recent evidence.
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Affiliation(s)
- Mahesh Ramanan
- Caboolture and The Prince Charles Hospitals, Metro North Hospital and Health Services, Brisbane, Queensland
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales
- James Mayne Academy of Critical Care, The University of Queensland, St Lucia, Queensland
| | - Anthony Delaney
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales
- Royal North Shore Hospital, St Leonards, New South Wales
| | - Balasubramanian Venkatesh
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales
- Wesley Hospital, Auchenflower, Queensland, Australia
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Shi J, Chen F, Zheng K, Su T, Wang X, Wu J, Ni B, Pan Y. Clinical nomogram prediction model to assess the risk of prolonged ICU length of stay in patients with diabetic ketoacidosis: a retrospective analysis based on the MIMIC-IV database. BMC Anesthesiol 2024; 24:86. [PMID: 38424557 PMCID: PMC10902986 DOI: 10.1186/s12871-024-02467-z] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 02/23/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND The duration of hospitalization, especially in the intensive care unit (ICU), for patients with diabetic ketoacidosis (DKA) is influenced by patient prognosis and treatment costs. Reducing ICU length of stay (LOS) in patients with DKA is crucial for optimising healthcare resources utilization. This study aimed to establish a nomogram prediction model to identify the risk factors influencing prolonged LOS in ICU-managed patients with DKA, which will serve as a basis for clinical treatment, healthcare safety, and quality management research. METHODS In this single-centre retrospective cohort study, we performed a retrospective analysis using relevant data extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Clinical data from 669 patients with DKA requiring ICU treatment were included. Variables were selected using the Least Absolute Shrinkage and Selection Operator (LASSO) binary logistic regression model. Subsequently, the selected variables were subjected to a multifactorial logistic regression analysis to determine independent risk factors for prolonged ICU LOS in patients with DKA. A nomogram prediction model was constructed based on the identified predictors. The multivariate variables included in this nomogram prediction model were the Oxford acute severity of illness score (OASIS), Glasgow coma scale (GCS), acute kidney injury (AKI) stage, vasoactive agents, and myocardial infarction. RESULTS The prediction model had a high predictive efficacy, with an area under the curve value of 0.870 (95% confidence interval [CI], 0.831-0.908) in the training cohort and 0.858 (95% CI, 0.799-0.916) in the validation cohort. A highly accurate predictive model was depicted in both cohorts using the Hosmer-Lemeshow (H-L) test and calibration plots. CONCLUSION The nomogram prediction model proposed in this study has a high clinical application value for predicting prolonged ICU LOS in patients with DKA. This model can help clinicians identify patients with DKA at risk of prolonged ICU LOS, thereby enhancing prompt intervention and improving prognosis.
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Affiliation(s)
- Jincun Shi
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Fujin Chen
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Kaihui Zheng
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Tong Su
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Xiaobo Wang
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Jianhua Wu
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Bukao Ni
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Yujie Pan
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China.
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Kumar M, Dixit R, Kapoor R, Singh S. From neglect to peril: diabetic ketoacidosis unleashing colonic necrosis and perforation in an adolescent girl with type 1 diabetes mellitus. J Pediatr Endocrinol Metab 2024; 37:170-173. [PMID: 38167416 DOI: 10.1515/jpem-2023-0412] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES Abdominal pain is a common presentation in patients of diabetic ketoacidosis (DKA). However, this pain generally resolves with resolution of dehydration and acidosis. Persistence of abdominal pain even after resolution of ketosis and acidosis should warrant careful reassessment to find evidence of sepsis and concomitant abdominal pathology. CASE PRESENTATION We report a rare case of type 1 diabetes mellitus in a 15 year old girl diagnosed 6 months ago who presented with mild DKA (pH 7.24, HCO3 - 13.5 mmol/L). Her hospital course was extremely stormy and despite best of our efforts she succumbed due to colonic ischemia and perforation peritonitis. CONCLUSIONS A high index of suspicion for gut ischemia or perforation should be kept if DKA is associated with septic shock and there is suboptimal response to standard treatment. Mesenteric ischemia can occur in pediatric patients even with mild DKA having very poor diabetes control.
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Affiliation(s)
- Mritunjay Kumar
- Department of Pediatrics, All India Institute of Medical Sciences - Raebareli, Raebareli, Uttar Pradesh, India
| | - Rini Dixit
- Department of Pediatrics, All India Institute of Medical Sciences - Raebareli, Raebareli, Uttar Pradesh, India
| | - Rohit Kapoor
- Department of Paediatric Surgery, All India Institute of Medical Sciences - Raebareli, Raebareli, Uttar Pradesh, India
| | - Sunita Singh
- Department of Paediatric Surgery, All India Institute of Medical Sciences - Raebareli, Raebareli, Uttar Pradesh, India
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Doğan D, Gökalp HDC, Eren E, Sağlam H, Tarım Ö. Revised one-bag IV fluid protocol for pediatric DKA: a feasible approach and retrospective comparative study. J Trop Pediatr 2024; 70:fmae003. [PMID: 38339873 PMCID: PMC10858344 DOI: 10.1093/tropej/fmae003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
BACKGROUND This study compared the effectiveness of the traditional and revised one-bag protocols for pediatric diabetic ketoacidosis (DKA) management. METHODS This single-center retrospective cohort study included children diagnosed with DKA upon admission between 2012 and 2019. Our institution reevaluated and streamlined the traditional one-bag protocol (revised one-bag protocol). The revised one-bag protocol rehydrated all pediatric DKA patients with dextrose (5 g/100 ml) containing 0.45% NaCl at a rate of 3500 ml/m2 per 24 h after the first 1 h bolus of normal saline, regardless of age or degree of dehydration. This study examined acidosis recovery times and the frequency of healthcare provider interventions to maintain stable blood glucose levels. RESULTS The revised one-bag protocol demonstrated a significantly shorter time to acidosis recovery than the traditional protocol (12.67 and 18.20 h, respectively; p < 0.001). The revised protocol group required fewer interventions for blood glucose control, with an average of 0.25 dextrose concentration change orders per patient, compared to 1.42 in the traditional protocol group (p < 0.001). Insulin rate adjustments were fewer in the revised protocol group, averaging 0.52 changes per patient, vs. 2.32 changes in the traditional protocol group (p < 0.001). CONCLUSION The revised one-bag protocol for pediatric DKA is both practical and effective. This modified DKA management achieved acidosis recovery more quickly and reduced blood glucose fluctuations compared with the traditional one-bag protocol. Future studies, including randomized controlled trials, should assess the safety and effectiveness of the revised protocol in a broad range of pediatric patients with DKA.
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Affiliation(s)
- Durmuş Doğan
- Department of Pediatric Endocrinology, School of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Türkiye
| | - Hatice D C Gökalp
- Department of Pediatric Medicine, Pediatric Endocrinology, Bursa City Hospital, Bursa, Türkiye
| | - Erdal Eren
- Department of Pediatric Endocrinology, School of Medicine, Bursa Uludag University, Bursa, Türkiye
| | - Halil Sağlam
- Department of Pediatric Endocrinology, School of Medicine, Bursa Uludag University, Bursa, Türkiye
| | - Ömer Tarım
- Department of Pediatric Endocrinology, School of Medicine, Bursa Uludag University, Bursa, Türkiye
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Wang Y, Jiao T, Muschett MR, Brown JD, Guo SJ, Kulshreshtha A, Zhang Y, Winterstein AG, Shao H. Associations Between Postdischarge Care and Cognitive Impairment-Related Hospital Readmissions for Ketoacidosis and Severe Hypoglycemia in Adults With Diabetes. Diabetes Care 2024; 47:225-232. [PMID: 38048487 DOI: 10.2337/dca23-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 08/01/2023] [Accepted: 11/01/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE Patients with severe hypoglycemia (SH) or diabetic ketoacidosis (DKA) experience high hospital readmission after being discharged. Cognitive impairment (CI) may further increase the risk, especially in those experiencing an interruption of medical care after discharge. This study examined the effect modification role of postdischarge care (PDC) on CI-associated readmission risk among U.S. adults with diabetes initially admitted for DKA or SH. RESEARCH DESIGN AND METHODS We used the Nationwide Readmissions Database (NRD) (2016-2018) to identify individuals hospitalized with a diagnosis of DKA or SH. Multivariate Cox regression was used to compare the all-cause readmission risk at 30 days between those with and without CI identified during the initial hospitalization. We assessed the CI-associated readmission risk in the patients with and without PDC, an effect modifier with the CI status. RESULTS We identified 23,775 SH patients (53.3% women, mean age 65.9 ± 15.3 years) and 140,490 DKA patients (45.8% women, mean age 40.3 ± 15.4 years), and 2,675 (11.2%) and 1,261 (0.9%), respectively, had a CI diagnosis during their index hospitalization. For SH and DKA patients discharged without PDC, CI was associated with a higher readmission risk of 23% (adjusted hazard ratio [aHR] 1.23, 95% confidence interval 1.08-1.40) and 35% (aHR 1.35, 95% confidence interval 1.08-1.70), respectively. However, when patients were discharged with PDC, we found PDC was an effect modifier to mitigate CI-associated readmission risk for both SH and DKA patients (P < 0.05 for all). CONCLUSIONS Our results suggest that PDC can potentially mitigate the excessive readmission risk associated with CI, emphasizing the importance of postdischarge continuity of care for medically complex patients with comorbid diabetes and CI.
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Affiliation(s)
- Yehua Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Tianze Jiao
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Matthew R Muschett
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Joshua D Brown
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Serena Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Ambar Kulshreshtha
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA
| | - Yongkang Zhang
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Hui Shao
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA
- Hubert Department of Global Health, Rollin School of Public Health, Emory University, Atlanta, GA
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Kao KT, Lei S, Cheek JA, White M, Hiscock H. Paediatric diabetes-related presentations to emergency departments in Victoria, Australia from 2008 to 2018. Emerg Med Australas 2024; 36:101-109. [PMID: 37783473 DOI: 10.1111/1742-6723.14320] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/28/2023] [Accepted: 09/08/2023] [Indexed: 10/04/2023]
Abstract
OBJECTIVES Despite significant treatment advances in paediatric diabetes management, ED presentations for potentially preventable (PP) complications such as diabetic ketoacidosis (DKA) remains a major issue. We aimed to examine the characteristics, rates and trends of diabetes-related ED presentations and subsequent admissions in youth aged 0-19 years from 2008 to 2018. METHODS Data were obtained from the Victorian Emergency Minimum Dataset and the National Diabetes Register. A diabetes-related ED presentation is defined using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification diagnosis codes. 'Non-preventable' presentations were the number of youths with newly diagnosed diabetes, and the remaining are classified as PP diabetes-related presentations. Poisson regression model was used to examine the trends in incidence rate and prevalence. RESULTS Four thousand eight hundred and seventy-two (59%) of 8220 presentations were PP, 4683 (57%) were for DKA whereas 6200 (82%) required hospital admission. Diabetes-related ED presentations decreased from 38.4 to 27.5 per 100 youth with diabetes per year between 2008 and 2018 (β = -0.04; confidence interval [CI] -0.04 to -0.03; P < 0.001). Females, those aged 0-4 years and rural youth had higher rates of ED presentations than males, older age groups and metropolitan youth. DKA presentations decreased from 20.1 presentations per 100 youth with diabetes in 2008-2009 to 14.9 presentations per 100 youth with diabetes in 2017-2018. The rate of DKA presentations was 68% higher in rural areas compared to metropolitan areas (incidence rate ratio 1.68; CI 1.59-1.78; P < 0.001). CONCLUSIONS Although the rates of diabetes-related ED presentations declined, PP diabetes-related presentations and subsequent hospitalisation remain high. Patient level research is required to understand the increased DKA presentations in rural youth.
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Affiliation(s)
- Kung-Ting Kao
- Department of Endocrinology and Diabetes, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Shaoke Lei
- Health Services Research Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - John A Cheek
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Mary White
- Department of Endocrinology and Diabetes, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Health Services Research Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Harriet Hiscock
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Health Services Research Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
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Koyama K, Anno T, Kimura Y, Kawasaki F, Kaku K, Tomoda K, Kaneto H. Pathology of Ketoacidosis in Emergency of Diabetic Ketoacidosis and Alcoholic Ketoacidosis: A Retrospective Study. J Diabetes Res 2024; 2024:8889415. [PMID: 38225984 PMCID: PMC10789514 DOI: 10.1155/2024/8889415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 12/10/2023] [Accepted: 12/20/2023] [Indexed: 01/17/2024] Open
Abstract
This study is aimed at examining which factors are useful for the diagnosis and distinction of ketoacidosis. We recruited 21 diabetic ketoacidosis (DKA) and alcoholic ketoacidosis (AKA) patients hospitalized in Kawasaki Medical School General Medical Center from April 2015 to March 2021. Almost all patients in this study were brought to the emergency room in a coma and hospitalized. All patients underwent blood gas aspiration and laboratory tests. We evaluated the difference in diagnosis markers in emergencies between DKA and alcoholic ketoacidosis AKA. Compared to AKA patients, DKA patients had statistically higher values of serum acetoacetic acid and lower values of serum lactate, arterial blood pH, and base excess. In contrast, total ketone bodies, β-hydroxybutyric acid, and β-hydroxybutyric acid/acetoacetic acid ratio in serum did not differ between the two patient groups. It was shown that evaluation of each pathology such as low body weight, diabetes, liver dysfunction, and dehydration was important. It is important to perform differential diagnosis for taking medical histories such as insulin deficiency, alcohol abuse, or starvation as the etiology in Japanese subjects with DKA or AKA. Moreover, it is important to precisely comprehend the pathology of dehydration and alcoholic metabolism which would lead to appropriate treatment for DKA and AKA.
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Affiliation(s)
- Katsumasa Koyama
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Takatoshi Anno
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Yukiko Kimura
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Fumiko Kawasaki
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Kohei Kaku
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Koichi Tomoda
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Hideaki Kaneto
- Department of Diabetes, Metabolism and Endocrinology, Kawasaki Medical School, Kurashiki 701-0192, Japan
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11
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Burnett C, Evans DD, Mueller K. Managing Diabetes Mellitus in the Emergency Department. Adv Emerg Nurs J 2024; 46:58-70. [PMID: 38285424 DOI: 10.1097/tme.0000000000000500] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 01/30/2024]
Abstract
Diabetes mellitus (DM) is a chronic medical condition that continues to increase in prevalence. Complications of DM, including diabetic ketoacidosis and hyperglycemic hyperosmolar state, often present in the emergency department requiring emergent management. Prompt assessment, diagnosis, evaluation of laboratory values, treatment, monitoring, and strict follow-up education are essential to the successful management of this complex disease. Common medications and management strategies are key elements to control DM. This article presents an overview of DM, including its prevalence, pathophysiology, presentations, and management.
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Affiliation(s)
- Caitlin Burnett
- Nell Hodgson Woodruff School of Nursing, Emory University Atlanta, Georgia
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12
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Sharif A, Brewer JM, El Banayosy A, Mihu MR, Reaves Z, Swant LV, Schoaps RS, Benson C, Khalid MI, Maybauer MO. Extracorporeal membrane oxygenation in diabetic ketoacidosis-related cardiac and respiratory failure. Int J Artif Organs 2024; 47:35-40. [PMID: 38053302 DOI: 10.1177/03913988231214448] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) is a common clinical problem. When patients develop severe shock and/or respiratory failure, extracorporeal membrane oxygenation (ECMO) may be considered. This case series describes the clinical presentation and outcomes of patients with DKA supported with ECMO. METHODS We conducted a retrospective and anonymized review of 15 patients with DKA who required ECMO at our institution. Demographic and ECMO-specific data were collected. Additional variables include ICU length of stay (LOS), acute kidney injury and use of continuous renal replacement therapy, disposition, and mortality. RESULTS All ECMO cannulations were performed by an intensivist using peripheral vascular access. The majority of patients were female (73%) with a median age of 27 (IQR = 21.5-45) years. A diagnosis of diabetes mellitus (DM) prior to ECMO was present in 11 (73%) patients. Venoarterial ECMO was the initial mode used in 11 (73%) patients. The median duration of ECMO support was 7 (IQR = 6-14) days. The median ICU LOS was 12 (IQR = 8.5-20.5) days, and the median hospital LOS was 21 (IQR = 11-36.5) days. Eight patients had cardiac arrest and underwent extracorporeal cardiopulmonary resuscitation (ECPR) of which 4 (50%) patients survived to discharge. Overall, 10 (66.7%) patients were successfully weaned from ECMO and survived to discharge. CONCLUSION This is the largest case series regarding the use of ECMO for patients with refractory shock, cardiac arrest, or respiratory failure related to DKA. The findings suggest that ECMO is a viable support option for managing these patients and has excellent outcomes, including patients with cardiac arrest.
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Affiliation(s)
- Ammar Sharif
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - J Michael Brewer
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Aly El Banayosy
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Mircea R Mihu
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
- Department of Medicine, Division of Cardiology, Oklahoma State University Health Science Center, Tulsa, OK, USA
| | - Zachary Reaves
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Laura V Swant
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Robert S Schoaps
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Clayne Benson
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Malik Ibithaj Khalid
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Marc O Maybauer
- Department of Anesthesiology, Division of Critical Care Medicine, University of Florida College of Medicine, Gainesville, FL, USA
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, QLD, Australia
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany
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13
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Tomic D, Craig ME, Magliano DJ, Shaw JE. Reasons for hospitalisation in youth with type 1 diabetes, 2010-2019. Diabet Med 2024; 41:e15218. [PMID: 37652152 DOI: 10.1111/dme.15218] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/15/2023] [Accepted: 08/28/2023] [Indexed: 09/02/2023]
Abstract
AIMS To determine the incidence of hospitalisation for all diagnoses among Australian youth with type 1 diabetes. METHODS We linked Australians aged under 20 years with type 1 diabetes on the National Diabetes Services Scheme (n = 45,685) to hospital admission data from 2010 to 2019. We determined relative risks (RR) of hospitalisation among those with type 1 diabetes in the states of Victoria and Queensland (n = 21,898) compared to the general population for 2010-2017 using Poisson regression. RESULTS Australian youth with type 1 diabetes had increased risk for almost all reasons for hospitalisation compared to the general population, especially infections such as anogenital herpesviral infections (RR 54.83, 95% CI 33.21-90.53), and mental health disorders including personality disorders (RR 9.70, 95% CI 8.02-11.72). Among those with type 1 diabetes, over 60% of hospitalisations were directly related to diabetes, almost half of which were for ketoacidosis. Approximately 15% of ketoacidosis admissions occurred within 3 months of diabetes diagnosis. One quarter of those with admissions for ketoacidosis were readmitted for ketoacidosis within 12 months. Residence in areas of high socio-economic disadvantage was an independent risk factor for admission and readmission for ketoacidosis. CONCLUSIONS Youth with type 1 diabetes are susceptible to a wide range of complications. Clinicians should consider screening and prevention for conditions such as infections and mental health disorders. Targeted support and education around glycaemic management should be considered in those at high risk for ketoacidosis admission including those living in areas of high socio-economic disadvantage.
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Affiliation(s)
- Dunya Tomic
- Baker Heart and Diabetes Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Maria E Craig
- School of Medicine, University of New South Wales, Kensington, Australia
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia
| | - Dianna J Magliano
- Baker Heart and Diabetes Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jonathan E Shaw
- Baker Heart and Diabetes Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Paul S, Nirmal G, Chadha V, Sharma R, Kochar I, Jerath N, Vohra R, Kharya G. Sirolimus-induced Hypertriglyceridemia Leads to Acute Pancreatitis and Diabetic Ketoacidosis Post Stem Cell Transplant for Sickle Cell Disease. J Pediatr Hematol Oncol 2024; 46:e91-e93. [PMID: 38019672 DOI: 10.1097/mph.0000000000002793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 07/18/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
Sirolimus (mammalian target of rapamycin inhibitor) is a potent immunosuppressive agent, used in patients receiving hematopoietic stem cell transplant (HSCT) for Graft vs Host disease prophylaxis. Compared to calcineurin inhibitors, sirolimus has no neurotoxicity or nephrotoxicity, but sirolimus causes dose-dependent thrombocytopenia, leukopenia, delayed wound healing, hyperlipidemia, and hypertriglyceridemia. Here we report a case of acute pancreatitis and diabetic ketoacidosis in a patient with sickle cell disease post haploidentical family donor HSCT which was managed conservatively without plasmapheresis. Based on our review of the literature, this is the first reported case of developing acute pancreatitis as an adverse effect of sirolimus-induced hypertriglyceridemia leading to diabetic ketoacidosis in a recipient of HSCT.
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Affiliation(s)
- Subhasish Paul
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
| | - Garima Nirmal
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
| | - Vaibhav Chadha
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
| | - Rahul Sharma
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
| | | | - Namith Jerath
- Pediatrics, Indraprastha Apollo Hospital, Delhi, India
| | - Rohit Vohra
- Pediatrics, Indraprastha Apollo Hospital, Delhi, India
| | - Gaurav Kharya
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
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15
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Benitez Cruz A, Pellegrini D, Recalde M, Rella M, Saban M. [Diabetic ketoacidosis secondary to immunotherapy]. Medicina (B Aires) 2024; 84:138-142. [PMID: 38271940] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that are increasingly used in cancer treatments. As experience in the use of immunotherapy increases, more is known about its safety profile and immune-mediated adverse effects. Among them is diabetic ketoacidosis (DKA), a rare but serious fatal complication of treatment. In this paper we describe the cases of three patients who presented with episodes of DKA during treatment with ICIs, two of which manifested with fulminant forms, leading to an acute course with initially normal glycosylated hemoglobin values. In addition, we conducted a review of the literature on DKA associated with ICIs in order to highlight the importance of noticing these potentially fatal complications and promptly establishing appropriate therapy.
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Affiliation(s)
- Agustina Benitez Cruz
- Servicio de Clínica Médica, Hospital Británico de Buenos Aires, Buenos Aires, Argentina. E-mail:
| | - Débora Pellegrini
- Servicio de Clínica Médica, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Maricel Recalde
- Servicio de Endocrinología, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Mariana Rella
- Servicio de Clínica Médica, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Melina Saban
- Servicio de Endocrinología, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
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Kumar A, Doola R, Zahumensky A, Shaikh A, Tabah A, Laupland KB, Ramanan M. Association between elevated lactate and clinical outcomes in adults with diabetic ketoacidosis. J Crit Care 2023; 78:154377. [PMID: 37478533 DOI: 10.1016/j.jcrc.2023.154377] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To assess the occurrence of hyperlactatemia among patients admitted to the intensive care unit (ICU) with diabetic ketoacidosis (DKA), and effect on in-hospital mortality. MATERIALS AND METHODS A retrospective, multicentre, cohort study of adult patients admitted to ICU with a primary diagnosis of DKA in Australia and New Zealand, utilising a pre-existing dataset. The primary exposure variable was lactate, dichotomised into normolactatemia (lactate <2.0 mmol/L) and hyperlactatemia (lactate ≥ 2.0 mmol/L) groups. The primary outcome was in-hospital mortality. Secondary outcomes included ICU and hospital length of stay (LOS), requirement for ventilation, renal replacement therapy (RRT) and inotropes. RESULTS The final dataset included 9061 patients. Hyperlactatemia was associated with in-hospital mortality (Odds Ratio [OR] 1.785 (95% CI 1.122-2.841, p = 0.014), hospital LOS (Geometric mean ratio [GMR] 1.063, 95% CI 1.025-1.103, p = 0.001), ICU LOS (GMR 1.057, 95% CI 1.026-1.09. p < 0.001), RRT (OR 2.198, 95% CI 1.449-3.334, p < 0.001) and inotropes (OR 1.578, 95% CI 1.311-1.899, p < 0.001). These associations persisted in Type 2 but not Type 1 diabetics. CONCLUSIONS Hyperlactatemia in patients admitted to ICU with DKA is associated with higher mortality, longer hospital and ICU LOS, and higher rates of mechanical ventilation, RRT and inotropes.
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Affiliation(s)
- Aashish Kumar
- Intensive Care Unit, Logan Hospital, Queensland, Brisbane, Australia
| | - Ra'eesa Doola
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Queensland, Brisbane, Australia; PA-Southside Clinical Unit, School of Clinical Medicine, The University of Queensland, Brisbane, Australia
| | - Amanda Zahumensky
- Intensive Care Unit, Caboolture Hospital, Queensland, Brisbane, Australia
| | - Arif Shaikh
- Intensive Care Unit, Caboolture Hospital, Queensland, Brisbane, Australia
| | - Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Queensland, Brisbane, Australia
| | - Kevin B Laupland
- Intensive Care Unit, Royal Brisbane and Women's Hospital, Queensland, Brisbane, Australia; Queensland University of Technology (QUT), Brisbane, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Queensland, Brisbane, Australia; Intensive Care Unit, The Prince Charles Hospital, Queensland, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia; Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia.
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17
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Brown KM, Glaser NS, McManemy JK, DePiero A, Nigrovic LE, Quayle KS, Stoner MJ, Schunk JE, Trainor JL, Tzimenatos L, Rewers A, Myers SR, Kwok MY, Ghetti S, Casper TC, Olsen CS, Kuppermann N. Rehydration Rates and Outcomes in Overweight Children With Diabetic Ketoacidosis. Pediatrics 2023; 152:e2023062004. [PMID: 37920947 PMCID: PMC10657773 DOI: 10.1542/peds.2023-062004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in Diabetic Ketoacidosis (DKA) (FLUID) Trial found that rapid fluid infusion does not increase the risk of cerebral injury. Concern persists, however, whether fluid rates should be adjusted for overweight or obese patients. We used the FLUID Trial database to evaluate associations between fluid infusion rate and outcomes in these patients. METHODS We compared children and youth who were overweight, obese, or normal weight, in regard to protocol adherence, mental status changes, time to DKA resolution, and electrolyte abnormalities. We investigated associations between outcomes and the amount of fluid received in these groups. RESULTS Obese children and youth were more likely to receive fluids at rates slower than dictated by protocol. Overweight and obese children and youth in the fast fluid arms, who received fluids per the study protocol based on their measured weight, had similar rates of mental status changes or clinically apparent cerebral injury as those with normal weights. Risk of hypophosphatemia was increased in those receiving larger initial bolus volumes and reduced in those receiving higher rehydration rates. No other metabolic outcomes were associated with rehydration. CONCLUSIONS Protocol adherence data in the FLUID Trial suggest that physicians are uncomfortable using weight-based fluid calculations for overweight or obese children. However, higher rates of fluid infusion were not associated with increased risk of mental status changes or cerebral injury, suggesting that physicians should not limit fluid resuscitation in obese children and youth with DKA.
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Affiliation(s)
- Kathleen M. Brown
- Division of Emergency Medicine, Department of Pediatrics, Children’s National Medical Center, the George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | | | - Julie K. McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Andrew DePiero
- Division of Emergency Medicine, Nemours/A.I. DuPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kimberly S. Quayle
- Division of Emergency Medicine, Department of Pediatrics, St Louis Children’s Hospital, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael J. Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - Jeff E. Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jennifer L. Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Leah Tzimenatos
- Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, California
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, the Colorado Children’s Hospital, University of Colorado-Denver School of Medicine, Aurora, Colorado
| | - Sage R. Myers
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria Y. Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Simona Ghetti
- Department of Psychology, University of California, Davis, Davis, California
| | - T. Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nathan Kuppermann
- Departments of Pediatrics
- Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, California
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18
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Pannu AK, Kiran R, Kumar A, Sharda SC, Bhatia M, Saroch A, Dutta P, Sharma N. Comparative study of diabetic ketoacidosis in the elderly and non-elderly patients: A nine-year experience from an academic hospital in North India. Diabetes Metab Syndr 2023; 17:102903. [PMID: 37988830 DOI: 10.1016/j.dsx.2023.102903] [Citation(s) in RCA: 1] [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: 05/03/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND AND AIMS Despite an increasing prevalence of the aged population with diabetes in low-middle-income countries, there is limited literature on geriatric hyperglycemic emergencies. The present study aimed to compare the spectrum and outcomes of diabetic ketoacidosis (DKA) between elderly and non-elderly adult patients in India. METHODS Seventy-seven elderly patients (≥60 years) were compared to 477 non-elderly patients (13-59 years) with DKA admitted to the medical emergency, Postgraduate Institute of Medical Education and Research, Chandigarh, India, between January 2014 and December 2022. Clinical features, laboratory parameters, precipitating factors, and in-hospital outcomes were reviewed. RESULTS Elderly patients less commonly had vomiting and abdominal pain than non-elderly patients (31.3 % vs. 66.2 %, 27.3 % vs. 60.1 %, respectively) and typically presented with dyspnea (48.5 %), altered mental status (47.8 %), and fever (46.3 %). Ketonemia and metabolic acidosis were significantly more marked in non-elderly patients, whereas elderly patients frequently had anemia, hypoalbuminemia, and renal dysfunction. The most common precipitations of geriatric DKA were infections (70.1 %), followed by treatment non-adherence (66.2 %) and non-infectious disorders (35.1 %). Infections and non-infectious disorders were significantly more frequent in elderly patients than in non-elderly patients. Respiratory and urinary tract infections were prevalent in both age groups. In-hospital survival was 74.9 % (n = 415) and remained lower in older patients (48.1 % vs. 79.2 %, P-value <0.001). The independent prognostic factors were age (OR 1.030, 95 % CI 1.006-1.054, P = 0.014), Glasgow coma scale (OR 0.789, 95 % CI 0.717-0.869, P <0.001), and infection trigger (OR 6.635, 95 % CI 2.852-15.441, P <0.001). CONCLUSION Older patients with DKA present atypically, frequently have precipitation with infections and noninfectious disorders, and have poor outcomes.
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Affiliation(s)
- Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Ravindran Kiran
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Abhishek Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Saurabh Chandrabhan Sharda
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Mandip Bhatia
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Atul Saroch
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Pinaki Dutta
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
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Choi AY, Park E. The impact of pediatric intensivists on the management of pediatric diabetic ketoacidosis in pediatric intensive care units. BMC Pediatr 2023; 23:562. [PMID: 37957591 PMCID: PMC10644449 DOI: 10.1186/s12887-023-04398-z] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/29/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION The impact of pediatric intensivists on managing pediatric patients with diabetic ketoacidosis (DKA) remains unknown. This study aimed to evaluate the impact of pediatric intensivists on outcomes in pediatric intensive care units (PICUs). METHODS This was a two-institution retrospective study of patients with DKA admitted to the PICU between 2012 and 2023. Pediatric patients (< 19 years of age) were included if they met the moderate to severe DKA criteria on PICU admission. The patients were subsequently divided into two groups based on the presence or absence of a pediatric intensivist. The primary outcome was the PICU length of stay (LOS). Secondary outcomes were adverse events during DKA treatment, hospital LOS, and mortality. RESULTS Fifty-two patients admitted to the PICU with a median age of 13.00 years (range, 0-18 years) were included; 32 (61.54%) were female. Patients managed by pediatric intensivists had significantly shorter PICU LOS (2.52 vs. 3.69 days, p < 0.05). Also, adverse events during DKA treatment were significantly decreased in the high-intensity group compared to the low-intensity group (12.50% vs. 50.00%, p < 0.05). CONCLUSIONS High-intensity ICU staffing was associated with shorter PICU LOS and lower adverse events in pediatric patients with DKA. Our results suggest that dedicated pediatric intensivists can improve outcomes of critically ill pediatric patients with DKA.
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Affiliation(s)
- Ah Young Choi
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Esther Park
- Department of Pediatrics, Jeonbuk National University Children's Hospital, Jeonju, Republic of Korea.
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea.
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20
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Abstract
Diabetic ketoacidosis (DKA) is an acute life-threatening emergency in patients with diabetes, it can result in serious morbidity and mortality. Management of DKA requires reversing metabolic derangements, correcting volume depletion, electrolyte imbalances and acidosis while concurrently treating the precipitating illness. There are still controversies regarding certain aspects of DKA management. Different society guidelines have inconsistencies in their recommendations, while some aspects of treatment are not precise enough or have not been thoroughly studied. These controversies may include issues such as optimal fluid resuscitation, rate and type of Insulin therapy, potassium and bicarbonate replacement. Many institutions follow common society guidelines, however, other institutions either develop their own protocols for internal use or do not routinely use any protocols, resulting in inconsistencies in treatment and increased risk of complications and suboptimal outcomes. The objectives of this article are to review knowledge gaps and controversies in the treatment of DKA and provide our perspective on these issues. Moreover, we believe that special patient factors and comorbidities should receive more careful attention and consideration. Factors like pregnancy, renal disease, congestive heart failure, acute coronary syndrome, older age, use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and site of care all impact the treatment approach and require tailored management strategies. However, guidelines often lack sufficient recommendations regarding specific conditions and comorbidities, we aim to address unique circumstances and provide an approach to managing complex patients with specific conditions and co-morbidities. We also sought to examine changes and trends in the treatment of DKA, illuminate on aspects of latest research with a perspective towards future developments and modifications.
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Affiliation(s)
- Leonid Barski
- Department of Internal Medicine F, Soroka Univerity Medical Center, P.O.Box 151, Beer-Sheva 84101, Israel.
| | - Evgeny Golbets
- Department of Internal Medicine F, Soroka Univerity Medical Center, P.O.Box 151, Beer-Sheva 84101, Israel
| | - Alan Jotkowitz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Dan Schwarzfuchs
- Department of Emergency Medicine, Soroka University Medical Center, Beer-Sheva, Israel
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Hepprich M, Roser P, Stiebitz S, Felix B, Schultes B, Schmitz D, Rutishauser J, Schubert S, Aberle J, Rudofsky G. Awareness and knowledge of diabetic ketoacidosis in people with type 1 diabetes: a cross-sectional, multicenter survey. BMJ Open Diabetes Res Care 2023; 11:e003662. [PMID: 37949471 PMCID: PMC10649772 DOI: 10.1136/bmjdrc-2023-003662] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/14/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION To evaluate awareness and knowledge of diabetic ketoacidosis (DKA), a common and potentially life-threatening complication in people living with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS A survey was developed to assess individuals' current knowledge, management, and unmet needs regarding DKA. The study was conducted in six Swiss and three German endocrine outpatient clinics specialized in the treatment of diabetes. RESULTS A total of 333 participants completed the questionnaire (45.7% female, mean age of 47 years, average duration of T1D at 22 years). Surprisingly, 32% of individuals were not familiar with the term 'diabetic ketoacidosis'. Participants rated their own knowledge of DKA significantly lower than their physicians (p<0.0001). 46% of participants were unable to name a symptom of DKA, and 45% were unaware of its potential causes. 64% of participants did not test for ketones at all. A significant majority (67%) of individuals expressed the need for more information about DKA. CONCLUSIONS In patients treated in specialized centers, knowledge of DKA was found to be inadequate, with a lack of understanding regarding symptoms and causes. Healthcare professionals tended to overestimate individuals' knowledge. Future efforts should focus on addressing these knowledge gaps and incorporating protective factors into the treatment of T1D.
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Affiliation(s)
- Matthias Hepprich
- Division of Endocrinology, Diabetes and Metabolism, University Hospital Basel and University of Basel, Basel, Switzerland
- Metabolic Center, Cantonal Hospital Olten, Olten, Switzerland
| | - Pia Roser
- Department of Endocrinology and Diabetology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Barbara Felix
- Division of Endocrinology, Department of Internal Medicine, Cantonal Hospital Basel-Landschaft Campus Bruderholz, Binningen, Switzerland
| | - Bernd Schultes
- Metabolic Center St Gallen, friendlyDocs, St Gallen, Switzerland
| | - Daniela Schmitz
- Endocrinology, Hospital Rheinfelden, Rheinfelden, Switzerland
| | | | | | - Jens Aberle
- Department of Endocrinology and Diabetology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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22
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Sanchez A, Ruttan T. Pediatric diabetes: management of acute complications in the emergency department. Pediatr Emerg Med Pract 2023; 20:1-24. [PMID: 37877752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Children with diabetes mellitus are at high risk for acute life-threatening complications of their chronic disease. Identification and management of these emergencies can be complex and challenging. This issue provides guidance for recognizing pediatric patients with new-onset diabetes as well as diabetic crises in established patients. The most recent literature is reviewed and an approach to managing emergent diabetic complications in the pediatric patient is provided, with a focus on initial stabilization and management. Key features in treating pediatric patients with hyperglycemic emergencies are discussed, including rapid fluid resuscitation when indicated, initiation of insulin, and addressing complicating comorbidities.
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Affiliation(s)
- Amani Sanchez
- Fellow Physician, Department of Pediatrics, University of Texas at Austin Dell Medical School; Division of Pediatric Emergency Medicine, Dell Children's Medical Center, Austin, TX
| | - Timothy Ruttan
- Associate Professor of Pediatrics, Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, TX; US Acute Care Solutions, Canton, OH
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23
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Bomphrey L, George A, Williams J, Yip WNA, Dalzell J, Kempegowda P, De P, Narendran P, Krishnasamy S, Dekode Working Group. Evaluating adherence to national diabetic ketoacidosis management guidelines within six hospitals across the UK. Clin Med (Lond) 2023; 23 Suppl 6:112. [PMID: 38614693 DOI: 10.7861/clinmed.23-6-s112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Affiliation(s)
| | - Arun George
- The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Janet Williams
- Wirral University Teaching Hospital NHS Foundation Trust, Wirral, UK
| | | | - Joseph Dalzell
- Sandwell and West Birmingham NHS Trust, West Bromwich, UK
| | | | - Parijat De
- Sandwell and West Birmingham NHS Trust, West Bromwich, UK
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24
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Mounouchos S, Hebbar M, Kauser-Malik S, Soghal S, Needs C, Tabasum M, Ahmed N, Panneerselvam H, Nizza J, Karamat M, The Dekode Working Group. Assessing variation in complications and outcomes of diabetic ketoacidosis management in the United Kingdom: a multicentre quality improvement initiative. Clin Med (Lond) 2023; 23 Suppl 6:98. [PMID: 38614767 DOI: 10.7861/clinmed.23-6-s98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Affiliation(s)
| | | | | | | | - Catherine Needs
- Wirral University Teaching Hospitals NHS Foundation Trust, Wirral, UK
| | - Maria Tabasum
- Wirral University Teaching Hospitals NHS Foundation Trust, Wirral, UK
| | - Nabeel Ahmed
- Wirral University Teaching Hospitals NHS Foundation Trust, Wirral, UK
| | | | - Jael Nizza
- Wirral University Teaching Hospitals NHS Foundation Trust, Wirral, UK
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25
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Nevo N, Evola G, Sagnelli C, Pencovich N, Carbone G, Rispoli C. Severe Ketoacidosis After One Anastomosis Gastric Bypass Surgery. Am J Case Rep 2023; 24:e939581. [PMID: 37667468 PMCID: PMC10492420 DOI: 10.12659/ajcr.939581] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 07/21/2023] [Accepted: 05/20/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Bariatric surgeries, such as one anastomosis gastric bypass (OAGB), has become a popular treatment option for managing obesity and associated comorbidities, including type-2 diabetes mellitus (T2DM). However, severe starvation ketoacidosis is a rare but potentially life-threatening complication that can occur postoperatively in patients with T2DM. Despite the increasing prevalence of these surgeries, the existing literature has limited information on severe starvation ketoacidosis as a postoperative complication. It is essential for healthcare professionals to be aware of this complication, its manifestations, and risk factors to ensure patient safety and improve outcomes. Therefore, this article aims to address the current gap in the literature and provide a comprehensive review of severe starvation ketoacidosis as a postoperative complication of bariatric surgeries, specifically OAGB, and its associated risk factors and manifestations. CASE REPORT A 38-year-old man with severe obesity and inadequately managed T2DM underwent OAGB surgery. On the second postoperative day, the patient experienced severe starvation ketoacidosis, exhibiting symptoms such as drowsiness, fatigue, weakness, and Kussmaul breathing. Blood gas analysis indicated significant metabolic acidosis. He was quickly transferred to the Intensive Care Unit (ICU) and given intravenous glucose and insulin therapy. Following this intervention, he showed rapid recovery and normalization of blood gases. He was discharged 6 days after surgery with normal clinical examination results and laboratory indices. CONCLUSIONS This case study emphasizes the significance of thorough preoperative glycemic control, comprehensive perioperative multidisciplinary management, and close postoperative monitoring for diabetic patients undergoing metabolic and bariatric surgeries. By implementing these strategies, healthcare professionals can reduce the risk of complications such as hypoglycemia or hyperglycemia/diabetic ketoacidosis (DKA) and enhance patient outcomes. The case also highlights the need for continuous education and training for healthcare providers to identify and manage such rare complications effectively.
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Affiliation(s)
- Nadav Nevo
- Bariatric Surgery Unit, Division of General Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Giuseppe Evola
- General and Emergency Division, Garibaldi Hospital, Catania, Italy
| | - Carlo Sagnelli
- Department of Laparoscopic and Robotic General Surgery, Azienda Ospedaliera dei Colli “Monaldi Hospital”, Naples, Italy
| | - Niv Pencovich
- Bariatric Surgery Unit, Division of General Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gabriele Carbone
- Department of Laparoscopic and Robotic General Surgery, Azienda Ospedaliera dei Colli “Monaldi Hospital”, Naples, Italy
| | - Corrado Rispoli
- Department of Laparoscopic and Robotic General Surgery, Azienda Ospedaliera dei Colli “Monaldi Hospital”, Naples, Italy
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Kappy B, Lindgren C. Diagnosis and Acute Management of Hyperglycemic Hyperosmolar Syndrome in Children and Adolescents. Pediatr Emerg Care 2023; 39:721-725. [PMID: 37642637 DOI: 10.1097/pec.0000000000003022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/31/2023]
Abstract
ABSTRACT Hyperglycemic hyperosmolar syndrome (HHS) is an indolent process characterized by significantly increased levels of serum glucose, high osmolality, and electrolyte abnormalities. The incidence of HHS has steadily risen in the pediatric population over the past several years. Patients with HHS often present with profound dehydration, fatigue, and early mental status changes. Primary emergency management of HHS involves fluid replacement, hemodynamic support, correcting electrolyte derangements, and addressing complications and underlying illnesses. Insulin is not an initial therapy in HHS and should be considered only after the patient's fluids and electrolytes have been repleted. Unlike in diabetic ketoacidosis, HHS patients are not acidotic, although children may present with mixed HHS/diabetic ketoacidosis syndromes. Complications of HHS include thrombosis, rhabdomyolysis, and, rarely, malignant hyperthermia.
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Affiliation(s)
- Brandon Kappy
- From the Fellow and Assistant Professor, Division of Emergency Medicine, Children's National Hospital, Washington, DC
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27
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Healy AM, Faherty M, Khan Z, Emara N, Carter C, Scheidemantel A, Abu-Jubara M, Young R. Diabetic ketoacidosis diagnosis in a hospital setting. J Osteopath Med 2023; 123:499-503. [PMID: 37406169 DOI: 10.1515/jom-2023-0019] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/08/2023] [Indexed: 07/07/2023]
Abstract
CONTEXT Diabetic ketoacidosis (DKA) is an endocrine emergency that can occur in people with diabetes. Its incidence is estimated to be 220,340 hospital admissions each year. Treatment algorithms include fluid resuscitation, intravenous (IV) insulin infusion, and scheduled electrolyte and glucose monitoring. The misdiagnosis of DKA in the setting of hyperglycemic emergencies results in overtreatment and unnecessary increases in healthcare utilization and costs. OBJECTIVES The aims of this study were to determine how often DKA is overdiagnosed in the context of other acute hyperglycemic emergencies, to describe the baseline characteristics of patients, to determine the hospital treatments for DKA, and to identify the frequency of endocrinology or diabetology consultation in the hospital setting. METHODS A retrospective chart review was conducted utilizing charts from three different hospitals within a hospital system. Charts were identified utilizing ICD-10 codes for admissions to the hospital for DKA. If the patient was over 18 and had one of the diagnostic codes of interest, the chart was reviewed for further details regarding the criteria for DKA diagnosis as well as admission and treatment details. RESULTS A total of 520 hospital admissions were included for review. DKA was incorrectly diagnosed in 28.4 % of the hospital admissions reviewed, based on a review of the labs and DKA diagnostic criteria. Most patients were admitted to the intensive care unit (ICU) and treated with IV insulin infusion (n=288). Consultation of endocrinology or diabetology occurred in 40.2 % (n=209) of all hospital admissions, and 128 of those consults occurred in ICU admissions. The diagnosis of DKA was incorrect in 92 of the patients admitted to the medical surgical unit (MSU) and in 49 of patients admitted to the ICU. CONCLUSIONS Almost one third of hospital admissions for hyperglycemic emergencies were misdiagnosed and managed as DKA. DKA diagnostic criteria are specific; however, other diagnoses like hyperosmolar hyperglycemic syndrome (HHS), hyperglycemia, and euglycemic DKA can make an accurate diagnosis more complicated. Education directed at improving the diagnostic accuracy of DKA among healthcare providers is needed to improve diagnostic accuracy, ensure the appropriate use of hospital resources, and potentially reduce costs to the healthcare system.
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Affiliation(s)
- Amber M Healy
- Ohio Health Physician Group Heritage College Diabetes and Endocrinology, Athens, OH, USA
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | | | - Zeryab Khan
- Ohio Health Doctors Hospital, Columbus, OH, USA
| | | | - Cody Carter
- Ohio Health Doctors Hospital, Columbus, OH, USA
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28
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Schneiter R, Gerber PA. [Metabolische Ursachen von Dyspnoe]. Ther Umsch 2023; 80:280-283. [PMID: 37855532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Endocrinological or metabolic disorders often affect a wide variety of functions of the organism. This can also include an impairment of respiratory function. Diabetic ketoacidosis as a result of insulin deficiency is a typical metabolic acidosis, which the body tries to compensate by an increased exhalation of carbon dioxide. This leads to the classic picture of "Kussmaul" breathing. Due to the increased use of SGLT2 inhibitors, which can reduce the otherwise typical hyperglycemia and thus complicate diagnosis, the occurrence of diabetic ketoacidosis has remained an important differential diagnosis in recent years. Pathologies of the thyroid gland can lead to dyspnea not only by morphological changes, for example in the case of goiter (compression). Functional disorders must also be considered here. Both hypo- and hyperthyroidism affect the cardiovascular system in different ways and may ultimately lead to the clinical picture of dyspnea. If the corresponding entities are thought of, the laboratory diagnosis of the aforementioned metabolic/endocrinological disorders is then basically straightforward. Accordingly, knowledge of these disorders as a differential diagnosis of tachy- and dyspnea is important.
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Affiliation(s)
- Roger Schneiter
- Klinik für Endokrinologie, Universitätsspital Zürich, Zürich
- Klinik für Nuklearmedizin, Universitätsspital Zürich, Zürich
| | - Philipp A Gerber
- Klinik für Endokrinologie, Universitätsspital Zürich, Zürich
- Klinik für Nuklearmedizin, Universitätsspital Zürich, Zürich
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29
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Attokaran AG, Ramanan M, Hunt L, Chandra K, Sandha R, Watts S, Venkatesh B. Sodium chloride or plasmalyte-148 for patients presenting to emergency departments with diabetic ketoacidosis: A nested cohort study within a multicentre, cluster, crossover, randomised, controlled trial. Emerg Med Australas 2023; 35:657-663. [PMID: 36970972 DOI: 10.1111/1742-6723.14198] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 02/15/2023] [Accepted: 02/21/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE To test the hypothesis that fluid resuscitation in the ED with plasmalyte-148 (PL) compared with 0.9% sodium chloride (SC) would result in a lower proportion of patients with diabetic ketoacidosis (DKA) requiring intensive care unit (ICU) admission. METHODS We performed a prespecified nested cohort study at two hospitals within a cluster, crossover, open label, randomised, controlled trial comparing the effects of PL versus SC as fluid therapy for patients who presented to the ED with DKA. All patients presenting within a fixed recruitment period were included. The primary outcome was the proportion of patients admitted to ICU. RESULTS Eighty-four patients were enrolled (SC n = 38, PL n = 46). The SC group had a lower median pH on admission (SC: 7.09 [interquartile range (IQR) 7.01-7.21], PL: 7.17 [IQR 6.99-7.26]). The median volume of intravenous fluids administered in ED was 2150 mL (IQR 2000-3200 mL; SC) and 2200 mL (IQR 2000-3450; PL); respectively. A higher proportion of patients in the SC group, 19 (50%), was admitted to ICU compared with PL group, 18 (39.1%); however, after adjustment for pH at presentation and diabetes type in a multivariable logistic regression model, the PL group did not have a significantly different rate of ICU admission compared with the SC group (odds ratio for ICU admission 0.73, 95% confidence interval 0.13-3.97, P = 0.71). CONCLUSION Patients with DKA treated with PL compared with SC in the EDs had similar rates of requiring ICU admission.
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Affiliation(s)
- Antony George Attokaran
- Rockhampton Hospital, Rockhampton, Queensland, Australia
- Rural Clinical School, The University of Queensland, Rockhampton, Queensland, Australia
| | - Mahesh Ramanan
- Caboolture Hospital, Caboolture, Queensland, Australia
- The Prince Charles Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Lisa Hunt
- Caboolture Hospital, Caboolture, Queensland, Australia
| | - Kavita Chandra
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Rajbir Sandha
- Rockhampton Hospital, Rockhampton, Queensland, Australia
| | - Stacey Watts
- Caboolture Hospital, Caboolture, Queensland, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Wesley Hospital, Brisbane, Queensland, Australia
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30
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Kohata M, Kodama S, Yaoita N, Hosaka S, Takahashi K, Kaneko K, Imai J, Yasuda S, Katagiri H. A case of fulminant type 1 diabetes and protein C deficiency complicated by deep vein thrombosis. J Diabetes Investig 2023; 14:1005-1008. [PMID: 37322823 PMCID: PMC10360373 DOI: 10.1111/jdi.14020] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/29/2023] [Accepted: 04/06/2023] [Indexed: 06/17/2023] Open
Abstract
A 25-year-old man was diagnosed with diabetic ketoacidosis (DKA) at the onset of fulminant type 1 diabetes. After acute-phase DKA treatment including placement of a central venous catheter, a massive deep vein thrombosis (DVT) and pulmonary embolism (PE) were detected on hospital day 15. His protein C (PC) activity and antigen levels were low even 33 days after completing the DKA treatment, indicating partial type I PC deficiency. Severe PC dysfunction, due to overlapping of partial PC deficiency and hyperglycemia-induced PC suppression, concomitant with dehydration and catheter treatment, may have induced the massive DVT with PE. This case suggests that anti-coagulation therapy should be combined with acute-phase DKA treatment in patients with PC deficiency, even those who have been asymptomatic. As patients with partial PC deficiency should perhaps be included among those with severe DVT complications of DKA, venous thrombosis should always be considered as a potential complication of DKA.
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Affiliation(s)
- Masato Kohata
- Department of Diabetes and MetabolismTohoku University HospitalSendaiJapan
| | - Shinjiro Kodama
- Department of Diabetes and MetabolismTohoku University HospitalSendaiJapan
| | - Nobuhiro Yaoita
- Department of Cardiovascular MedicineTohoku University HospitalSendaiJapan
| | - Shinichiro Hosaka
- Department of Diabetes and MetabolismTohoku University HospitalSendaiJapan
| | - Kei Takahashi
- Department of Diabetes and MetabolismTohoku University HospitalSendaiJapan
| | - Keizo Kaneko
- Department of Diabetes and MetabolismTohoku University HospitalSendaiJapan
| | - Junta Imai
- Department of Diabetes and MetabolismTohoku University HospitalSendaiJapan
| | - Satoshi Yasuda
- Department of Cardiovascular MedicineTohoku University HospitalSendaiJapan
| | - Hideki Katagiri
- Department of Diabetes and MetabolismTohoku University HospitalSendaiJapan
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Waddell K, Gaither SL, Rockwell N, Tofil NM, Rutledge C. The Impact of a Multifaceted Simulation Education and Feedback Program for Community Emergency Departments on Pediatric Diabetic Ketoacidosis Management. Pediatr Emerg Care 2023; 39:413-417. [PMID: 37163689 DOI: 10.1097/pec.0000000000002961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/12/2023]
Abstract
OBJECTIVES We sought to determine if general emergency departments (GEDs) were managing pediatric diabetic ketoacidosis (DKA) correctly and if management could be improved using a multilayered educational initiative. We hypothesized that a multifaceted program of in situ simulation education and formal feedback on actual patient management would improve community GED management of pediatric DKA. METHODS This study combined a prospective simulation-based performance evaluation and a retrospective chart review. A community outreach simulation education initiative was developed followed by a formal patient feedback process. RESULTS Fifteen hospitals participated in simulation sessions and the feedback process. All hospitals were scored for readiness to provide care for critically ill pediatric patients using the Emergency Medical Services for Children (EMSC) Pediatric Readiness Assessment. Six of the 15 have had a second hospital visit that included a DKA scenario with an average performance score of 60.3%. A total of 158 pediatric patients with DKA were included in the chart review. The GEDs with higher patient volumes provided best practice DKA management more often (63%) than those with lower patient volumes (40%). Participating in a DKA simulated scenario showed a trend toward improved care, with 47.2% before participation and 68.2% after participation ( P = 0.091). Participating in the formal feedback process improved best practice management provided to 68.6%. Best practice management was further improved to 70.3% if the GED participated in both a DKA simulation and the feedback process ( P = 0.04). CONCLUSIONS A multifaceted program of in situ simulation education and formal feedback on patient management can improve community GED management of pediatric patients with DKA.
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Affiliation(s)
- Kristen Waddell
- From the Pediatric Intensive Care Unit, Children's of Alabama, Birmingham, AL
| | - Stacy L Gaither
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Nicholas Rockwell
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Nancy M Tofil
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Chrystal Rutledge
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
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Passanisi S, Salzano G, Basile P, Bombaci B, Caime F, Rulli I, Valenzise M, Gitto E, Lombardo F. Prevalence and clinical features of severe diabetic ketoacidosis treated in pediatric intensive care unit: a 5-year monocentric experience. Ital J Pediatr 2023; 49:58. [PMID: 37210518 PMCID: PMC10199737 DOI: 10.1186/s13052-023-01448-1] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/23/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is one of the most alarming concerns in the management of type 1 diabetes (T1D) in pediatric age. Prevalence of DKA at the onset of diabetes ranges from 30 to 40%. In selected cases of severe DKA, admission to pediatric intensive care unit (PICU) should be considered. METHODS This study aims to assess the prevalence of severe DKA treated in PICU in our 5-year monocentric experience. Secondary outcome of the study was to describe the main demographical and clinical features of individuals who required admission to PICU. All clinical data were collected by retrospectively reviewing the electronic medical records of children and adolescents with diabetes hospitalized in our University Hospital from January 2017 to December 2022. RESULTS During the study period, 103 children and adolescents were newly diagnosed with T1D. Among these, 51.5% presented clinical criteria for DKA and almost 10% needed to be treated in PICU. A higher rate of new T1D diagnoses was observed in 2021, as well as episodes of severe DKA being more frequent than in previous years. Due to severe clinical manifestations of DKA, 10 subjects (9.7%) with T1D onset needed to be treated in PICU. Of these, four children were younger than 5. The great majority came from a low household income and some of them had also immigrant background. The most common complication of DKA was acute kidney injury presented by four children. Other complications were cerebral edema, papilledema and acute esophageal necrosis. A 15-year-old girl had deep vein thrombosis (DVT) that evolved into multiple organ failure leading to death. CONCLUSIONS Our findings demonstrated that severe DKA is still quite common in children and adolescents at T1D onset, especially in some areas such as Southern Italy. Public awareness campaigns should be increasingly promoted to facilitate the recognition of early symptoms of diabetes and to reduce morbidity and mortality related to DKA.
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Affiliation(s)
- Stefano Passanisi
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98124, Messina, ME, Italy.
| | - Giuseppina Salzano
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98124, Messina, ME, Italy
| | - Pietro Basile
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98124, Messina, ME, Italy
| | - Bruno Bombaci
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98124, Messina, ME, Italy
| | - Flavia Caime
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98124, Messina, ME, Italy
| | - Immacolata Rulli
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", Neonatal and Pediatric Intensive Care Unit, University of Messina, Messina, Italy
| | - Mariella Valenzise
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98124, Messina, ME, Italy
| | - Eloisa Gitto
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", Neonatal and Pediatric Intensive Care Unit, University of Messina, Messina, Italy
| | - Fortunato Lombardo
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98124, Messina, ME, Italy
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Saeed A, Ziyaee F. Treatment of septic shock in two pediatric patients with severe diabetic ketoacidosis using invasive hemodynamic monitoring: a case report. BMC Endocr Disord 2023; 23:65. [PMID: 36941647 PMCID: PMC10026410 DOI: 10.1186/s12902-023-01315-4] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 03/01/2023] [Indexed: 03/22/2023] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus. DKA associated with shock is a rare condition that occurs due to the fluid deficit or septic shock. It is not easy to differentiate these two conditions by clinical judgment and laboratory findings. Although the fluid therapy is the mainstay in DKA treatment, it looks like a double-edged sword-underhydration may result in organ failure whereas overhydration may lead to pulmonary and cerebral edema (CE). CASE PRESENTATION Herein, we report on two pediatric patients presenting with DKA and septic shock. The first patient was an 8-year-old boy newly diagnosed with type 1 diabetes mellitus (T1DM) who presented with DKA and septic shock. We used a device for continuous hemodynamic monitoring (proAQT) to estimate his volume status. The patient was extubated 48 hours of hospitalization; the DKA was resolved after 52 hours of admission. He was discharged home in good condition on the 5th day. The second patient was a 13-year-old girl, a known case of T1DM, who presented with mixed DKA- hyperosmolar-hyperglycemic state (HHS) and septic shock. She was intubated and treated according to the data derived from pulse Contour Cardiac Output (PiCCO). After 3 days, she was extubated and transferred to the ward in good condition. CONCLUSION Using invasive hemodynamic monitoring in critically ill children with severe DKA and hypotension might guide the physicians for hydration and selecting the most appropriate inotrope.
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Affiliation(s)
- Amir Saeed
- Division of Intensive Care Unit, Department of Pediatrics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fateme Ziyaee
- Department of Pediatrics, Shiraz University of Medical Sciences, Zand Ave., Shiraz, Iran
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Khan AA, Ata F, Yousaf Z, Aljafar MS, Seijari MN, Matarneh A, Dakkak B, Halabiya M, Muthanna B, Maliyakkal AM, Kartha A. A retrospective study on comparison of clinical characteristics and outcomes of diabetic ketoacidosis patients with and without acute pancreatitis. Sci Rep 2023; 13:4347. [PMID: 36928586 PMCID: PMC10018622 DOI: 10.1038/s41598-023-31465-3] [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] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
The co-existence of diabetic ketoacidosis (DKA) with acute pancreatitis (AP) is associated with unfavorable clinical outcomes. However, diagnosing AP in DKA patients is challenging and often missed due to overlapping symptoms. The aim of this retrospective observational study was to compare the clinical characteristics and outcomes of patients with concomitant DKA and AP or DKA alone. Data of patients with DKA admitted between January 2015 to August 2021 to four hospitals in Qatar was extracted from the electronic health record (Cerner). American Diabetes Association criteria and Atlanta criteria were used for DKA and AP diagnosis, respectively. Independent T-test or Mann-Whitney U test was used to analyze continuous variables, whereas categorical variables were analyzed via Chi-square or Fischer exact tests as appropriate. Univariate and multivariate logistic regression models were generated to assess the correlations. A p-value of < 0.05 was considered statistically significant. Of 936 patients with DKA, 84 (9.0%) had coexisting AP. AP was most common in the Asian race (66%, p < 0.001). Patients with DKA and AP were older, had higher admission anion-gap, white cell count, hemoglobin (hb), neutrophil/lymphocyte ratio, urea, creatinine, maximum blood glucose during the episode, total cholesterol and triglyceride level (TGL) (p < 0.05). They had a lower admission venous pH and bicarbonate at 6 h. Patients in the DKA with AP group also had a longer length of stay (LOS), DKA duration and a higher rate of ICU admission (p-values ≤ 0.001). In-hospital mortality, 3-month all-cause readmission, 6-month and 12-month DKA recurrence did not differ between the two groups. Univariate logistic regression analysis showed age, Asian ethnicity, male gender, T2D, admission WBC count, hb, urea, creatinine, potassium, venous pH, bicarbonate, anion gap, total cholesterol, TGL and LDL level were significantly associated with the development of DKA with AP (p < 0.05). In multivariate logistic regression analysis, age and total cholesterol level were associated with concomitant DKA and AP (p < 0.05). Patients with concomitant DKA and AP have more severe derangement in markers of DKA severity, inflammation, kidney injury and metabolic profile, along with a longer DKA duration, LOS and requirement for ICU support compared to DKA patients without AP. This highlights the clinical significance of diagnosing the co-existence of DKA with AP, as the combination results in significantly worse clinical outcomes and greater healthcare utilization than in patients with only DKA.
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Affiliation(s)
- Adeel Ahmad Khan
- Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar.
| | - Fateen Ata
- Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar
| | - Zohaib Yousaf
- Department of Medicine, Tower Health, West Reading, PA, USA
| | | | | | - Ahmad Matarneh
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Bassel Dakkak
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Malik Halabiya
- Department of Gastroenterology, Hamad Medical Corporation, Doha, Qatar
| | - Bassam Muthanna
- Department of Geriatric Medicine, University of Illinois, Chicago, USA
| | | | - Anand Kartha
- Head of Hospital Medicine, Hamad Medical Corporation, Doha, Qatar
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Garrett CJ, Moulton CD, Lee T, Amiel SA, Fonagy P, Ismail K. Can a mental health treatment reduce admissions for diabetic ketoacidosis? Acta Diabetol 2023; 60:455-457. [PMID: 36383301 DOI: 10.1007/s00592-022-01999-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 09/30/2022] [Accepted: 10/21/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Christopher J Garrett
- Diabetes and Metabolism Department, Barts Health NHS Trust, London, UK.
- Diabetes, Psychiatry and Psychology Research Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Calum D Moulton
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Tennyson Lee
- Deancross Personality Disorder Service, East London Foundation Trust, London, UK
| | - Stephanie A Amiel
- Division of Diabetes and Nutritional Sciences, King's College London, London, UK
| | - Peter Fonagy
- Division of Psychology and Language Sciences, University College London, London, UK
| | - Khalida Ismail
- Diabetes, Psychiatry and Psychology Research Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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McCoy RG, Herrin J, Galindo RJ, Sindhu Swarna K, Umpierrez GE, Hill Golden S, O'Connor PJ. All-cause mortality after hypoglycemic and hyperglycemic emergencies among U.S. adults with diabetes, 2011-2020. Diabetes Res Clin Pract 2023; 197:110263. [PMID: 36693542 PMCID: PMC10023431 DOI: 10.1016/j.diabres.2023.110263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/12/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023]
Abstract
Estimated all-cause mortality within 30-days of hypoglycemic emergencies is 0.8 % in adults with type 1 diabetes and 1.7 % with type 2 diabetes; and within 30-days of hyperglycemic emergencies, it is 1.2 % with type 1 diabetes and 2.8 % with type 2 diabetes. These rates changed little between 2011 and 2020.
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Affiliation(s)
- Rozalina G McCoy
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN, United States; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First Street SW, Rochester, MN, United States.
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Rodolfo J Galindo
- Division of Endocrinology, Department of Medicine, Comprehensive Diabetes Center at Lennar Medical Foundation, University of Miami, Miami, FL, United States
| | - Kavya Sindhu Swarna
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First Street SW, Rochester, MN, United States; OptumLabs, Eden Prairie, MN, United States
| | - Guillermo E Umpierrez
- Emory University School of Medicine, Department of Medicine, Division of Endocrinology, Grady Memorial Hospital, Atlanta, GA, United States
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine Johns Hopkins Medicine, Baltimore, MD, United States; Office of Diversity, Inclusion, and Health Equity, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Patrick J O'Connor
- Center for Chronic Care Innovation, HealthPartners Institute, Minneapolis, MN, United States
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Kikani N, Balasubramanyam A. Remission in Ketosis-Prone Diabetes. Endocrinol Metab Clin North Am 2023; 52:165-174. [PMID: 36754492 DOI: 10.1016/j.ecl.2022.06.005] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Heterogeneous forms of Ketosis-prone diabetes (KPD) are characterized by patients who present with diabetic ketoacidosis (DKA) but lack the typical features and biomarkers of autoimmune T1D. The A-β+ subgroup of KPD provides unique insight into the concept of "remission" since these patients have substantial preservation of beta-cell function permitting the discontinuation of insulin therapy, despite initial presentation with DKA. Measurements of C-peptide levels are essential to predict remission and guide potential insulin withdrawal. Further studies into predictors of remission and relapse can help us guide patients with A-β+ KPD toward remission and develop targeted treatments for this form of atypical diabetes.
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Affiliation(s)
- Nupur Kikani
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Unit 1461, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology, and Metabolism, Baylor College of Medicine, BCM 179A, One Baylor Plaza, Houston, TX 77030, USA.
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McCoy RG, Herrin J, Galindo RJ, Swarna KS, Umpierrez GE, Golden SH, O’Connor PJ. Rates of Hypoglycemic and Hyperglycemic Emergencies Among U.S. Adults With Diabetes, 2011-2020. Diabetes Care 2023; 46:e69-e71. [PMID: 36520618 PMCID: PMC9887609 DOI: 10.2337/dc22-1673] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Rozalina G. McCoy
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Rodolfo J. Galindo
- Division of Endocrinology, Department of Medicine, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
| | - Kavya Sindhu Swarna
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- OptumLabs, Eden Prairie, MN
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Department of Medicine, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD
- Office of Diversity, Inclusion, and Health Equity, Johns Hopkins Medicine, Baltimore, MD
| | - Patrick J. O’Connor
- Center for Chronic Care Innovation, HealthPartners Institute, Minneapolis, MN
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Bergmann KR, Boes M, Velden HV, Abuzzahab MJ, Watson D. Intravenous Fluid Bolus Volume and Resolution of Acute Kidney Injury in Children With Diabetic Ketoacidosis. Pediatr Emerg Care 2023; 39:67-73. [PMID: 36719386 DOI: 10.1097/pec.0000000000002616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/03/2023]
Abstract
OBJECTIVES To describe trends in creatinine and acute kidney injury (AKI) in children who present with diabetic ketoacidosis (DKA) and receive low versus high intravenous (IV) fluid bolus volumes. Further, to determine whether resolution of AKI is hastened by low versus high bolus volumes. METHODS We conducted an observational retrospective cohort study between January 2012 and March 2020 among children ≤21 years presenting with DKA. Acute kidney injury was defined by the Kidney Disease/Improving Global Outcomes creatinine criteria, using the Schwartz estimating equation to calculate an expected baseline creatinine. Bolus volume was categorized as low (<15 mL/kg) or high (≥15 mL/kg). Generalized additive mixed models were used to model trends of creatinine ratios. Estimated mean creatinine ratios and differences by bolus volumes were assessed at the time of bolus, and 12, 24, 36, 48 hours. Cox proportional hazard models were used to estimate the association between resolution of AKI and bolus volume after adjustment for confounders. RESULTS We identified 708 eligible encounters with DKA, of which 169 (23.9%) had AKI at presentation and 10 (1.4%) developed AKI after hospitalization. Comparing patients who received low versus high bolus volumes, the proportion of encounters with AKI on presentation was similar (P = 0.364) as was the mean difference in creatinine ratios over time. In adjusted analysis, treatment with high IV fluid bolus volume was only associated with a 6.2% faster resolution of AKI (hazard ratio, 1.062; 95% confidence interval, 0.61-1.87). CONCLUSIONS Intravenous fluid bolus volume was not associated with resolution of AKI in our cohort of children with DKA.
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Affiliation(s)
| | - Morgan Boes
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis
| | | | - M Jennifer Abuzzahab
- Department of Pediatric Endocrinology and McNeely Diabetes Center, Children's Minnesota, St. Paul
| | - David Watson
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
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Tas E, Wooley K, Tas V, Wang YCA. Delayed Management of Insulin-Dependent Diabetes Mellitus in Children. J Pediatr Health Care 2023; 37:56-62. [PMID: 35977849 PMCID: PMC9771990 DOI: 10.1016/j.pedhc.2022.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/11/2022] [Accepted: 07/25/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) is a common presentation for pediatric new-onset insulin-dependent diabetes mellitus (IDDM). Delayed diagnosis is the major risk factor for DKA at disease onset. METHOD Two pediatric endocrinologists independently reviewed the admission records to assess the appropriateness of preadmission management in various health care settings. RESULTS Eighteen percent (n = 45) of patients with new-onset IDDM had a delayed diagnosis. Twenty-eight were misdiagnosed (respiratory [n = 9], nonspecific [n = 7], genitourinary [n = 4], gastrointestinal [n = 8] issues) and 17 were mismanaged. One child died within 4 hr of hospitalization, presumably because of a hyperosmolar coma. Forty-six percent (n = 21) of patients with delayed diagnosis presented with DKA, comprising 18% of all DKA cases. DISCUSSION A significant number of patients with new-onset IDDM were either misdiagnosed or mismanaged. All providers must be appropriately trained in diagnosing new-onset IDDM and follow the standard of clinical care practices.
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Affiliation(s)
- Emir Tas
- Emir Tas, Attending Physician, Division of Endocrinology and Diabetes, Arkansas Children's Hospital, and Assistant Professor, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR.
| | - Katrin Wooley
- Katrin Wooley, Advanced Nurse Practitioner, Department of Pediatrics, University of Arkansas for Medical Sciences, and Division of Endocrinology and Diabetes, Arkansas Children's Hospital, Little Rock, AR
| | - Vildan Tas
- Vildan Tas, Assistant Professor, Department of Pediatrics, University of Arkansas for Medical Sciences, and Attending Physician, Division of General Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Yu-Chi Annie Wang
- Yu-Chi Annie Wang, Attending Physician, Division of Endocrinology and Diabetes, Arkansas Children's Hospital, and Associate Professor, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
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Rais N, Ahmad R, Ved A, Parveen K, Bari DG, Prakash O. Diabetic Ketoacidosis (DKA), a Leading Risk Factor for Mucormycosis (Black Fungus), during the Era of Coronavirus Disease-2019 (COVID-19): An Overview. Curr Diabetes Rev 2023; 19:33-45. [PMID: 35293299 DOI: 10.2174/1573399818666220315162424] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/06/2022] [Accepted: 01/31/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Diabetes mellitus (DM) and steroid medication, coincided with coronavirus disease 2019 (COVID-19), results in a weakened immune system, allowing some commonly found pathogens to become more harmful. Mucormycosis (black fungus) is a type of opportunistic infection caused by fungi belonging to the Mucorales family. DM is the most prominent risk factor for mucormycosis. Excessive blood sugar and decreased insulin levels lead to diabetic ketoacidosis (DKA), a devastating complication of DM that can be fatal if left untreated. METHODS Diabetic ketoacidosis is more common in type 1 diabetic patients, although it can also be fall in type 2 diabetic patients. DKA occurs when the body lacks enough insulin to allow blood sugar to enter the cells and is used for energy. Instead, the liver breaks down fat for fuel-producing chemicals known as ketones. RESULTS When too many ketones are created too quickly, they can reach dangerously high levels in the body. Mucormycosis is a rare but serious infectious disease that requires medication or surgical removal. CONCLUSION The confluence of diabetes and COVID-19 makes managing mucormycosis a serious and dead issue. Although the effectiveness of prophylactic antifungal therapy has yet to be demonstrated, hyperglycemia control appears to be the most important step in managing mucormycosis in DKA patients.
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Affiliation(s)
- Nadeem Rais
- Department of Pharmacy, Bhagwant University, Ajmer, Rajasthan-305004, India
- Department of Pharmacy, Vivek College of Technical Education, Bijnor, Uttar Pradesh-246701, India
| | - Rizwan Ahmad
- Department of Pharmacy, Vivek College of Technical Education, Bijnor, Uttar Pradesh-246701, India
| | - Akash Ved
- Goel Institute of Pharmaceutical Sciences, Lucknow, Uttar Pradesh-226028, India
| | - Kehkashan Parveen
- Interdisciplinary Biotechnology Unit, Aligarh Muslim University, Aligarh, Uttar Pradesh-202002, India
| | - Darakhshan Gazala Bari
- Department of Pharmacy, Vivek College of Technical Education, Bijnor, Uttar Pradesh-246701, India
| | - Om Prakash
- Goel Institute of Pharmacy and Sciences, Lucknow, Uttar Pradesh-226028, India
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Dhanasekaran M, Mohan S, Erickson D, Shah P, Szymanski L, Adrian V, Egan AM. Diabetic Ketoacidosis in Pregnancy: Clinical Risk Factors, Presentation, and Outcomes. J Clin Endocrinol Metab 2022; 107:3137-3143. [PMID: 35917830 PMCID: PMC9681617 DOI: 10.1210/clinem/dgac464] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Diabetic ketoacidosis (DKA) in pregnancy is an obstetric emergency with risk of maternofetal death. OBJECTIVE This work aimed to evaluate DKA events in pregnant women admitted to our inpatient obstetric service, and to examine associated clinical risk factors, presentation, and pregnancy outcomes. METHODS A retrospective cohort study was conducted at the Mayo Clinic, Rochester, Minnesota, USA, and included women aged 17 to 45 years who were treated for DKA during pregnancy between January 1, 2004 and December 31, 2021. Main outcome measures included maternal and fetal death along with a broad spectrum of maternal and fetal pregnancy outcomes. RESULTS A total of 71 DKA events were identified in 58 pregnancies among 51 women, 48 (82.8%) of whom had type 1 diabetes. There were no maternal deaths, but fetal demise occurred in 10 (17.2%) pregnancies (6 miscarriages and 4 stillbirths). Maternal social stressors were frequently present (n = 30, 51.0%), and glycemic control was suboptimal (median first trimester glycated hemoglobin A1c = 9.0%). Preeclampsia was diagnosed in 17 (29.3%) pregnancies. Infants born to women with DKA were large for gestational age (n = 16, 33.3%), suffered from neonatal hypoglycemia (n = 29, 60.4%) and required intensive care unit admission (n = 25, 52.1%). CONCLUSION DKA is associated with a high rate of maternofetal morbidity and fetal loss. Prenatal education strategies for women with diabetes mellitus should include a strong focus on DKA prevention, and clinicians and patients should have a high index of suspicion for DKA in all pregnant women who present with symptoms that could be attributed to this condition.
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Affiliation(s)
- Maheswaran Dhanasekaran
- Correspondence: Maheswaran Dhanasekaran, MBBS, Department of Endocrinology, Diabetes, Metabolism and Nutrition, 200 1st St SW, Rochester, MN 55905, USA.
| | - Sneha Mohan
- Department of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Dana Erickson
- Department of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Pankaj Shah
- Department of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Linda Szymanski
- Division of Maternal and Fetal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Vella Adrian
- Department of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Aoife M Egan
- Department of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
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Wilkinson K, Sanghamitra S, Nair P, Sanchez J, Ambati S. Utility of head CT scan in treatment decisions for suspected cerebral edema in children with DKA. J Pediatr Endocrinol Metab 2022; 35:1257-1263. [PMID: 36168879 DOI: 10.1515/jpem-2022-0245] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/17/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Cerebral edema (CE) remains one of the most feared complications of diabetic ketoacidosis (DKA) with severe morbidity and mortality. The use of computerized tomography (CT) scan in the setting of suspected cerebral edema in DKA has been minimally studied. The objective of our study was to evaluate the utility of CT scans in children with suspected cerebral edema, and secondarily to analyze the various patient characteristics of those with and without cerebral edema. METHODS We performed a retrospective chart review of all the children with DKA secondary to T1DM admitted to our tertiary PICU in order to obtain demographic data, laboratory results, and their treatment course. Differences between the groups of suspected CE and no suspected CE were compared using linear and logistic regression for continuous and binary variables respectively. RESULTS We identified 251 patients with DKA, 12 of which had suspected CE; 67% (8/12) of those patients received head CT and 87.5% (7/8) of them were read as normal. On the other hand, 33% (4/12) did not receive CT scan of head, and yet three of the four patients were treated for CE. CONCLUSIONS In our cohort of patients, CT results did not influence CE treatment or lack thereof; most patients with suspected CE were treated with or without head CT findings of CE, indicating that imaging has very little utility in our cohort of patients. In some cases, the use of head CT delayed the onset of treatment for CE.
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Affiliation(s)
| | - Sinha Sanghamitra
- Division of Neonatal-Perinatal Medicine, Brown University, Providence, USA
| | | | - Javier Sanchez
- Department of Pediatrics, Albany Medical Center, Albany, USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical Center, Albany, USA
| | - Shashikanth Ambati
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical Center, Albany, USA
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Eledrisi MS, Alkabbani H, Aboawon M, Ali A, Alabdulrazzak I, Elhaj M, Ahmed A, Alqahwachi H, Daghfal J, Beshyah SA, Malik RA. Clinical characteristics and outcomes of care in patients hospitalized with diabetic ketoacidosis. Diabetes Res Clin Pract 2022; 192:110041. [PMID: 35985426 DOI: 10.1016/j.diabres.2022.110041] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/25/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022]
Abstract
AIMS To assess the clinical characteristics and outcomes of patients hospitalized with DKA. METHODS We examined the hospital database for patients admitted with DKA to all government hospitals in Qatar over 6 years. RESULTS We evaluated a total of 1330 patients [(37.3 % with type 1 diabetes (T1DM) and 62.7 % with type 2 diabetes (T2DM)] with 1613 episodes of DKA. Patients with T2DM were older than those with T1DM [48.0 (38.0-60.0), 26.0 (21.0-31.0) years] while there was no difference in DKA severity and laboratory values on admission or time to resolution of DKA. Admission to the intensive care unit was higher (38.9 % vs. 26.6 %; P < 0.001) with a longer hospital stay [5 (2.0-9.0) vs. 2 (2.0-4.0) days, P < 0.001] and markedly higher mortality (7.4 % vs. 1 %; P < 0.001) in patients with T2DM compared to T1DM. On multivariable logistic regression analysis, significant predictors of mortality were older age (odds ratio, 1.11; 95 % CI, 1.07-1.15; P = 0.0001), and admission to the intensive care unit (odds ratio, 3.61; 95 % CI, 1.69-7.72;P = 0.001). CONCLUSION In this national cohort of patients hospitalized with DKA, those with T2DM had a 7-fold increase in inpatient mortality associated with older age and admission to the intensive care unit.
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Affiliation(s)
- Mohsen S Eledrisi
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar; Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar.
| | - Haifaa Alkabbani
- Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
| | - Malk Aboawon
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Aya Ali
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Maab Elhaj
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Ashraf Ahmed
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Joanne Daghfal
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Salem A Beshyah
- Department of Endocrinology, Yas Clinic, Abu Dhabi, United Arab Emirates; Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Rayaz A Malik
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar; Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar; Faculty of Biology, Medicine & Health, The University of Manchester, Manchester, United Kingdom
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45
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Dicks HN, Naidoo K. COVID-19 and diabetic ketoacidosis: A case series at an urban district hospital in South Africa. S Afr Fam Pract (2004) 2022; 64:e1-e5. [PMID: 36226949 PMCID: PMC9557943 DOI: 10.4102/safp.v64i1.5590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/14/2022] [Accepted: 07/18/2022] [Indexed: 11/03/2022] Open
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Heather N Dicks
- Department of Family Medicine, Northdale Hospital, Pietermaritzburg, South Africa; and, Department of Family Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban.
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Miyamura K, Nawa N, Nishimura H, Fushimi K, Fujiwara T. Association between heat exposure and hospitalization for diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia in Japan. Environ Int 2022; 167:107410. [PMID: 35868079 DOI: 10.1016/j.envint.2022.107410] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 07/03/2022] [Accepted: 07/11/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND An increase in extreme heat events has been reported along with global warming. Heat exposure in ambient temperature is associated with all-cause diabetes mortality and all-cause hospitalization in diabetic patients. However, the association between heat exposure and hospitalization for hyperglycemic emergencies, such as diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS), and hypoglycemia is unclear. The objective of our study is to clarify the impact of heat exposure on the hospitalization for DKA, HHS, and hypoglycemia. METHODS Data of daily hospitalizations for hyperglycemic emergencies (i.e., DKA or HHS) and hypoglycemia was extracted from a nationwide administrative database in Japan and linked with temperature in each prefecture in Japan during 2012-2019. We applied distributed lag non-linear model to evaluate the non-linear and lagged effects of heat exposure on hospitalization for hyperglycemic emergencies. RESULTS The pooled relative risk for hyperglycemic emergencies of heat effect (the 90th percentile of temperature with reference to the 75th percentile of temperature) and extreme heat effect (the 99th percentile of temperature with reference to the 75th percentile of temperature) over 0-3 lag days was 1.27 (95 %CI: 1.16-1.39) and 1.64 (95 %CI: 1.38-1.93), respectively. The pooled relative risk for heat effect on hospitalization for hypoglycemia and extreme heat effect over 0-3 lag days was 1.33 (95 %CI: 1.17-1.52) and 1.65 (95 %CI: 1.29-2.10), respectively. These associations were consistent by type of hyperglycemic emergencies and type of diabetes and were generally consistent by regions. DISCUSSION Heat exposure was associated with hospitalizations for DKA, HHS and hypoglycemia. These results may be useful to guide preventive actions for the risk of fatal hyperglycemic emergencies and hypoglycemia.
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Affiliation(s)
- Keitaro Miyamura
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobutoshi Nawa
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hisaaki Nishimura
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Information Section, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeo Fujiwara
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan.
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Yoo MS, Daniels A, Maslow RA, Gomez JA, Meyers NL, Bohrer PS, Nemazie S, Sanford CE, Peterson EA, Hamann KL, Walsh DE, O’Herlihy AM, Kumra V. Management of hospitalized patients with mild to moderate diabetic ketoacidosis using a continuous insulin infusion protocol on a medical surgical ward and observation level of care: A retrospective cohort study. Medicine (Baltimore) 2022; 101:e29665. [PMID: 35945801 PMCID: PMC9351868 DOI: 10.1097/md.0000000000029665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Although the practice of using rapid-acting subcutaneous insulin for the management of mild-to-moderate diabetic ketoacidosis is becoming increasingly popular, the continuous insulin infusion remains widely utilized, and its real-world applicability and safety on a medical surgical unit (Med Surg) and observation level of care are unclear. We assessed whether a continuous insulin infusion protocol for mild-to-moderate diabetic ketoacidosis on Med Surg/observation level of care over a 6.5-year period was associated with adverse outcomes. A retrospective cohort study of adults hospitalized with mild-to-moderate diabetic ketoacidosis was conducted at 2 community hospitals in Northern California, USA, from January 2014 to May 2020. Demographic and clinical variables were collected using an electronic health record. Admission to Med Surg/observation was compared to intensive care unit admission for the outcomes of 30-day readmission, presence of hypoglycemia, rate of hypoglycemic episodes, in-hospital and 30-day mortality, and length of stay using bivariate analysis. Among 227 hospital encounters (mean age 41 years, 52.9% women, 79.3% type 1 diabetes, 97.4% utilization of continuous insulin infusion), 19.4% were readmitted within 30 days, and 20.7% developed hypoglycemia. For Med Surg/observation encounters compared to the intensive care unit, there were no statistically significant differences in the risk of readmission (RR 1.48, 95% CI, 0.86-2.52), hypoglycemia (RR 1.17, 95% CI, 0.70-1.95), or increased length of stay (RR 0.71, 95% CI, 0.55-1.02); there was a lower risk of hypoglycemic events during hospitalization (RR 0.69, 95% CI, 0.54-0.96). Continuous insulin infusion utilization may be a safe option for treatment of mild-to-moderate diabetic ketoacidosis on Med Surg/observation level of care. Further investigation is needed.
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Affiliation(s)
- Michael S. Yoo
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
- *Correspondence: Michael S. Yoo, Kaiser Permanente Santa Rosa Medical Center, 401 Bicentennial Way, Santa Rosa, CA 95403, USA (e-mail: )
| | - Abraham Daniels
- Department of Medical Administration Strategic Activities, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Rene A. Maslow
- Department of Critical Care, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - John A. Gomez
- Department of National Quality, Safety, Experience and Health Systems Performance, Kaiser Permanente, Oakland, CA, USA
| | - Nannette L. Meyers
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Pamela S. Bohrer
- Department of Head and Neck Surgery, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Siamack Nemazie
- Department of Nephrology, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Christina E. Sanford
- Department of Clinical Adult Services, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Emily A. Peterson
- Department of Inpatient Pharmacy Services, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Kendal L. Hamann
- Department of Endocrinology, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Darcy E. Walsh
- Department of Oncology and Adult Infusion, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Alison M. O’Herlihy
- Department of Clinical Adult Services, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Vivek Kumra
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
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Sengupta I, Nayak T. Coincidence or reality behind Mucormycosis, diabetes mellitus and Covid-19 association: A systematic review. J Mycol Med 2022; 32:101257. [PMID: 35219907 PMCID: PMC8855615 DOI: 10.1016/j.mycmed.2022.101257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 01/31/2022] [Accepted: 02/17/2022] [Indexed: 12/24/2022]
Abstract
Mucormycosis is a rare but life-threatening disease with high morbidity and mortality and is difficult to diagnose. Mucormycosis, is a severe but rare fungal infection caused by a group of molds called mucormycetes. Diabetes, use of corticosteroids, metabolic/diabetic acidosis and Covid-19 mediated immunosuppression are reported in more than 70% of cases in mucormycosis patients. Coexisting mucormycosis, Covid-19 along with diabetes mellitus increase the likelihood of mortality. Despite its occurrence since the beginning of the pandemic, there are still unanswered concerns regarding the origin of this fungal infection and mortality rate and/or relation with diabetic patients. In this review, we describe the detailed view of causative pathogens responsible for mucormycosis, diabetes mellitus and Covid-19 association along with the morbidity cases during the latest Covid-19 crisis. In the case of mucormycosis diagnosis, imaging, histopathological confirmation, fungal culture and molecular identification methods should be considered. Once mucormycosis is diagnosed, a combined treating method consisting of antifungals administration like amphotericin B, surgical intervention is needed for the reversal of the underlying condition. Early detection of this potentially life-threatening infection and timely care is needed in lowering mortality rates.
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Affiliation(s)
- Indraneel Sengupta
- Department of Life Science and Biotechnology, Jadavpur University, Kolkata 700032, India
| | - Tilak Nayak
- Department of Life Science and Biotechnology, Jadavpur University, Kolkata 700032, India.
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Lantos J, Barta Z, Nagy A, Vincze R, Füle K, Bihari K. A case study of acute oropharyngeal palsy concomitant with diabetic ketoacidosis. Ideggyogy Sz 2022; 75:275-278. [PMID: 35916614 DOI: 10.18071/isz.75.0275] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Acute oropharyngeal palsy is a rare variant of Guillain-Barré syndrome. In our study we present the case of a 63-year-old man with general symptoms who was diagnosed with diabetic ketoacidosis and prescribed insulin therapy. Two weeks later, the patient complained of paraesthesia of the perioral region and the tip of the tongue, dysphagia, and dysarthria. These symptoms were initially thought to be complications of the patient's type-1 diabetes. Due to rapidly developing paraparesis, the patient became bedridden. Clinical symptoms, cerebrospinal fluid analysis and a nerve conduction study resulted in a diagnosis of acute oropharyngeal palsy, a variant of Guillain-Barré syndrome. After five consecutive days of intravenous immunoglobulin treatment, neurological symptoms improved and the need for insulin ceased. One year later, the patient's only remaining neurological symptom was loss of tendon reflexes in the lower extremities. Furthermore, the patient's blood glucose level was normal without the use of medications or a special diet. Here, we report that oropharyngeal palsy can co-occur with diabetic ketoacidosis, and that immuntherapy is effective in treating both oropharyngeal palsy and type-1 diabetes. To our knowledge, this is the first description of a patient presenting with acut oropharyngeal palsy concomitant with diabetic ketoacidosis.
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Affiliation(s)
- Judit Lantos
- Bács-Kiskun County Hospital, Neurology and Stroke Department, Kecskemét
| | | | - Albert Nagy
- Bács-Kiskun County Hospital, Neurology and Stroke Department, Kecskemét
| | - Rita Vincze
- Bács-Kiskun County Hospital, Neurology and Stroke Department, Kecskemét
| | - Kálmán Füle
- Bács-Kiskun County Hospital, Neurology and Stroke Department, Kecskemét
| | - Katalin Bihari
- Bács-Kiskun County Hospital, Neurology and Stroke Department, Kecskemét
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Blank SP, Blank RM, Campbell L. What Is the Optimal Speed of correction of the Hyperosmolar Hyperglycemic State in Diabetic Ketoacidosis? An Observational Cohort Study of U.S. Intensive Care Patients. Endocr Pract 2022; 28:875-883. [PMID: 35688365 DOI: 10.1016/j.eprac.2022.06.001] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/28/2022] [Accepted: 06/01/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The international guidelines for the treatment of diabetic ketoacidosis (DKA) advise against rapid changes in osmolarity and glucose; however, the optimal rates of correction are unknown. We aimed to evaluate the rates of change in tonicity and glucose level in intensive care patients with DKA and their relationship with mortality and altered mental status. METHODS This is an observational cohort study using 2 publicly available databases of U.S. intensive care patients (Medical Information Mart for Intensive Care-IV and Electronic Intensive Care Unit), evaluating adults with DKA and associated hyperosmolarity (baseline Osm ≥300 mOsm/L). The primary outcome was hospital mortality. The secondary neurologic outcome used a composite of diagnosed cerebral edema or Glasgow Coma Scale score of ≤12. Multivariable regression models were used to control for confounding factors. RESULTS On adjusted analysis, patients who underwent the most rapid correction of up to approximately 3 mmol/L/hour in tonicity had reduced mortality (n = 2307; odds ratio [OR], 0.21; overall P < .001) and adverse neurologic outcomes (OR, 0.44; P < .001). Faster correction of glucose levels up to 5 mmol/L/hour (90 mg/dL/hour) was associated with improvements in mortality (n = 2361; OR, 0.24; P = .020) and adverse neurologic events (OR, 0.52; P = .046). The number of patients corrected significantly faster than these rates was low. A maximal hourly rate of correction between 2 and 5 mmol/L for tonicity was associated with the lowest mortality rate on adjusted analysis. CONCLUSION Based on large-volume observational data, relatively rapid correction of tonicity and glucose level was associated with lower mortality and more favorable neurologic outcomes. Avoiding a maximum hourly rate of correction of tonicity >5 mmol/L may be advisable.
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Affiliation(s)
- Sebastiaan P Blank
- Intensive Care Unit, Royal Darwin Hospital, Tiwi, Northern Territory, Australia.
| | - Ruth M Blank
- Royal Darwin Hospital, Tiwi, Darwin, Northern Territory, Australia
| | - Lewis Campbell
- Intensive Care Unit, Royal Darwin Hospital, Tiwi, Northern Territory, Australia; Flinders University, Adelaide, Australia; Menzies School of Health Research, Royal Darwin Hospital Campus, Tiwi, Northern Territory, Australia
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