Dka Algorithm

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Presented January 16, 2014 by Dr. Krishan Yadav The objectives for this talk are: 1) Iodinated Contrast: the basics 2) Contrast Allergy 3) Contrast Induced Nephropathy 4) Metformin and Contrast This is a Grand Rounds from the Department of Emergency Medicine at the University of Ottawa. Dr. Yadav has no financial conflicts to disclose. The views and opinions expressed on this video are those of Dr. Yadav's and do not necessarily reflect the views and opinions of The Department of Emergency Medicine at the University of Ottawa or The Ottawa Hospital. This video should not be construed as personal medical advice and is not intended to replace medical advice offered by physicians.

Emergency Department

This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use. TITLE: GASHA Pediatric Diabetic Ketoacidosis (DKA) Physician and Nursing Protocol NUMBER: 1-450 Applies to: All Nursing Staff and Physicians Caring for Children with DKA POLICY Diabetic Ketoacidosis (DKA) involves a combination of hyperglycemia, acidosis, and ketones. It is diagnosed when: 1. the blood glucose is greater than or equal to 11 mmol/L 2. capillary pH is less than or equal to 7.3 and/or capillary bicarbonate is less than or equal to 15 mmol/L 3. ketones are present in the blood and/or urine (see below). It usually takes days to develop DKA, but it can take hours in children with acute illness, insulin omission or insulin pump failure. Causes of DKA Include: • undiagnosed type 1 diabetes • insulin omission or manipulation • inadequate insulin dosing and monitoring during periods that significantly increase insulin needs: (illness, infection, major stress, puberty, pregnancy) • insulin pump or infusion site malfunction or misuse Signs and symptoms Include: • polyu Continue reading >>

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  1. blurfocus

    Your first, best, and cheapest option is not to use them.
    Ketostix do not measure what many people expect that they do.
    Ketostix only measure excess levels of acetoacetate, which is not the type of ketones that correlate with nutritional ketosis.
    Ketostix may show negative ketones when your blood ketones are high and then may show positive ketones when your blood ketones are low.
    Misinterpretation of what they show is one of the most common unnecessary causes of keto anxiety and wasted time. You can be perfectly successful on a ketogenic or low-carb diet without ever measuring ketones.
    Many people are already overwhelmed with learning about keto diets. Adding another layer of unnecessary complexity doesn't help the matter. Often, people are most successful on keto when they treat it as a lifestyle and not a diet. Obsessively measuring ketones can be at odds with attempting to live a keto lifestyle.
    If you decide to use Ketostix anyway, please be kind to those who answer questions here by not submitting a question that begins with I know that Ketostix are unreliable, but ...
    If you consume few enough carbohydrates and avoid excessive intake of protein, you can trust that your liver will be producing ketones within a single day. That is how human metabolism works.
    If you consume too many carbs, you will be kicked out of ketosis temporarily. However, if you once again restrict carbs, you will go right back into ketosis within 24 hours. This is because the liver can store only 100 grams of glycogen. If you restrict carbs, the liver will run out of glycogen within a day and begin burning fat instead. The liver produces ketones as a side effect of burning fat.
    As an example of how Ketostix can be misleading, it is possible to eat a high-carbohydrate meal followed by a positive Ketostix result. You may think that you cheated the system, but you didn't. It takes time for excess ketones to appear in urine. Ketostix are showing you what happened in the past before you cheated.
    If you have the time and really want to know why Ketostix will not tell you much, read pages 164 and 165 of The Art and Science of Low Carbohydrate Living by Volek and Phinney. This is the section headed by Ketones: To Measure or Not.
    If you do not have this book, read this summary:
    Ketostix were designed to help diabetics avoid ketoacidosis which is a dangerous condition involving very high blood sugar and very high serum ketones. If you have near normal blood sugar and serum ketone levels consistent with nutritional ketosis, you don't need to worry about this.
    Ketostix only measure excess levels of acetoacetate, which is not the type of ketones that correlate with nutritional ketosis.
    The ketones that correlate with nutritional ketosis are known as beta-hydroxybutyrate. This type can be measured only with a blood ketone meter.
    There is a built-in time lag. Ketostix are measuring what has happened in the past since it takes a while for the kidneys to produce urine.
    Exercise can influence how many excess ketones are excreted.
    You can be in nutritional ketosis even when Ketostix show no excess acetoacetate. In the keto-adapted state, very little acetoacetate ketones will be excreted in urine even though blood ketones may be high.
    Note that it takes a period of four to six weeks of being in ketosis every day in order to become keto-adapted. Someone who is keto-adapted has adapted to using fat as the primary fuel for muscles and various organs. The keto-adapted brain uses ketones in place of glucose for most of its energy needs. When keto-adapted, most acetoacetate is not excreted. Instead, muscles convert it to beta-hydroxybutyrate and return it to the blood for use by the brain.
    If after all of this, you still want to use Ketostix because you bought them and cannot bring yourself to throw them away or because they are comforting in some way, here is how they may be useful.
    When you are first starting a low-carb or keto diet and transitioning into ketosis from a moderate to high-carb diet, Ketostix will confirm that your body has in fact done what biology says that it must do. It will show that your liver has begun producing ketones.
    Once you are a few days into the diet, you can give them away to a keto newbie or toss them. Note that Ketostix will eventually expire, especially if you keep them in a moist environment like a bathroom.
    If you have a medical condition that makes monitoring blood ketone levels necessary or if you are a numbers geek with spending money, you may be interested in purchasing a ketone blood meter and test strips for measuring beta hydroxybutyrate in your blood. The test strips cost somewhere between $2 and $5 per strip.
    There are a few meters to choose from.
    Precision Xtra - https://www.abbottdiabetescare.com/products/patient/pxtra-overview.html
    Nova Max Plus - http://www.novacares.com/nova-max-plus/
    CardioChek Home - http://www.healthchecksystems.com/CardioChek.cfm#home
    Most use one of the first two listed (Precision Xtra or Nova Max Plus). Some say that the Precision Xtra is the more accurate of the two. I've found that readings from these two track fairly closely with each other. The Nova Max Plus has cheaper test strips.
    To detect nutritional ketosis, look for a reading between 0.5 and 5.0 mmol / liter. Some experts recommend aiming for a level of 1.0 to 5.0 mmol / liter.
    Another option is the Ketonix Sport breath meter. This meter measures acetate in the breath. It does not require test strips.
    Acetate forms when acetoacetate spontaneously breaks down to acetate. According to Volek and Phinney (page 165 of The Art and Science of Low Carbohydrate Living), it should be linearly correlated with blood ketones. In practice, it is not as accurate as the blood meters in part because it is difficult to breathe in the same way every time you test.
    Ketonix Sport (order direct from Sweden) - https://www.ketonix.com/index.php/product/sport
    Again, remember that you can be perfectly successful on a ketogenic or low-carb diet without ever measuring ketones whether in urine, blood, or breath.
    In the final analysis, ketone concentrations are what they are. Chasing ketone concentrations often becomes as unnecessary and distracting as Ketostix. Unless you are treating epilepsy, cancer, or other medical condition, the concentration of ketones do not matter too much. You can achieve weight loss and a sense of well-being even with lower levels of ketones.
    Focus on how you feel, not on the number. Use ketone meters for interest and experimentation, but don't let the results stress you out.
    tl;dr never, unless you have read and understood this post, yet still want to use them anyway
    [If anyone has any suggestions for improving this post or correcting misinformation, let me know. I'll correct this and re-post it once in a while]

  2. anbeav

    tl;dr never
    If you want to do it for experimentation, go for it but please spare the rest of us the unnecessary ketosis anxiety
    edits: In addition to false negatives, ketostix commonly show false positives as in when people eat a high carb meal and think they cheated biology. Also I might remove the bit about using ketostix to monitor keto-adaptation, just asking for more posts about the issue. Also I might emphasize that people seem to already be overwhelmed with keto when starting and adding another layer of unnecessary complexity doesn't help the matter. People always talk about lifestyle, live a lifestyle and IMO living a lifestyle certainly shouldn't have to include measuring. Lastly, ketone concentrations are what they are. If you want to measure with a blood or breath meter, they are what they are and chasing ketone concentrations often becomes as unnecessary as ketostix. Unless someone has a medical condition for which a particular concentration is required for management, focus on how you feel not the number. Use the meter for interest and experimentation, but don't let it stress you out.

  3. blurfocus

    Thanks. I have incorporated your feedback.

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Diabetic Ketoacidosis Mortality Prediction Model (dka Mpm) Score

Note: This calculator is not externally validated and should be used with caution. It is not intended to routinely disposition patients. The APACHE II Score may be a better mortality predictor. Use in patients with DKA. Continue reading >>

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  1. WhoAteMyPsyche

    I've been trying to find the science between how the body reacts in ketosis vs someone who just tries to keep their carbs low. I know some people can be in ketosis with 50 carbs or less, but I do not think that is the case for most people.
    When I first started losing weight I was keeping my carbs between 40-50, and lost between 80-90 lbs. doing that. I then started doing more research (I stalled for a long time) and switched to keto and keep my carbs below 20. However, I'm working on a blog post trying to explain keto and would like to be able to explain, intelligently, the difference in ketosis vs "lowish" carbs.

    Can anyone point me to good research on this? Thank you!

  2. Fiorella

    Honestly, I think the best data or research is testing your own body, as in n=1. Starting at 20 g carbs is a starter's template. From there, you may need to go lower, or get away with pushing it higher. Let's say someone comes up with a bell curve showing where people have there carbs set at. It will still be a snapshot in time, possibly skewed to men/women only, age groups, metabolic diseases, athletic/sedentary, etc. Also, some people noticed that with time, the carb level requirement changed as their bodies health modified, too.

  3. WhoAteMyPsyche

    I completely agree that everyone is different and that the carb levels can change over time. I know, at least in my experience, just because someone knows about low carb doesn't mean they know what ketosis is. When I first started I was going off a plan I had followed in the 90s (Protein Power Plan) and knew nothing about ketosis. I had heard the term "keto" thrown around by a few people but just thought it was a different way of saying the same thing - Protein Power, Atkins, etc. So I guess the key is telling people WHAT keto is and why lowering your carbs works. They can then take that info and learn for themselves what works for them.

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In this video we can know about UNIVERSITY ADMISSION ||FAKE UNIVERSITY IN INDIA|| UGC LIST OF FAKE UNIVERSITY IN INDIA Useful Application for IGNOU Students: Click to Download Now(IGNOUMANIA APP)- http://bit.ly/2kjPBmv and (STUDENT ADDA APP)-http://bit.ly/2zY2gyx ! LIKE https://www.facebook.com/ignouhelpforum/ For more updates Please subscribe now!! Watch More... (IGNOU)How to make assignment properly?? ??(in hindi) complete details https://www.youtube.com/watch?v=7IDtH... (IGNOU) HOW TO ATTEMPT QUESTION PAPER FOR JUNE AND DEC. EXAM? https://www.youtube.com/watch?v=G4kxR... HOW TO COMPLETE GRAUATION IN 3 YEARS? ? https://www.youtube.com/watch?v=MJfN9... (IGNOU) IGNOU degree is valid for all competitive exams ( SSC,UPSC,BANKING ETC)? IGNOU ? https://www.youtube.com/watch?v=qk1jZ... (IGNOU) CALCULATE YOUR MARKS AND FIND OUT YOUR PERCENTAGE? ? https://www.youtube.com/watch?v=xAh0p... ** ? https://www.youtube.com/watch?v=kDvaN... 2016 IGNOU RESULT CHECK HERE https://admission.ignou.ac.in/changea... {Student adda} provides basic and advanced level knowledge about IGNOU UNIVERSITY, you can ask question about your problem

University Of Zagreb

SCHOOL OF MEDICINE Mohammad Imran Khan Malik A review of the efficacy of the Milwaukee protocol in the treatment of ketoacidosis in pediatric Intensive Care Unit patients at Rebro hospital between 2009-2014. GRADUATE THESIS Zagreb, 2014 UNIVERSITY OF ZAGREB SCHOOL OF MEDICINE Mohammad Imran Khan Malik A review of the efficacy of the Milwaukee protocol in the treatment of ketoacidosis in pediatric Intensive Care Unit patients at Rebro hospital between 2009-2014. GRADUATE THESIS Zagreb, 2014 This graduation paper has been completed at the Department of Paediatrics at the University Hospital Centre Zagreb (Rebro hospital) under the supervision of Dr. sc. Mario Ćuk and was submitted for evaluation during the academic year 2013 /2014. LIST OF TABLES Table 1: DKA laboratory diagnosis criteria Table 2: Classification of DKA. Modified from Kliegman et al. Nelson Textbook of Pediatrics, 2011. Table 3: Table 3: Summary of key data of patients admitted to pediatric ICU at Rebro hospital. LIST OF FIGURES Figure 1: DKA pathogenesis. Figure 2: Ketone bodies: showing formation of negatively charged conjugate bases of the ketoacids. The conjugate bases cause the increased anion gap in DKA meta Continue reading >>

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  1. Silky

    I became diabetic (Insulin Dependent) when I was just 10 and I'm now 19 (just turned yesterday actually) and in the past year I have been in hospital 5 TIMES!! with ketones, also had to be put in ICU on one occasion aswell, BIG SCARE! Thought I was going to die
    My diabeties is fairly well controlled but the thing that is worrying me is the fact I keep getting ketones, even though I control my sugars well. It's confusing for me, my doctor said it my of been caused from when I was younger (Between about 15 and 17) and neglected my diabeties and ate sweets and all that.
    Anyways... the thing that scares me the most is;
    1. I keep getting ketones.
    2. The way I have been told to get rid of them is quite dangerous.
    The reason for it being dangerous is because my doctor told me that I should inject insulin, untill the ketones are gone (unless my ketone level is at 3, then I should come into hospital), but the has caused my sugars to drop rapidly and I get shakey, blurred vision etc (you all know the signs)... I tried drinking sips on luzozade sport (my favorite drink), and it seemed to work, and I can successfully get rid of the ketones and also avoid going hypo... but tends to leave my bloods, a bit out of whack untill my next injection, and I tend to wee and drink a lot.
    Has anyone even had this problem? or is currently going through it?
    If so then please chat to me, it's driving me nuts!!

  2. Shelley

    Hiya Silky,
    Sorry l dont know much about T1 apart from what l've read in passing on this board.
    However have you tried just drinking lots of water to flush away ketones (if thats (poss)? - lt was just a thought, l dont really have a clue.
    l know water is good at keeping the kidney's flushed.
    l'm sure someone else will answer you soon, l saw a few of your posts and just thought l'd try.
    Welcome to the Diabetes Daily Forum.

  3. Silky

    thanks for the welcome Shelly.
    Yeah I tried drinking water, doesn't do that much in my opinion... mass' of insulin seems to be the only way and that is why I'm sooo scared! because I know how serious ketones is, the doctors once told me that if I didn't come in hospital when I did, then another hour and I'd be in a coma or worse... but thankfully I'm still here and alive and well.

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