Electrolyte Imbalance In Diabetic Ketoacidosis
If you have diabetes, it's important to be familiar with diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes that occurs when lack of insulin and high blood sugar lead to potentially life-threatening chemical imbalances. The good news is DKA is largely preventable. Although DKA is more common with type 1 diabetes, it can also occur with type 2 diabetes. High blood sugar causes excessive urination and spillage of sugar into the urine. This leads to loss of body water and dehydration as well as loss of important electrolytes, including sodium and potassium. The level of another electrolyte, bicarbonate, also falls as the body tries to compensate for excessively acidic blood. Video of the Day Insulin helps blood sugar move into cells, where it is used for energy production. When insulin is lacking, cells must harness alternative energy by breaking down fat. Byproducts of this alternative process are called ketones. High concentrations of ketones acidify the blood, hence the term "ketoacidosis." Acidosis causes unpleasant symptoms like nausea, vomiting and rapid breathing. Bicarbonate is an electrolyte that normally counteracts blood acidity. In DKA, the bicarbonate level falls as ketone production increases and acidosis progresses. Treatment of DKA includes prompt insulin supplementation to lower blood sugar, which leads to gradual restoration of the bicarbonate level. Potassium may be low in DKA because this electrolyte is lost due to excessive urination or vomiting. When insulin is used to treat DKA, it can further lower the blood potassium by pushing it into cells. Symptoms associated with low potassium include fatigue, muscle weakness, muscle cramps and an irregular heart rhythm. Severely low potassium can lead to life-threatening heart rhythm abnorm Continue reading >>
Were There Any American Citizens Living On Us Soil Who Died Because They Couldn't Afford Healthcare?
Various answers to answers (I guess coming from incredulous non-Americans) have asked why the American people would put up with such a system, or why anyone could think it is better than the “socialist” model. Some have mentioned the stigma associated with the word socialism which Americans have been indoctrinated with since the Cold War. While that is true, it’s important to consider where that message originated, and why it was spread. “Single payer” healthcare is paid for by tax revenue. Healthcare is expensive in any country compared to other parts of the federal budget like public building maintenance, forestry etc., so a significant percentage of all taxes collected go to pay for socialist healthcare. That applies to the taxes of a poor American who doesn’t pay any taxes (20% of zero is zero), just as it does to a wealthy “1%er”, or an ultra-wealthy billionaire like Trump or Koch. In the American private health insurance system, if your insurance for a family costs $20k per year, that’s your liability for private health insurance regardless of your income. Joe the Plummer or Mitt Romney or Bill Gates - That same insurance costs each of them $20k more or less. This is from the Fraser Institute (Conservative Canadian “think tank”): “The 10% of Canadian families with the lowest incomes will pay an average of about $477 for public health care insurance in 2015. The 10% of Canadian families who earn an average income of $59,666 will pay an average of $5,684 for public health care insurance and the families among the top 10% of income earners in Canada will pay $37,180.” For extremely high-income wealthy Americans like Koch or Trump, that number would be a lot higher. If 20% of tax revenue goes to pay for healthcare, and George Soros pays $100 Continue reading >>
Managing Diabetes Complicated By Ketoacidosis
Go to site For Pet Owners Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus that has to be aggressively treated. Diagnosis The diagnosis is based on the presence of ketonuria with signs of systemic illness. Management guidelines Goals of treatment include the correction of fluid deficits, acid-base balance and electrolyte balance, reduction of blood glucose and ketonuria, and beginning insulin therapy and treatment of concurrent diseases. Many protocols for treatment exist but rapid-acting insulin (regular) must be administered first, as decreases in the hyperglycemia must be achieved quickly. When blood sugar levels are lowered and maintained at 200−250 mg/dL for 4−10 hours, then Vetsulin® (porcine insulin zinc suspension) can be used. Evaluation of treatment When evaluating the regulation of insulin therapy, it is important to consider several areas including the evaluation of glycemia, urine monitoring, routine rechecks and glycated protein evaluations. Evaluation of the glycemia Creating a blood glucose curve is the most accurate way to evaluate glycemia in order to adjust the dose of Vetsulin. Indications for creating a blood glucose curve are: First, to establish insulin dose, dosing interval, and insulin type when beginning regulation. Second, to evaluate regulation especially if problems occur. Third, when rebound hyperglycemia (Somogyi effect) is suspected. Contraindications for creating a blood glucose curve are: Concurrent administration of drugs affecting glycemia. Presence of a known infection or disease. Stressed animal. The procedure is as follows: The most accurate way to assess response to management is by generating a blood glucose curve. Ideally, the first sample should be taken just prior to feeding Continue reading >>
Emergency Management Of Diabetic Ketoacidosis In Adults
Diabetic ketoacidosis (DKA) is a potentially fatal metabolic disorder presenting most weeks in most accident and emergency (A&E) departments.1 The disorder can have significant mortality if misdiagnosed or mistreated. Numerous management strategies have been described. Our aim is to describe a regimen that is based, as far as possible, on available evidence but also on our experience in managing patients with DKA in the A&E department and on inpatient wards. A literature search was carried out on Medline and the Cochrane Databases using “diabetic ketoacidosis” as a MeSH heading and as textword. High yield journals were hand searched. Papers identified were appraised in the ways described in the Users’ guide series published in JAMA. We will not be discussing the derangements in intermediary metabolism involved, nor would we suggest extrapolating the proposed regimen to children. Although some of the issues discussed may be considered by some to be outwith the remit of A&E medicine it would seem prudent to ensure that A&E staff were aware of the probable management of such patients in the hours after they leave the A&E department. AETIOLOGY AND DEFINITION DKA may be the first presentation of diabetes. Insulin error (with or without intercurrent illness) is the most common precipitating factor, accounting for nearly two thirds of cases (excluding those where DKA was the first presentation of diabetes mellitus).2 The main features of DKA are hyperglycaemia, metabolic acidosis with a high anion gap and heavy ketonuria (box 1). This contrasts with the other hyperglycaemic diabetic emergency of hyperosmolar non-ketotic hyperglycaemia where there is no acidosis, absent or minimal ketonuria but often very high glucose levels (>33 mM) and very high serum sodium levels (>15 Continue reading >>
Diabetes: What Is Ketoacidosis And How Can Be Avoided & Treated?
Good question! According to Wikipedia: Diabetic ketoacidosis is a potentially life-threatening complication in patients with diabetes mellitus. In order to define ketoacidosis a little better, let's go back to the source: diabetes. Someone who is diabetic is unable to produce insulin, a hormone necessary for the transfer of sugar from the bloodstream to the cells, which in turn produce energy. If this progression is disrupted, through lack of insulin for example, the body has to try to compensate by creating energy elsewhere. And so the body starts to burn fat and muscle to meet its energy needs. Unfortunately, this chemical reaction produces molecules known as ketone bodies. In small quantities, these are fine, and it is in fact normal to have traces of them in your blood (approximately 1mg/dl). However, if the quantity of ketones surpasses this threshold by too much, it starts to affect the pH of your blood (which becomes progressively more acidic). Even the slightest drop in pH can have dangerous effects: as the quantity of the ketones in your blood increases, and the blood pH diminishes, your kidneys start having problems. Eventually, if the ketoacidosis is left untreated, your kidneys can fail and you can die from dehydration, tachycardia and hypotension. A number of other symptoms can appear in extreme cases. Fortunately for us, the quantity of ketones has to be consequential, and it usually takes a while before individuals start manifesting symptoms. In my case, my diabetes went undiagnosed for a month and a half before it was discovered, and even then my ketone levels were relatively normal. If you're a diabetic, ketoacidosis can be easily avoided by controlling your blood sugar levels and maintaining a healthy lifestyle. Some doctors, preferring to stay on the Continue reading >>
Diabetic Ketoacidosis And Hyperosmolar Hyperglycemic State In Adults: Treatment
INTRODUCTION Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS, also known as hyperosmotic hyperglycemic nonketotic state [HHNK]) are two of the most serious acute complications of diabetes. They are part of the spectrum of hyperglycemia, and each represents an extreme in the spectrum. The treatment of DKA and HHS in adults will be reviewed here. The epidemiology, pathogenesis, clinical features, evaluation, and diagnosis of these disorders are discussed separately. DKA in children is also reviewed separately. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Epidemiology and pathogenesis".) (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis".) Continue reading >>
Can Diabetes Kill You?
Here’s what you need to know about the life-threatening diabetes complication called diabetic ketoacidosis. Diabetic ketoacidosis is one of the most serious complications of diabetes. Symptoms can take you by surprise, coming on in just 24 hours or less. Without diabetic ketoacidosis treatment, you will fall into a coma and die. “Every minute that the person is not treated is [another] minute closer to death,” says Joel Zonszein, MD, professor of medicine at Albert Einstein College of Medicine in New York City. Diabetic ketoacidosis occurs when your body doesn’t produce enough insulin. (Diabetic ketoacidosis most often affects people with type 1 diabetes, but there is also type 2 diabetes ketoacidosis.) Without insulin, sugar can’t be stored in your cells to be used as energy and builds up in your blood instead. Your body has to go to a back-up energy system: fat. In the process of breaking down fat for energy, your body releases fatty acids and acids called ketones. Ketones are an alternative form of energy for the body, and just having them in your blood isn’t necessarily harmful. That’s called ketosis, and it can happen when you go on a low-carb diet or even after fasting overnight. “When I put people on a restricted diet, I can get an estimate of how vigorously they’re pursuing it by the presence of ketones in the urine,” says Gerald Bernstein, MD, an endocrinologist and coordinator of the Friedman Diabetes Program at Lenox Hill Hospital in New York City. RELATED: The Ketogenic Diet Might Be the Next Big Weight Loss Trend, But Should You Try It? But too many ketones are a problem. “In individuals with diabetes who have no or low insulin production, there is an overproduction of ketones, and the kidneys can’t get rid of them fast enough,” sa Continue reading >>
Use Of A Computer-based Insulin Infusion Algorithm To Treat Diabetic Ketoacidosis In The Emergency Department
Diabetes Technology & Therapeutics Authors Jagdeesh Ullal,1 Raymie McFarland,2 Margaret Bachand,3 Joseph Aloi4 Abstract Background Efforts at improving quality metrics in diabetes focus on minimizing adverse events and avoiding re-admissions to the hospital. Our experience with Glucommander (Glytec, Greenville, SC), a cloud-based insulin management software system, suggested that its use in the emergency department (ED) would be useful in treating patients with mild diabetic ketoacidosis (DKA). Materials and Methods Thirty-five patients seen in the ED with hyperglycemic crises and diagnosed with DKA during one calendar year were reviewed. A retrospective chart review was performed on patients who were placed on Glucommander for DKA management. We excluded patients with significant acidosis or concomitant medical illnesses. Results Initial average capillary glucose level was 487 + 68mg/dL, average time to target glucose was 5 h 11min, and rate of hypoglycemia (blood glucose level < 70mg/dL) was less than 0.3%. Sixteen patients treated with the protocol were discharged from the ED directly, and 19 were admitted. Patients were maintained for an average of 14 + 1 h on the Glucommander protocol. There was a significantly higher anion gap (P = 0.002) and lower serum bicarbonate level (P= 0.006) in the admitted group. We found very low evidence of re-admission (6%) within 30 days of discharge from the ED for DKA patients. No significant glucose-related adverse events were noted. Conclusions Use of Glucommander for guiding the insulin treatment of mild DKA in the ED can decrease admissions to the hospital for DKA by 45%. Low rates of hypoglycemia make this an option to improve efficiency of utilization of inpatient hospital beds. The cost savings for nonadmissions were estimate Continue reading >>
The Facts Diabetic ketoacidosis (DKA) is a condition that may occur in people who have diabetes, most often in those who have type 1 (insulin-dependent) diabetes. It involves the buildup of toxic substances called ketones that make the blood too acidic. High ketone levels can be readily managed, but if they aren't detected and treated in time, a person can eventually slip into a fatal coma. DKA can occur in people who are newly diagnosed with type 1 diabetes and have had ketones building up in their blood prior to the start of treatment. It can also occur in people already diagnosed with type 1 diabetes that have missed an insulin dose, have an infection, or have suffered a traumatic event or injury. Although much less common, DKA can occasionally occur in people with type 2 diabetes under extreme physiologic stress. Causes With type 1 diabetes, the pancreas is unable to make the hormone insulin, which the body's cells need in order to take in glucose from the blood. In the case of type 2 diabetes, the pancreas is unable to make sufficient amounts of insulin in order to take in glucose from the blood. Glucose, a simple sugar we get from the foods we eat, is necessary for making the energy our cells need to function. People with diabetes can't get glucose into their cells, so their bodies look for alternative energy sources. Meanwhile, glucose builds up in the bloodstream, and by the time DKA occurs, blood glucose levels are often greater than 22 mmol/L (400 mg/dL) while insulin levels are very low. Since glucose isn't available for cells to use, fat from fat cells is broken down for energy instead, releasing ketones. Ketones accumulate in the blood, causing it to become more acidic. As a result, many of the enzymes that control the body's metabolic processes aren't able Continue reading >>
How The Treatment Of Diabetic Ketoacidosis Has Improved
For patients with type 1 diabetes, one of the most serious medical emergencies is diabetic ketoacidosis (DKA). It can be life-threatening and, in most cases, is caused by a shortage of insulin. Glucose is the “fuel” which feeds human cells. Without it, these cells are forced to “burn” fatty acids in order to survive. This process leads to the production of acidic ketone bodies which can cause serious symptoms and complications such as passing out, confusion, vomiting, dehydration, coma, and, if not corrected in a timely manner, even death. High levels of ketones poison the body. DKA can be diagnosed with blood and urine tests and is distinguished from other ketoacidosis by the presence of high blood sugar levels. Typical treatment for DKA consists of using intravenous fluids to correct the dehydration, insulin dosing to suppress the production of ketones, and treatment for any underlying causes such as infections. Medical history notes that DKA was first diagnosed and described in 1886 and until insulin therapy was introduced in the 1920’s, this condition was almost universally fatal. However, with availability and advances in insulin therapy, the mortality rate is less than one percent when timely treatment is applied. A Clinical Pharmacist Examines DKA Ron Fila (RPh) is a clinical pharmacist at McLaren Northern Michigan in Petoskey, MI. He has first-hand experience in treating patients with DKA and, as one of the early adaptors of EndoTool he has seen how this algorithmically-based glucose management software can help physicians save lives and improve patient outcomes. “We started using EndoTool in 2013, for treating patients in the ICU,” he noted in a recent interview. “Later, we expanded our use of this software for DKA and pediatrics. “Since DKA i Continue reading >>
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Insulin Sliding Scale
This sliding scale should NOT to be used to treat people with: Diabetic Ketoacidosis (DKA) Hyperglycaemic Hyperosmolar State (HHS) / Hyperosmolar Non-Ketotic Coma (HONC) See individual guidelines for the management of these conditions. This sliding scale can be used to manage glucose levels in people with diabetes mellitus. It can be used in surgical patients with diabetes mellitus undergoing operations however local anaesthetic departments may have their own scales. Prior to using the scale below, discuss with local anaesthetists that they are happy for it to be used. This scale can also be used in medical patients with diabetes mellitus in whom regulation of glucose is deemed important. The principles of the sliding scale are: Desired glucose control is achieved and maintained Avoidance of hypoglycaemia Avoidance of ketosis by providing adequate carbohydrate and insulin Maintenance of fluid and electrolyte balance. Before starting on the sliding scale it is important to specify the target glucose level and whether intravenous fluids are to be given with insulin. Urea and electrolytes should be checked before starting the sliding scale to guide potassium administration. If patient is already on a background insulin (eg Insulatard®, Lantus® or Levemir®), administer at the usual time whilst using sliding scale, unless advised not to by Diabetes team or anaesthetist. Insulin Preparation: Add 50units of soluble insulin (Actrapid® or Humulin S®), drawn up using an insulin syringe, to 50ml of 0.9% sodium chloride in a 50ml syringe. Infuse IV using a syringe pump and adjust according to sliding scale below, which is an initial guide. Please review insulin rate and blood glucose response on a regular basis (see supplementary notes below) and amend if need be to achieve ta Continue reading >>
Authors Runa Acharya, MD, University of Iowa-Des Moines Internal Medicine Residency Program at UnityPoint Health, Des Moines, IA Udaya M. Kabadi, MD, FACP, FRCP(C), FACE, Veteran Affairs Medical Center and Broadlawns Medical Center, Des Moines, IA; Des Moines University of Osteopathic Medicine, Iowa City; and University of Iowa Carver College of Medicine, Iowa City; Adjunct Professor of Medicine and Endocrinology, University of Iowa, Iowa City, and Des Moines University, Des Moines Peer Reviewer Jay Shubrook, DO, FAAFP, FACOFP, Professor, Primary Care Department, Touro University, College of Osteopathic Medicine, Vallejo, CA Statement of Financial Disclosure To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, Dr. Kabadi (author) reports he is a consultant and on the speakers bureau for Sanofi. Dr. Shubrook (peer reviewer) reports he receives grant/research support from Sanofi and is a consultant for Eil Lilly, Novo Nordisk, and Astra Zeneca. Dr. Acharya (author) reports no financial relationships relevant to this field of study. Continue reading >>
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Using Rapid Acting Insulin Analogues To Treat Diabetic Ketoacidosis In Dogs
K. W. Sears, K. J. Drobatz, and R. S. Hess Journal of Veterinary Emergency and Critical Care 2012;doi: 10.1111/j.1476-4431.2012.00719.x Diabetic ketoacidosis (DKA) is a life-threatening condition that develops in many dogs and cats with diabetes mellitus (1). The critical factors in the treatment of DKA include careful and frequent monitoring of the patient, skillful fluid and electrolyte adjustment, and the initiation of insulin therapy after the initial restoration of fluid volume has been achieved (2-4). The mainstay in treatment of dogs with DKA involves administration of low doses of regular insulin, either by intramuscular or subcutaneous injection (2) or by use of a continuous intravenous infusion (3). The regular insulin used today is conventional human recombinant insulin, but this preparation is gradually being replaced by more rapid-acting insulin analogs. One of these new rapid-acting insulin analogs is insulin lispro (Humalog, Lilly), the first commercially available insulin analog (5,6). Compared with regular human insulin, this insulin analog offers the advantages of faster subcutaneous absorption, an earlier and greater insulin peak, and a shorter duration of action. The benefits achieved by insulin lispro are related to a sequence switch of two beta-chain amino acids. Engineered through recombinant DNA technology, the lysine and proline residues on the C-terminal end of the B-chain are reversed. This modification does not alter receptor binding, but blocks the formation of insulin dimers and hexamers. This allows for the active monomeric insulin to be absorbed almost immediately after injection. The use of rapid-acting insulin analogs for treatment of DKA in dogs has not previously been reported. In this study by Sears et al (7), the investigators evalu Continue reading >>
Diabetic Ketoacidosis Treatment
Diabetic ketoacidosis is a life-threatening medical condition that is a complication of diabetes mellitus that is not in control. It is more common among type 1 diabetics that have no insulin but it can also be seen in severe cases of type 2 diabetes. In diabetic ketoacidosis, there are ketones in the bloodstream and urine because the fat in the body is broken down with ketones as a byproduct. Diabetic ketoacidosis occurs when the body isn’t making enough insulin by the pancreatic islet cells. In a normal person, insulin is secreted by the pancreas in response to elevated blood sugar levels. The insulin helps glucose (sugar) to enter the cells to be used as cellular fuel. If insulin is absent, the body breaks down fatty acids to be used for fuel. Ketones build up in the urine and blood, leading to the condition known as diabetic ketoacidosis. The main cause is being a type 1 diabetic who has not taken enough insulin. Symptoms of Diabetic Ketoacidosis The signs and symptoms of diabetic ketoacidosis can come on suddenly, within a day or so of having no insulin. When signs and symptoms do show up, the patient may have any or all of the following symptoms: Confusion Breath that smells fruity Shortness of breath Tiredness or weakness Pain in the abdomen Nausea and vomiting Increased frequency of urination Being excessively thirsty Clinical signs that the individual has diabetic ketoacidosis includes have extremely high blood sugar levels as well as elevated levels of ketones in the urine. Causes of Diabetic Ketoacidosis The main source of cellular fuel is glucose. All of the cells of the body rely on glucose to make energy to allow the cells to function in whatever capacity they happen to be in. When insulin is lacking, the body is unable to use glucose as fuel. These caus Continue reading >>