Cerebrovascular Complications Of Diabetic Ketoacidosis In Children
CLINICAL CASE REPORT Complicações cerebrovasculares da cetoacidose diabética em crianças Luis Felipe Mendonça de Siqueira Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG); Department of Pediatrics, Faculty of Medicine, UFMG, Belo Horizonte, MG, Brazil SUMMARY Neurological deterioration in children with diabetic ketoacidosis (DKA) is commonly caused by cerebral edema. However, subtle cerebral injuries including strokes should also be suspected, since children with hyperglycemia and DKA are prone to thrombosis. In this paper, a case involving a 2 month-old patient that presented cerebral edema and stroke as complications of DKA is reported. In the discussion, the literature on neurological complications of DKA in children is briefly reviewed, emphasizing the prothrombotic tendency of these patients. SUMÁRIO Alterações neurológicas em crianças com cetoacidose diabética (CAD) são comuns, sobretudo em decorrência de edema cerebral. Contudo, lesões cerebrais agudas, como acidente vascular cerebral (AVC), também devem ser investigadas, já que as crianças com hiperglicemia e cetoacidose têm maior chance de apresentar essa complicação. Neste relato, descreve-se a história de um paciente de 2 meses de idade que apresentou edema cerebral e AVC como complicações de um quadro de cetoacidose diabética. Durante a discussão, será feita uma breve revisão da literatura sobre as complicações neurológicas da CAD nos pacientes pediátricos enfatizando sua tendência pró-trombótica. INTRODUCTION Children with new onset type 1 diabetes mellitus (T1DM) frequently have diabetic ketoacidosis (DKA) as their initial presentation, a disorder that is associated with significant morbidity and mortality. In this context, neurological complications, in Continue reading >>
Diabetic Ketoacidosis - Symptoms
A A A Diabetic Ketoacidosis Diabetic ketoacidosis (DKA) results from dehydration during a state of relative insulin deficiency, associated with high blood levels of sugar level and organic acids called ketones. Diabetic ketoacidosis is associated with significant disturbances of the body's chemistry, which resolve with proper therapy. Diabetic ketoacidosis usually occurs in people with type 1 (juvenile) diabetes mellitus (T1DM), but diabetic ketoacidosis can develop in any person with diabetes. Since type 1 diabetes typically starts before age 25 years, diabetic ketoacidosis is most common in this age group, but it may occur at any age. Males and females are equally affected. Diabetic ketoacidosis occurs when a person with diabetes becomes dehydrated. As the body produces a stress response, hormones (unopposed by insulin due to the insulin deficiency) begin to break down muscle, fat, and liver cells into glucose (sugar) and fatty acids for use as fuel. These hormones include glucagon, growth hormone, and adrenaline. These fatty acids are converted to ketones by a process called oxidation. The body consumes its own muscle, fat, and liver cells for fuel. In diabetic ketoacidosis, the body shifts from its normal fed metabolism (using carbohydrates for fuel) to a fasting state (using fat for fuel). The resulting increase in blood sugar occurs, because insulin is unavailable to transport sugar into cells for future use. As blood sugar levels rise, the kidneys cannot retain the extra sugar, which is dumped into the urine, thereby increasing urination and causing dehydration. Commonly, about 10% of total body fluids are lost as the patient slips into diabetic ketoacidosis. Significant loss of potassium and other salts in the excessive urination is also common. The most common Continue reading >>
Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus.[1] Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion, and occasionally loss of consciousness.[1] A person's breath may develop a specific smell.[1] Onset of symptoms is usually rapid.[1] In some cases people may not realize they previously had diabetes.[1] DKA happens most often in those with type 1 diabetes, but can also occur in those with other types of diabetes under certain circumstances.[1] Triggers may include infection, not taking insulin correctly, stroke, and certain medications such as steroids.[1] DKA results from a shortage of insulin; in response the body switches to burning fatty acids which produces acidic ketone bodies.[3] DKA is typically diagnosed when testing finds high blood sugar, low blood pH, and ketoacids in either the blood or urine.[1] The primary treatment of DKA is with intravenous fluids and insulin.[1] Depending on the severity, insulin may be given intravenously or by injection under the skin.[3] Usually potassium is also needed to prevent the development of low blood potassium.[1] Throughout treatment blood sugar and potassium levels should be regularly checked.[1] Antibiotics may be required in those with an underlying infection.[6] In those with severely low blood pH, sodium bicarbonate may be given; however, its use is of unclear benefit and typically not recommended.[1][6] Rates of DKA vary around the world.[5] In the United Kingdom, about 4% of people with type 1 diabetes develop DKA each year, while in Malaysia the condition affects about 25% a year.[1][5] DKA was first described in 1886 and, until the introduction of insulin therapy in the 1920s, it was almost univ Continue reading >>
Hyperglycemia And Hypoglycemia In Stroke
Practice Essentials Preexisting hyperglycemia worsens the clinical outcome of acute stroke. Nondiabetic ischemic stroke patients with hyperglycemia have a 3-fold higher 30-day mortality rate than do patients without hyperglycemia. In diabetic patients with ischemic stroke, the 30-day mortality rate is 2-fold higher. [1] With regard to hypoglycemia, the condition can mimic acute stroke or symptoms of transient ischemic attack (TIA). [2, 3, 4, 5] Signs and symptoms Hyperglycemia in stroke Patients may come to the attention of clinicians because of preexisting diabetes mellitus Diabetes may also be seen with other risk factors for stroke, such as hypertension and hypercholesterolemia High glycemic levels may also be seen in the setting of an acute stroke without a history of diabetes, presumably due to a sympathetic response to the infarct Retinopathy, neuropathy, and peripheral vascular disease may be found in patients with long-standing diabetes Hypoglycemia in strokelike occurrences In the literature, signs of an acute stroke, such as hemiplegia, aphasia, and cortical blindness, have been reported with hypoglycemia. In individuals presenting with low glycemic levels and strokelike symptoms, diabetes mellitus may have been previously diagnosed, and recent changes in the doses of hypoglycemic agents and insulin may have been instituted. In particular, aggressively tight glucose control, either patient driven or clinician directed, may give rise to chronic or recurrent episodes of hypoglycemia. However, if factitious hypoglycemia is suspected, such behavior may have manifested earlier as similar episodes or other factitious behaviors. Symptoms caused by hypoglycemia can occur suddenly and fluctuate, suggesting a vascular etiology. Diagnosis Laboratory studies In the settin Continue reading >>
> Hyperglycemia And Diabetic Ketoacidosis
When blood glucose levels (also called blood sugar levels) are too high, it's called hyperglycemia. Glucose is a sugar that comes from foods, and is formed and stored inside the body. It's the main source of energy for the body's cells and is carried to each through the bloodstream. But even though we need glucose for energy, too much glucose in the blood can be unhealthy. Hyperglycemia is the hallmark of diabetes — it happens when the body either can't make insulin (type 1 diabetes) or can't respond to insulin properly (type 2 diabetes). The body needs insulin so glucose in the blood can enter the cells to be used for energy. In people who have developed diabetes, glucose builds up in the blood, resulting in hyperglycemia. If it's not treated, hyperglycemia can cause serious health problems. Too much sugar in the bloodstream for long periods of time can damage the vessels that supply blood to vital organs. And, too much sugar in the bloodstream can cause other types of damage to body tissues, which can increase the risk of heart disease and stroke, kidney disease, vision problems, and nerve problems in people with diabetes. These problems don't usually show up in kids or teens with diabetes who have had the disease for only a few years. However, they can happen in adulthood in some people, particularly if they haven't managed or controlled their diabetes properly. Blood sugar levels are considered high when they're above someone's target range. The diabetes health care team will let you know what your child's target blood sugar levels are, which will vary based on factors like your child's age. A major goal in controlling diabetes is to keep blood sugar levels as close to the desired range as possible. It's a three-way balancing act of: diabetes medicines (such as in Continue reading >>
Transient Ischemic Attack
A temporary interruption of blood supply (and oxygen) to part of the brain, also known as a ministroke. The symptoms of a transient ischemic attack (TIA) are similar to those of a stroke, which include numbness or weakness in the face, arm, or leg, especially on one side of the body; confusion or difficulty in talking or understanding speech; trouble seeing in one or both eyes; and difficulty with walking, dizziness, or loss of balance or coordination. However, unlike a stroke, the symptoms of a TIA usually go away completely within an hour but may last up to 24 hours (symptoms lasting longer indicate a stroke). Since it is impossible for a person experiencing stroke-like symptoms to tell whether they are the short-lived result of a TIA or the result of a full-blown stroke, they should be considered an emergency if they occur. Time is of the essence when treating a stroke. People who have had a TIA are at great risk for a stroke, so doctors often prescribe certain treatments to reduce the likelihood of a stroke for people who have had a TIA. The most commonly used drugs for preventing strokes are antiplatelet drugs. Antiplatelet drugs make the blood platelets less likely to stick together and form clots. The most frequently used antiplatelet drug, which is the least expensive and has the fewest side effects, is aspirin. Other antiplatelet drugs include clopidogrel (brand name Plavix), ticlopidine (Ticlid), and a combination drug composed of aspirin and dipyridamole (Aggrenox). For someone with a severely narrowed carotid artery (an artery in the neck that supplies blood to the brain), a surgical procedure called carotid endarterectomy may help. In this procedure, atherosclerotic plaque is mechanically cleared out of the carotid artery to restore blood flow to the brain. Continue reading >>
When There Are Acute Changes In Mental Status In Patients With Diabetes
Author(s): Adam Lang, BS, and Kathleen Satterfield, DPM, FACFAOM As podiatric physicians in 2010, we are better trained than ever to manage patients’ problems. Even more importantly, we are well versed in making appropriate, well-timed referrals when needed. In the following case study, that particular acumen was critically important. A 78-year-old male with type 2 diabetes underwent resection of the first metatarsophalangeal base and debridement of an underlying ulcer, which has at times been infected. The plan was to inspect the bone for osteomyelitis, place the patient on oral antibiotics and not primarily close the plantar lesion, but pack it open instead. Resection of the phalangeal base would ease the deforming hallux interphalangeus. Examination revealed a hallux limitus and the physician determined that at the patient’s age and activity level, a Keller arthroplasty would serve him well, preventing further breakdown and possible osteomyelitis. The plantar lesion did not undergo primary closure but physicians packed it instead. The hospital discharged the patient within a week after bone cultures and histology showed no evidence of osteomyelitis. He received a prescription for oral antibiotics and received instruction to keep a clinic appointment in 48 hours. However, he was a no-show for his appointment. Phone calls to his home, all of which were documented, went unanswered over a period of two weeks. About a month after his discharge from the hospital, the patient went to the emergency department of the hospital accompanied by his wife. His extremity was in the same dressing he received upon preparation for discharge although now it was soiled and loose. His wife reported that they had never filled the prescription for antibiotics because they “did not und Continue reading >>
Diabetic Ketoacidosis
Introduction Diabetic ketoacidosis (DKA) is a dangerous complication of diabetes caused by a lack of insulin in the body. Diabetic ketoacidosis occurs when the body is unable to use blood sugar (glucose) because there isn't enough insulin. Instead, it breaks down fat as an alternative source of fuel. This causes a build-up of a by-product called ketones. Most cases of diabetic ketoacidosis occur in people with type 1 diabetes, although it can also be a complication of type 2 diabetes. Symptoms of diabetic ketoacidosis include: passing large amounts of urine feeling very thirsty vomiting abdominal pain Seek immediate medical assistance if you have any of these symptoms and your blood sugar levels are high. Read more about the symptoms of diabetic ketoacidosis. Who is affected by diabetic ketoacidosis? Diabetic ketoacidosis is a relatively common complication in people with diabetes, particularly children and younger adults who have type 1 diabetes. Younger children under four years of age are thought to be most at risk. In about 1 in 4 cases, diabetic ketoacidosis develops in people who were previously unaware they had type 1 diabetes. Diabetic ketoacidosis accounts for around half of all diabetes-related hospital admissions in people with type 1 diabetes. Diabetic ketoacidosis triggers These include: infections and other illnesses not keeping up with recommended insulin injections Read more about potential causes of diabetic ketoacidosis. Diagnosing diabetic ketoacidosis This is a relatively straightforward process. Blood tests can be used to check your glucose levels and any chemical imbalances, such as low levels of potassium. Urine tests can be used to estimate the number of ketones in your body. Blood and urine tests can also be used to check for an underlying infec Continue reading >>
Stroke And Diabetic Ketoacidosis – Some Diagnostic And Therapeutic Considerations
Authors Jovanovic A, Stolic R, Rasic D, Markovic-Jovanovic S, Peric V Accepted for publication 8 January 2014 Checked for plagiarism Yes Peer reviewer comments 2 3 1Department of Endocrinology, 2Department of Nephrology, 3Department of Cardiology, 4Department of Pediatrics, University of Pristina–Kosovska Mitrovica, Kosovska Mitrovica, Serbia Abstract: Cerebrovascular insult (CVI) is a known and important risk factor for the development of diabetic ketoacidosis (DKA); still, it seems that the prevalence of DKA among the patients suffering CVI and its influence on stroke outcome might be underestimated. Diabetic ketoacidosis itself has been reported to be a risk factor for the occurrence of stroke in children and youth. A cerebral hypoperfusion in untreated DKA may lead to cerebral injury, arterial ischemic stroke, cerebral venous thrombosis, and hemorrhagic stroke. All these were noted following DKA episodes in children. At least some of these mechanisms may be operative in adults and complicate the course and outcome of CVI. There is a considerable overlap of symptoms, signs, and laboratory findings in the two conditions, making their interpretation difficult, particularly in the elderly and less communicative patients. Serum pH and bicarbonate, blood gases, and anion gap levels should be routinely measured in all type 1 and type 2 diabetics, regardless of symptomatology, for the early detection of existing or pending ketoacidosis. The capacity for rehydration in patients with stroke is limited, and the treatment of the cerebrovascular disease requires intensive use of osmotic and loop diuretics. Fluid repletion may be difficult, and the precise management algorithms are required. Intravenous insulin is the backbone of treatment, although its effect may be diminished Continue reading >>
- The Pathophysiology of Hyperglycemia in Older Adults: Clinical Considerations
- Diagnostic accuracy of resting systolic toe pressure for diagnosis of peripheral arterial disease in people with and without diabetes: a cross-sectional retrospective case-control study
- Pharmacology and therapeutic implications of current drugs for type 2 diabetes mellitus
Neuroimaging Findings In Acute Pediatric Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA) is a state of severe insulin deficiency and a serious complication in children with diabetes mellitus type 1. In a small number of children, DKA is complicated by injury of the central nervous system. These children have a significant mortality and high long-term neurological morbidity. Cerebral edema is the most common neuroimaging finding in children with DKA and may cause brain herniation. Ischemic or hemorrhagic stroke during the acute DKA episode is less common and accounts for approximately 10% of intracerebral complications of DKA. Here we present the neuroimaging findings of two children with DKA and brain injury. Familiarity with the spectrum of neuroimaging findings seen in pediatric DKA is important to allow early detection as well as initiation of therapy and, hence, prevent complications of the central nervous system. Continue reading >>
What You Should Know About Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA) is a serious condition that can occur in diabetes. DKA happens when acidic substances, called ketones, build up in your body. Ketones are formed when your body burns fat for fuel instead of sugar, or glucose. That can happen if you don’t have enough insulin in your body to help you process sugars. Learn more: Ketosis vs. ketoacidosis: What you should know » Left untreated, ketones can build up to dangerous levels. DKA can occur in people who have type 1 or type 2 diabetes, but it’s rare in people with type 2 diabetes. DKA can also develop if you are at risk for diabetes, but have not received a formal diagnosis. It can be the first sign of type 1 diabetes. DKA is a medical emergency. Call your local emergency services immediately if you think you are experiencing DKA. Symptoms of DKA can appear quickly and may include: frequent urination extreme thirst high blood sugar levels high levels of ketones in the urine nausea or vomiting abdominal pain confusion fruity-smelling breath a flushed face fatigue rapid breathing dry mouth and skin It is important to make sure you consult with your doctor if you experience any of these symptoms. If left untreated, DKA can lead to a coma or death. All people who use insulin should discuss the risk of DKA with their healthcare team, to make sure a plan is in place. If you think you are experiencing DKA, seek immediate medical help. Learn more: Blood glucose management: Checking for ketones » If you have type 1 diabetes, you should maintain a supply of home urine ketone tests. You can use these to test your ketone levels. A high ketone test result is a symptom of DKA. If you have type 1 diabetes and have a glucometer reading of over 250 milligrams per deciliter twice, you should test your urine for keton Continue reading >>
Cerebral Venous Thrombosis During Diabetic Ketoacidosis
Cerebral oedema is the major cause of death and neurological morbidity in children with insulin dependent diabetes. However, other intracranial pathologies may present in a very similar manner and unless neuroimaging is performed, appropriate treatment may be withheld. We present a case where neuroimaging provided the correct diagnosis of cerebral venous sinus thrombosis, allowing anticoagulation to be started, and resulting in an improved clinical outcome. CASE REPORT A 5 year old previously fit and well white girl with insulin dependent diabetes was admitted to her local hospital with a 12 hour history of vomiting and lethargy. She had had diabetes since she was 2 years old and was well controlled on twice daily insulin (0.7 units/kg/day). On admission she was pale, afebrile, moderately dehydrated, and lethargic. No infective focus was found on clinical examination and there were no focal neurological manifestations. Admission laboratory studies revealed an increased true blood glucose of 14.8 mmol/l, with a compensated metabolic acidosis (pH 7.33, pco2 3.2 KPa, bicarbonate 12 mmol/l, base excess −11 mmol/l). Urinalysis showed ketones of 16 mmol/l. A blood count showed a microcytic anaemia, with a haemoglobin of 41 g/l, a mean cell volume of 59.3fL, a white cell count of 10.2 × 109/l, and platelet count of 348 × 109/l. A clotting screen was normal and laboratory investigations were consistent with iron deficiency anaemia. The patient had no history of chronic blood loss, pica, dietary deficiencies, or symptoms of coeliac disease. A diagnosis of mild diabetic ketoacidosis (DKA) with moderate dehydration and microcytic anaemia was made. Over the next 12 hours she was treated with around 30 ml/kg 4.5% albumin intravenously and commenced on a normal maintenance fluid Continue reading >>
Invokana Ketoacidosis, Kidney Failure, Kidney Disease, Heart Attack, Stroke, Amputation Lawsuits
If you or someone you love have suffered side effects such as Diabetic Ketoacidosis, Kidney Disease, Acute/Kidney Failure, Heart Attack, Stroke or Amputation after starting Invokana, Invokamet, Farxiga, Jardiance, Xigduo XR or Glyxambi, you may be eligible for compensation through a defective drug lawsuit against the manufacturer. Our Invokana attorneys are standing by, waiting to assist. Lawsuits allege that Janssen / Johnson & Johnson, manufacturer of Invokana, a popular type two diabetes drug, failed to warn both the medical community and consumers of serious potential side effects including heart attacks, stroke, amputation, kidney failure, kidney disease and diabetic ketoacidosis. Ketoacidosis is a serious condition, usually requiring hospitalization due to the possibility of fatal brain swelling, coma, and severe dehydration. It’s also been alleged that had the public been properly warned, doctors and patients may have chosen something other than Invokana for diabetes management or at the very least, monitored for health issues more frequently. New Lawsuit Accuses Johnson & Johnson, Janssen Pharmaceuticals of Failure to Adequately Research Invokana and Failure to Warn of Health Risks July 13, 2017 – In a lawsuit filed July 3, 2017, plaintiff Martha Williams of Tennessee accuses Janssen Pharmaceuticals and parent company Johnson & Johnson of failure to adequately research all potential health risks of its new generation diabetes drug Invokana as well as failure to warn the public and medical community of such risks. The lawsuit blames an onset of acute renal failure, a urinary tract infection, dehydration and hypokalemia suffered by Williams just one month after starting the medication. “Consumers of Invokana and their physicians relied on the Defendants’ f Continue reading >>
Dka And Thrombosis
Josephine Ho and associates1 report an unfortunate case of a 6-year-old girl with diabetic ketoacidosis (DKA) and thromboembolic stroke. Although the authors do a credible job of describing the diverse causes of pediatric stroke and the controversies surrounding treatment of children, there was little emphasis on the danger of extreme hyperosmolar states and risks of thrombosis. More information about the initial presentation of the patient, with specific reference to the concentration of serum sodium and serum osmolarity, would have been helpful in determining her risks of thrombosis. Diabetes is associated with a prothrombotic state through a number of mechanisms.2 The mostly adult entity of hyperosmolar nonketotic coma has had various degrees of association with thrombosis,2,3 as has extreme hypernatremia in breast-feeding neonates.4 Recent evidence has also demonstrated that among children with DKA, there is a higher incidence of deep venous thrombosis with femoral central venous lines.5,6 Serum glucose and sodium concentrations and hence effective plasma osmolarity were significantly higher in those patients with blood clots.5 Although there is no direct evidence for its efficacy, our practice has been to use prophylactic anticoagulation in patients with DKA who are in a significant hyperosmolar state, as well as to eliminate the use of femoral catheters in patients with these risk factors. There is significant controversy surrounding the dose of anticoagulant therapy, specifically whether the efficacy of dosages for prophylaxis of deep venous thrombosis outweighs the risks associated with full systemic anticoagulation.7 As with most clinical issues, particularly in pediatric critical illness, this controversy lends itself well to a clinical trial in patients with Continue reading >>
- Diabetes Complications in Dogs and Cats: Diabetes Ketoacidosis (DKA)
- Caffeinated and Decaffeinated Coffee Consumption and Risk of Type 2 Diabetes: A Systematic Review and a Dose-Response Meta-analysis
- Insulin, glucagon and somatostatin stores in the pancreas of subjects with type-2 diabetes and their lean and obese non-diabetic controls
Diabetes, Heart Attack Risk And Diabetic Ketoacidosis
People with diabetes have heart attacks or strokes more than twice as often as people without diabetes. 1 In addition, two out of three people with diabetes eventually die from these conditions, according to the American Diabetes Association. 2 Heart Disease Risk Factors According to the Centers for Disease Control and Prevention (CDC), if you have diabetes your risk of death by heart disease may be two to four times greater than for someone who doesn’t have diabetes. 3 The American Heart Association cites the same statistic, adding that at least 68 percent of people with diabetes who are older than 65 years of age die of heart disease. 4 Other risks for heart disease include high LDL cholesterol levels, high blood pressure (hypertension), and high triglyceride levels, according to the CDC. 5 Many people with diabetes also have a combination of other risk factors: low HDL cholesterol, obesity and a sedentary lifestyle. 6 High Blood Sugar and Heart Disease Over time, high blood sugar may lead to increased fatty deposits on blood vessel walls, affecting blood flow and increasing the chance of blood vessel hardening. This is according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health (NIH). 7 Heart Attack Warning Signs The risk of having a heart attack is higher for diabetics and diabetics who have already suffered one heart attack have an even greater risk of having a second. NIDDK mentions some important warning signs that may indicate you might be experiencing a heart attack, such as chest, arm, jaw, neck, back or stomach pain. 8 Other possible symptoms of a heart attack include shortness of breath, nausea, sweating and lightheadedness. 9 Reducing Your Risks as a Diabetic If you have diabetes, th Continue reading >>
