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Cerebral Edema In Dka Medscape

What Is The Pathogenesis Of Cerebral Edema In Patients With Hyperosmolar Hyperglycemic State (hhs)?

What Is The Pathogenesis Of Cerebral Edema In Patients With Hyperosmolar Hyperglycemic State (hhs)?

What is the pathogenesis of cerebral edema in patients with hyperosmolar hyperglycemic state (HHS)? Cerebral edema is a rare,but frequently fatal, complication in HHS. This occurrence is usually seen in newly diagnosed diabetic children with DKA. Cerebral edema occurs from rapid lowering of glucose levels and an ensuing rapid drop in plasma osmolarity. Brain cells, which trap osmotically active particles, preferentially absorb water and swell during rapid rehydration. Cerebral edema follows, and, given the constraints of the cranium, uncal herniation may be the cause of death in persons with HHS. [ 10 ] Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care. 2014 Nov. 37 (11):3124-31. [Medline] . [Full Text] . Nugent BW. Hyperosmolar hyperglycemic state. Emerg Med Clin North Am. 2005 Aug. 23(3):629-48, vii. [Medline] . Bhansali A, Sukumar SP. Hyperosmolar hyperglycemic state. World Clin Diabetol. 2016. 2(1):1-10. [Full Text] . Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. 2001 Jan. 24(1):131-53. [Medline] . [Full Text] . Trence DL, Hirsch IB. Hyperglycemic crises in diabetes mellitus type 2. Endocrinol Metab Clin North Am. 2001 Dec. 30(4):817-31. [Medline] . Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006 Dec. 29(12):2739-48. [Medline] . Campanella LM, Lartey R, Shih R. Severe hyperglycemic hyperosmolar nonketotic coma in a nondiabetic patient receiving aripiprazole. Ann Emerg Med. 2009 Feb. 53(2):264-6. [Medline] . Ahuja N, Palanichamy N, Mackin P, Lloyd A. Olanzap Continue reading >>

Diabetic Ketoacidosisworkup

Diabetic Ketoacidosisworkup

Author: Osama Hamdy, MD, PhD; Chief Editor: Romesh Khardori, MD, PhD, FACP more... Diabetic ketoacidosis is typically characterized by hyperglycemia over 250 mg/dL, a bicarbonate level less than 18 mEq/L, and a pH less than 7.30, with ketonemia and ketonuria. While definitions vary, mild DKA can be categorized by a pH level of 7.25-7.3 and a serum bicarbonate level between 15-18 mEq/L; moderate DKA can be categorized by a pH between 7.0-7.24 and a serum bicarbonate level of 10 to less than 15 mEq/L; and severe DKA has a pH less than 7.0 and bicarbonate less than 10 mEq/L. [ 17 ] In mild DKA, anion gap is greater than 10 and in moderate or severe DKA the anion gap is greater than 12. These figures differentiate DKA from HHS where blood glucose is greater than 600 mg/dL but pH is greater than 7.3 and serum bicarbonate greater than 15 mEq/L. Laboratory studies for diabetic ketoacidosis (DKA) should be scheduled as follows: Blood tests for glucose every 1-2 h until patient is stable, then every 4-6 h Serum electrolyte determinations every 1-2 h until patient is stable, then every 4-6 h Glaser NS, Marcin JP, Wootton-Gorges SL, et al. Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging. J Pediatr. 2008 Jun 25. [Medline] . Umpierrez GE, Jones S, Smiley D, et al. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care. 2009 Jul. 32(7):1164-9. [Medline] . [Full Text] . Herrington WG, Nye HJ, Hammersley MS, Watkinson PJ. Are arterial and venous samples clinically equivalent for the estimation of pH, serum bicarbonate and potassium concentration in critically ill patients?. Diabet Med. 201 Continue reading >>

Hyperosmolar Hyperglycemic Statetreatment & Management

Hyperosmolar Hyperglycemic Statetreatment & Management

Standard Care for Dehydration and Altered Mental Status Diagnosis and management guidelines for hyperglycemic crises are available from the American Diabetes Association. [ 6 , 10 , 24 ] The main goals in the treatment of hyperosmolar hyperglycemic state (HHS) are as follows: To vigorously rehydrate the patient while maintaining electrolyte homeostasis To monitor and assist cardiovascular, pulmonary, renal, and central nervous system (CNS) function In an emergency situation, whenever possible, contact the receiving facility while en route to ensure preparation for a comatose, dehydrated, or hyperglycemic patient. When appropriate, notify the facility of a possible cerebrovascular accident or myocardial infarction (MI). Initiation of insulin therapy in the emergency department (ED) through a subcutaneous insulin pump may be an alternative to intravenous (IV) insulin infusion. [ 25 ] Airway management is the top priority. In comatose patients in whom airway protection is of concern, endotracheal intubation may be indicated. Rapid and aggressive intravascular volume replacement is always indicated as the first line of therapy for patients with HHS. Isotonic sodium chloride solution is the fluid of choice for initial treatment because sodium and water must be replaced in these severely dehydrated patients. Although many patients with HHS respond to fluids alone, IV insulin in dosages similar to those used in diabetic ketoacidosis (DKA) can facilitate correction of hyperglycemia. [ 26 ] Insulin used without concomitant vigorous fluid replacement increases the risk of shock. Adjust insulin or oral hypoglycemic therapy on the basis of the patients insulin requirement once serum glucose level has been relatively stabilized. All patients diagnosed with HHS require hospitalizati Continue reading >>

Pediatric Diabetic Ketoacidosistreatment & Management

Pediatric Diabetic Ketoacidosistreatment & Management

Pediatric Diabetic KetoacidosisTreatment & Management Author: William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Timothy E Corden, MD more... In patients with diabetic ketoacidosis, the first principals of resuscitation apply (ie, the ABCs [airway, breathing, circulation]). [ 3 ] Outcomes are best when children are closely monitored and a changing status is promptly addressed. [ 39 , 2 ] Give oxygen, although this has no effect on the respiratory drive of acidosis. Diagnose by clinical history, physical signs, and elevated blood glucose. Fluid, insulin, and electrolyte (potassium and, in select cases, bicarbonate) replacement is essential in the treatment of diabetic ketoacidosis. Early in the treatment of diabetic ketoacidosis, when blood glucose levels are very elevated, the child can continue to experience massive fluid losses and deteriorate. Strict measurement of fluid balance is essential for optimal treatment. Continuous subcutaneous insulin infusion therapy using an insulin pump should be stopped during the treatment of diabetic ketoacidosis. Children with severe acidosis (ie, pH < 7.1) or with altered consciousness should be admitted to a pediatric intensive care unit. In cases in which the occurrence of diabetic ketoacidosis signals a new diagnosis of diabetes, the process of education and support by the diabetes team should begin when the patient recovers. In cases in which diabetic ketoacidosis occurs in a child with established diabetes, explore the cause of the episode and take steps to prevent a recurrence. Following recovery from diabetic ketoacidosis, patients require subcutaneous insulin therapy. Edge JA, Roy Y, Bergomi A, et al. Conscious level in children with diabetic ketoacidosis is related to severity of acidosis and not to blood g Continue reading >>

Pediatric Diabetic Ketoacidosisdifferential Diagnoses

Pediatric Diabetic Ketoacidosisdifferential Diagnoses

Pediatric Diabetic KetoacidosisDifferential Diagnoses Author: William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Timothy E Corden, MD more... Edge JA, Roy Y, Bergomi A, et al. Conscious level in children with diabetic ketoacidosis is related to severity of acidosis and not to blood glucose concentration. Pediatr Diabetes. 2006 Feb. 7(1):11-5. [Medline] . Harris GD, Fiordalisi I. Physiologic management of diabetic ketoacidemia. A 5-year prospective pediatric experience in 231 episodes. Arch Pediatr Adolesc Med. 1994 Oct. 148(10):1046-52. [Medline] . Wolfsdorf J, Craig ME, Daneman D, et al. Diabetic ketoacidosis. Pediatr Diabetes. 2007 Feb. 8(1):28-43. [Medline] . Marshall SM, Walker M, Alberti KGMM. Diabetic Ketoacidosis and Hyperglycaemic non-ketotic coma. Alberti, Zimmet, Defronzo eds. International Textbook of Diabetes Mellitus. 1997. 1215-30. Fagan MJ, Avner J, Khine H. Initial fluid resuscitation for patients with diabetic ketoacidosis: how dry are they?. Clin Pediatr (Phila). 2008 Nov. 47(9):851-5. [Medline] . Durr JA, Hoffman WH, Sklar AH, et al. Correlates of brain edema in uncontrolled IDDM. Diabetes. 1992 May. 41(5):627-32. [Medline] . Hale PM, Rezvani I, Braunstein AW, et al. Factors predicting cerebral edema in young children with diabetic ketoacidosis and new onset type I diabetes. Acta Paediatr. 1997 Jun. 86(6):626-31. [Medline] . Mel JM, Werther GA. Incidence and outcome of diabetic cerebral oedema in childhood: are there predictors?. J Paediatr Child Health. 1995 Feb. 31(1):17-20. [Medline] . Silver SM, Clark EC, Schroeder BM, Sterns RH. Pathogenesis of cerebral edema after treatment of diabetic ketoacidosis [published erratum appears in Kidney Int 1997 May;51(5):1662]. Kidney Int. 1997 Apr. 51(4):1237-44. [Medline] . Okuda Y, Adrogue HJ, Continue reading >>

Diabetic Ketoacidosisdifferential Diagnoses

Diabetic Ketoacidosisdifferential Diagnoses

Diabetic KetoacidosisDifferential Diagnoses Author: Osama Hamdy, MD, PhD; Chief Editor: Romesh Khardori, MD, PhD, FACP more... In considering a diagnosis of diabetic ketoacidosis (DKA), the following indications should be taken into account: uremia, acute hypoglycemia coma, and catheter-related venous thrombosis, especially with femoral central venous catheters in children. Glaser NS, Marcin JP, Wootton-Gorges SL, et al. Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging. J Pediatr. 2008 Jun 25. [Medline] . Umpierrez GE, Jones S, Smiley D, et al. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care. 2009 Jul. 32(7):1164-9. [Medline] . [Full Text] . Herrington WG, Nye HJ, Hammersley MS, Watkinson PJ. Are arterial and venous samples clinically equivalent for the estimation of pH, serum bicarbonate and potassium concentration in critically ill patients?. Diabet Med. 2012 Jan. 29(1):32-5. [Medline] . Mrozik LT, Yung M. Hyperchloraemic metabolic acidosis slows recovery in children with diabetic ketoacidosis: a retrospective audit. Aust Crit Care. 2009 Jun 26. [Medline] . Bowden SA, Duck MM, Hoffman RP. Young children (12 yr) with type 1 diabetes mellitus have low rate of partial remission: diabetic ketoacidosis is an important risk factor. Pediatr Diabetes. 2008 Jun. 9(3 Pt 1):197-201. [Medline] . Potenza M, Via MA, Yanagisawa RT. Excess thyroid hormone and carbohydrate metabolism. Endocr Pract. 2009 May-Jun. 15(3):254-62. [Medline] . Taylor SI, Blau JE, Rother KI. SGLT2 Inhibitors May Predispose to Ketoacidosis. J Clin Endocrinol Metab. 2015 Aug. 100 (8):2849-52. [Medline] . Zar Continue reading >>

Pediatric Dka Management In The Era Of Standardization

Pediatric Dka Management In The Era Of Standardization

Seattle Children's Hospital, Division of Endocrinology and Diabetes, 4800 Sand Point Way NE, Seattle, WA 98105, USA. Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript. Tel.: +1 206 987 5037 Fax: +1 206 987 2720 [email protected] Almost all episodes of diabetic ketoacidosis (DKA) are preventable The overall incidence of Type 1 diabetes mellitus has been rising, particularly in young children. Thus, there is a need for heightened awareness of DKA, a life-threatening complication of diabetes mellitus. Pediatric DKA is ideally managed at facilities that are familiar with its therapy and have availability of intense monitoring. Appropriate early management of DKA is crucial in preventing cerebral edema, the major cause of morbidity and mortality associated with DKA. This article provides a standardized approach to initial resuscitation, fluid and electrolyte management, insulin therapy and management of complications. The utilization of -hydroxybutyrate measurements improves the substantial hospital care-related costs. The use of the two-bag system is recommended, as it allows for rapid responses to changes in fluid and electrolyte requirements, thus reducing waste and complications. Routine diabetes care, attention to psychosocial needs and recurring sick day management education are essential to reduce the frequency of ketoacidosis- Continue reading >>

Diabetic Ketoacidosistreatment & Management

Diabetic Ketoacidosistreatment & Management

Diabetic KetoacidosisTreatment & Management Author: Osama Hamdy, MD, PhD; Chief Editor: Romesh Khardori, MD, PhD, FACP more... Managing diabetic ketoacidosis (DKA) in an intensive care unit during the first 24-48 hours always is advisable. When treating patients with DKA, the following points must be considered and closely monitored: Correction of fluid loss with intravenous fluids Correction of electrolyte disturbances, particularly potassium loss Treatment of concurrent infection, if present It is essential to maintain extreme vigilance for any concomitant process, such as infection, cerebrovascular accident, myocardial infarction, sepsis, or deep venous thrombosis . It is important to pay close attention to the correction of fluid and electrolyte loss during the first hour of treatment. This always should be followed by gradual correction of hyperglycemia and acidosis. Correction of fluid loss makes the clinical picture clearer and may be sufficient to correct acidosis. The presence of even mild signs of dehydration indicates that at least 3 L of fluid has already been lost. Patients usually are not discharged from the hospital unless they have been able to switch back to their daily insulin regimen without a recurrence of ketosis. When the condition is stable, pH exceeds 7.3, and bicarbonate is greater than 18 mEq/L, the patient is allowed to eat a meal preceded by a subcutaneous (SC) dose of regular insulin. Insulin infusion can be discontinued 30 minutes later. If the patient is still nauseated and cannot eat, dextrose infusion should be continued and regular or ultrashort-acting insulin should be administered SC every 4 hours, according to blood glucose level, while trying to maintain blood glucose values at 100-180 mg/dL. The 2011 JBDS guideline recommends the Continue reading >>

Pediatric Diabetic Ketoacidosisworkup

Pediatric Diabetic Ketoacidosisworkup

Author: William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Timothy E Corden, MD more... The following lab studies are indicated in patients with diabetic ketoacidosis: Bicarbonate - Usually available from blood gas analysis Perform head computed tomography (CT) scanning if coma is present or develops. Concurrently, initiate appropriate measures to manage cerebral edema. Perform chest radiography if clinically indicated. Check the patients consciousness level hourly for up to 12 hours, especially in a young child with a first presentation of diabetes. The Glasgow coma scale (see the image below) is recommended for this purpose. Glasgow Coma Scale, modified for age of verbal response. The normal maximum score on the Glasgow coma scale is 15. A score of 12 or less implies significant impairment of consciousness. A falling score may signify the development of cerebral edema. Capillary blood samples analyzed on any modern blood glucose meter are acceptable for monitoring changes in blood glucose levels as treatment progresses, but measure at least 1 whole blood glucose at presentation. Check blood glucose at least hourly during the initial stages of treatment (more frequently if blood glucose levels fall quickly or if changes to insulin infusion rates are made). Traditionally, arterial blood samples are used; however, free-flowing capillary or venous samples are as reliable as the arterial samples for monitoring acidosis, are much easier to collect, and are less traumatic for the child. [ 36 ] The severity of diabetic ketoacidosis can be defined by blood gas results, as follows: Mild diabetic ketoacidosis - pH level of less than 7.3, bicarbonate level of less than 15 mmol/L Moderate diabetic ketoacidosis - pH level of less than 7.2, bicarbonate level of less Continue reading >>

Pediatric Diabetic Ketoacidosis

Pediatric Diabetic Ketoacidosis

Author: William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Timothy E Corden, MD more... Diabetic ketoacidosis, in pediatric and adult cases, is a metabolic derangement caused by the absolute or relative deficiency of the anabolic hormone insulin. Together with the major complication of cerebral edema, it is the most important cause of mortality and severe morbidity in children with diabetes. Symptoms of acidosis and dehydration include the following: Abdominal pain - May be severe enough to present as a surgical emergency Shortness of breath - May be mistaken for primary respiratory distress Confusion and coma in the absence of recognized head injury [ 1 ] Symptoms of hyperglycemia, a consequence of insulin deficiency, include the following: Polyuria - Increased volume and frequency of urination Nocturia and secondary enuresis in a previously continent child Weight loss - May be dramatic due to breakdown of protein and fat stores Patients with diabetic ketoacidosis may also have the following signs and symptoms: Signs of intercurrent infection (eg, urinary or respiratory tract infection) Weakness and nonspecific malaise that may precede other symptoms of hyperglycemia Kussmaul breathing or deep sighing respiration - A mark of acidosis Ketone odor - Patient may have a smell of ketones on his/her breath Impaired consciousness - Occurs in approximately 20% of patients Abdominal tenderness - Usually nonspecific or epigastric in location Most cases of cerebral edema occur 4-12 hours after initiation of treatment. Diagnostic criteria of cerebral edema include the following: Abnormal motor or verbal response to pain Cranial nerve palsy - Especially III, IV, and VI Abnormal neurogenic breathing pattern (eg, Cheyne-Stokes), apneusis Altered mentation, fluctuating Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Practice Essentials Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but it is not uncommon in some patients with type 2 diabetes. This condition is a complex disordered metabolic state characterized by hyperglycemia, ketoacidosis, and ketonuria. Signs and symptoms The most common early symptoms of DKA are the insidious increase in polydipsia and polyuria. The following are other signs and symptoms of DKA: Malaise, generalized weakness, and fatigability Nausea and vomiting; may be associated with diffuse abdominal pain, decreased appetite, and anorexia Rapid weight loss in patients newly diagnosed with type 1 diabetes History of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons or history of mechanical failure of insulin infusion pump Altered consciousness (eg, mild disorientation, confusion); frank coma is uncommon but may occur when the condition is neglected or with severe dehydration/acidosis Signs and symptoms of DKA associated with possible intercurrent infection are as follows: See Clinical Presentation for more detail. Diagnosis On examination, general findings of DKA may include the following: Characteristic acetone (ketotic) breath odor In addition, evaluate patients for signs of possible intercurrent illnesses such as MI, UTI, pneumonia, and perinephric abscess. Search for signs of infection is mandatory in all cases. Testing Initial and repeat laboratory studies for patients with DKA include the following: Serum electrolyte levels (eg, potassium, sodium, chloride, magnesium, calcium, phosphorus) Serum or capillary beta-hydroxybutyrate levels Urine and blood cultures if intercurrent infection is suspected ECG Continue reading >>

Ask The Experts - Management Of Diabetic Ketoacidosis In Children

Ask The Experts - Management Of Diabetic Ketoacidosis In Children

Management of Diabetic Ketoacidosis in Children How is diabetic ketoacidosis managed in the pediatric age group? Response from Jos F. Cara, MD Despite significant advances in the management of childhood diabetes and in our understanding of the pathophysiology of the condition, diabetic ketoacidosis (DKA) remains a serious condition with significant morbidity and mortality.[ 1 ] Appropriate recognition and aggressive treatment by individuals experienced in the management of DKA are important for a successful outcome. Two excellent manuscripts describing the treatment guidelines for childhood DKA have recently been published.[ 1 , 2 ] In general, diabetic ketoacidosis can be arbitrarily considered as mild, moderate, or severe based on the clinical and biochemical presentations. Mild DKA is typically associated with hyperglycemia and ketonuria with a preserved ability to take in and retain oral fluids. It can be corrected with increased fluid intake (diet drinks when blood glucose levels are 240 mg/dL) and supplemental insulin lispro or regular insulin administration. Moderate DKA is characterized by hyperglycemia, ketonuria, and acidosis (pH between 7.25 and 7.4) in association with an impaired ability to retain oral fluids. Management requires evaluation and treatment by medical personnel in an emergency room and/or hospital setting. Suspension of oral fluid intake and intravenous fluid administration, combined with the administration of supplementary insulin, results in resolution of DKA. Potential precipitating or aggravating medical conditions (such as infections, trauma, etc.) must also be recognized, evaluated, and treated, especially when the individual fails to respond to routine management. Severe DKA is characterized by severe acidosis (pH < 7.25), dehydration, Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Author: Osama Hamdy, MD, PhD; Chief Editor: Romesh Khardori, MD, PhD, FACP more... Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but it is not uncommon in some patients with type 2 diabetes. This condition is a complex disordered metabolic state characterized by hyperglycemia, ketoacidosis, and ketonuria. The most common early symptoms of DKA are the insidious increase in polydipsia and polyuria. The following are other signs and symptoms of DKA: Malaise, generalized weakness, and fatigability Nausea and vomiting; may be associated with diffuse abdominal pain, decreased appetite, and anorexia Rapid weight loss in patients newly diagnosed with type 1 diabetes History of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons or history of mechanical failure of insulin infusion pump Altered consciousness (eg, mild disorientation, confusion); frank coma is uncommon but may occur when the condition is neglected or with severe dehydration/acidosis Signs and symptoms of DKA associated with possible intercurrent infection are as follows: Glaser NS, Marcin JP, Wootton-Gorges SL, et al. Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging. J Pediatr. 2008 Jun 25. [Medline] . Umpierrez GE, Jones S, Smiley D, et al. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care. 2009 Jul. 32(7):1164-9. [Medline] . [Full Text] . Herrington WG, Nye HJ, Hammersley MS, Watkinson PJ. Are arterial and venous samples clinically equivalent for the estimation Continue reading >>

Diabetic Ketoacidosisclinical Presentation

Diabetic Ketoacidosisclinical Presentation

Insidious increased thirst (ie, polydipsia) and urination (ie, polyuria) are the most common early symptoms of diabetic ketoacidosis (DKA). Malaise, generalized weakness, and fatigability also can present as symptoms of DKA. Nausea and vomiting usually occur and may be associated with diffuse abdominal pain, decreased appetite, and anorexia. A history of rapid weight loss is a symptom in patients who are newly diagnosed with type 1 diabetes. Patients may present with a history of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons. Decreased perspiration is another possible symptom of DKA. Altered consciousness in the form of mild disorientation or confusion can occur. Although frank coma is uncommon, it may occur when the condition is neglected or if dehydration or acidosis is severe. Among the symptoms of DKA associated with possible intercurrent infection are fever, dysuria, coughing, malaise, chills, chest pain, shortness of breath, and arthralgia. Acute chest pain or palpitation may occur in association with myocardial infarction. Painless infarction is not uncommon in patients with diabetes and should always be suspected in elderly patients. A study by Crossen et al indicated that in children with type 1 diabetes, those who have had a recent emergency department visit and have undergone a long period without visiting an endocrinologist are more likely to develop DKA. The study included 5263 pediatric patients with type 1 diabetes. [ 15 ] Glaser NS, Marcin JP, Wootton-Gorges SL, et al. Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging. J Pediatr. 2008 Jun 25. [Medline] . Umpierrez GE, Jones S, Smi Continue reading >>

Pediatric Diabetic Ketoacidosisclinical Presentation

Pediatric Diabetic Ketoacidosisclinical Presentation

Pediatric Diabetic KetoacidosisClinical Presentation Author: William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Timothy E Corden, MD more... When diabetic ketoacidosis occurs as a first presentation of diabetes, symptoms are likely to develop over several days, with progressive dehydration and ketosis. In a small child wearing diapers and with naturally high fluid intake, polyuria and polydipsia are easily missed. When diabetes is developing, the stress and symptoms of another illness may precipitate diabetic ketoacidosis, as well as mask the underlying problem. Diabetic ketoacidosis can develop very rapidly in a patient with established diabetes, particularly when insulin therapy has been forgotten, deliberately omitted, or disrupted, as with children on continuous subcutaneous insulin infusions or using the newer analogue insulins. Under these circumstances, diabetic ketoacidosis may present with relatively normal blood glucose levels (ie, 250 mg/dL, 15 mmol/L) or less. Symptoms of hyperglycemia include the following: Polyuria - Increased volume and frequency of urination Polydipsia - Thirst is often extreme, with children waking at night to consume large quantities of any available drink Nocturia and secondary enuresis in a previously continent child Weight loss - May be dramatic due to breakdown of protein and fat stores Symptoms of acidosis and dehydration include the following: Abdominal pain that may be severe enough to present as a surgical emergency; for children with a failure of continuous subcutaneous insulin infusion, this may be the first presenting sign, along with vomiting Shortness of breath that may be mistaken for primary respiratory distress Confusion and coma in the absence of recognized head injury [ 1 ] Presentation of cerebral ede Continue reading >>

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