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Dka And Heart Failure

Respiratory Failure In Diabetic Ketoacidosis

Respiratory Failure In Diabetic Ketoacidosis

Go to: INTRODUCTION Ketoacidosis in subjects with type 1, or less frequently, type 2 diabetes mellitus remains a potentially life-threatening diabetic manifestation. The subject has justifiably attracted attention in the literature. Sequential reviews[1-9] have documented important changes in the clinical concepts that are related to diabetic ketoacidosis (DKA) and its management. A large number of case series of DKA have addressed various aspects of its clinical presentation and management. For this review, we selected representative studies focused on management, outcome, age differences, gender differences, associated morbid conditions, ethnicity and prominent clinical and laboratory features[10-35]. In recognition of the complexity of treatment, the recommendation to provide this care in intensive care units was made more than 50 years ago[36]. Severe DKA is treated in intensive care units today[31]. Evidence-based guidelines for the diagnosis and management of DKA have been published and frequently revised in North America[37,38] and Europe[39]. Losses of fluids and electrolytes, which are important causes of morbidity and mortality in DKA, vary greatly between patients. Quantitative methods estimating individual losses and guiding their replacement have also been reported[40,41]. The outcomes of DKA have improved with new methods of insulin administration[42] and adherence to guidelines[43-46]. The aim of treatment is to minimize mortality and prevent sequelae. One study documented that the target of zero mortality is feasible[42]. However, mortality from DKA, although reduced progressively in the early decades after the employment of insulin treatment[1], remains high. Up to fifty plus years ago, mortality from DKA was between 3% and 10%[1,16]. A recent review re Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a serious problem that can occur in people with diabetes if their body starts to run out of insulin. This causes harmful substances called ketones to build up in the body, which can be life-threatening if not spotted and treated quickly. DKA mainly affects people with type 1 diabetes, but can sometimes occur in people with type 2 diabetes. If you have diabetes, it's important to be aware of the risk and know what to do if DKA occurs. Symptoms of diabetic ketoacidosis Signs of DKA include: needing to pee more than usual being sick breath that smells fruity (like pear drop sweets or nail varnish) deep or fast breathing feeling very tired or sleepy passing out DKA can also cause high blood sugar (hyperglycaemia) and a high level of ketones in your blood or urine, which you can check for using home-testing kits. Symptoms usually develop over 24 hours, but can come on faster. Check your blood sugar and ketone levels Check your blood sugar level if you have symptoms of DKA. If your blood sugar is 11mmol/L or over and you have a blood or urine ketone testing kit, check your ketone level. If you do a blood ketone test: lower than 0.6mmol/L is a normal reading 0.6 to 1.5mmol/L means you're at a slightly increased risk of DKA and should test again in a couple of hours 1.6 to 2.9mmol/L means you're at an increased risk of DKA and should contact your diabetes team or GP as soon as possible 3mmol/L or over means you have a very high risk of DKA and should get medical help immediately If you do a urine ketone test, a result of more than 2+ means there's a high chance you have DKA. When to get medical help Go to your nearest accident and emergency (A&E) department straight away if you think you have DKA, especially if you have a high level of ketones in Continue reading >>

Extreme Insulin Resistance In A Patient With Diabetes Ketoacidosis And Acute Myocardial Infarction

Extreme Insulin Resistance In A Patient With Diabetes Ketoacidosis And Acute Myocardial Infarction

Case Reports in Endocrinology Volume 2013 (2013), Article ID 520904, 7 pages 1Division of Endocrinology, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA 2Division of Endocrinology, Maimonides Medical Center, Brooklyn, NY 11219, USA Academic Editors: O. Isozaki, W. V. Moore, and R. Murray Copyright © 2013 Yin H. Oo et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Hyperglycemia is common in hospitalized patients and associated with adverse clinical outcomes. In hospitalized patients, multiple factors contribute to hyperglycemia, such as underlying medical conditions, pathophysiological stress, and medications. The development of transient insulin resistance is a known cause of hyperglycemia in both diabetic and nondiabetic patients. Though physicians are familiar with common diseases that are known to be associated with insulin resistance, the majority of us rarely come across a case of extreme insulin resistance. Here, we report a case of prolonged course of extreme insulin resistance in a patient admitted with diabetic ketoacidosis (DKA) and acute myocardial infarction (MI). The main purpose of this paper is to review the literature to identify the underlying mechanisms of extreme insulin resistance in a patient with DKA and MI. We will also briefly discuss the different clinical conditions that are associated with insulin resistance and a general approach to a patient with severe insulin resistance. 1. Introduction In hospitalized patients, the development of transient insulin resistance related to different medical conditions such as acute myocardial infarction (MI), sepsis, and Continue reading >>

The Silent Heart Attacks That Can Strike Diabetics Without Warning

The Silent Heart Attacks That Can Strike Diabetics Without Warning

Property consultant Michael Green was adamant that his type 2 diabetes was nothing to worry about. 'It's the non-serious type,' he'd say dismissively. Michael's laid-back attitude is in some ways understandable. The father-of-one had never suffered any obvious ill-effects from the condition he'd lived with for 28 years, and he'd been diagnosed not as a result of any troubling symptoms, but by chance following a routine blood test. Compared to a family friend who had type 1 diabetes, he was lucky, he insisted. At least he didn't have to monitor his blood sugar levels every few hours, and inject insulin. Then one night, two years ago, he went to sleep and never woke up. At just 53, he'd suffered a 'silent heart attack' - a little-known complication of diabetes. A silent attack is almost symptomless and occurs without any of the chest pain normally associated with a heart attack. Yet they can be just as dangerous - if not more so - as a normal heart attack. They're also surprisingly common. It is estimated that around a quarter of the 175,000 heart attacks in the UK each year are the silent type - and people with diabetes are at greatest risk. This is because the nerve damage linked to their condition can prevent warning signals being transmitted in the usual way. This, in turn, can lead to a delay in seeking treatment and result in damage to the blood vessels and heart muscle that make the heart attack more lethal. Heart attacks occur when there is a blockage in the artery supplying blood to the heart. Normally, this is as a result of a fatty plaque breaking off from the artery wall, triggering a blood clot. When the blood supply to the heart is reduced, the body produces chemicals that affect nerves and trigger pain. Often, people describe the pain of a heart attack as a Continue reading >>

Diabetes And Heart Disease

Diabetes And Heart Disease

Tweet Heart disease is a complication that may affect people with diabetes if their condition is not managed well for a prolonged period of time.. Coronary heart disease is recognized to be the cause of death for 80% of people with diabetes, however, the NHS states that heart attacks are largely preventable. [48] How are heart disease and diabetes linked? People suffering from type 1 and type 2 diabetes are more likely to be at risk from heart attacks, strokes and high blood pressure. Vascular problems, such as poor circulation to the legs and feet, are also more likely to affect diabetes patients. Like diabetes itself, the symptoms of cardiovascular disease may go undetected for years. A Diabetes UK report from 2007 estimates that the risk of cardiovascular disease in people with diabetes is: [1] 5 times higher in middle aged men 8 times higher in women with diabetes. More than half of type 2 diabetes patients will exhibit signs of cardiovascular disease complications at diagnosis. Who does heart disease affect? Many people think that heart disease only affects the middle-aged and elderly. However, serious cardiovascular disease may develop in diabetics before the age of 30. Both type 1 and type 2 diabetics are at greater risk of developing heart disease. What is the cause of heart disease amongst diabetics? Hyperglycemia, which characterises diabetes, in combination with free fatty acids in the blood can change the makeup of blood vessels, and this can lead to cardiovascular disease. The lining of the blood vessels may become thicker, and this in turn can impair blood flow. Heart problems and the possibility of stroke can occur. What symptoms can identify heart disease? The following are common symptoms of heart disease, although this may vary from individual to indiv Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

What Is It? Diabetic ketoacidosis is a potentially fatal complication of diabetes that occurs when you have much less insulin than your body needs. This problem causes the blood to become acidic and the body to become dangerously dehydrated. Diabetic ketoacidosis can occur when diabetes is not treated adequately, or it can occur during times of serious sickness. To understand this illness, you need to understand the way your body powers itself with sugar and other fuels. Foods we eat are broken down by the body, and much of what we eat becomes glucose (a type of sugar), which enters the bloodstream. Insulin helps glucose to pass from the bloodstream into body cells, where it is used for energy. Insulin normally is made by the pancreas, but people with type 1 diabetes (insulin-dependent diabetes) don't produce enough insulin and must inject it daily. Subscribe to Harvard Health Online for immediate access to health news and information from Harvard Medical School. Continue reading >>

Original Article Clinical Outcomes Of Septic Patients With Diabetic Ketoacidosis Between 2004 And 2013 In A Tertiary Hospital In Taiwan

Original Article Clinical Outcomes Of Septic Patients With Diabetic Ketoacidosis Between 2004 And 2013 In A Tertiary Hospital In Taiwan

Infection is the most common predisposing factor for diabetic ketoacidosis (DKA); however, studies are rare that have investigated the clinical outcomes of septic patients with infection-precipitated DKA. A retrospective cohort study was conducted at a tertiary hospital from 2004 to 2013. Patients with DKA in whom the presence of a predisposing infection was confirmed were enrolled. Characteristics at initial presentation, primary infection sources, and causative microorganisms were compared between the nonacute kidney injury (non-AKI) group and acute kidney injury (AKI) group at each stage. Risk factors for the development of failure-stage AKI and its outcomes were also analyzed. One hundred and sixty DKA episodes were assessed. The most common infection sites were the urinary and respiratory tracts. The leading causative microorganism was Escherichia coli, followed by Klebsiella pneumoniae. A complicated/severe infection state [odds ratio (OR), 15.27; p < 0.001] and a high level of C-reactive protein (OR, 1.012; p < 0.001) were independently associated with bacteremia. Corrected sodium (Na; OR, 1.062; p = 0.039), initial plasma glucose (OR, 1.003; p = 0.041), severe grade of DKA (OR, 13.41; p = 0.045), and the Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR, 1.08; p = 0.033) were identified as independent risk factors for the development of failure-stage AKI among septic patients with infection-precipitated DKA. Patients with failure-stage AKI had a higher frequency of incomplete recovery of renal function (20.4% of patients in failure vs. 5.9% of patients in risk and injury, p = 0.009). Bacteremia independently predicted the absence of complete recovery of renal function (OR, 5.86; p = 0.038). For patients with infection-precipitated DKA, the cli Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Print Overview Diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. The condition develops when your body can't produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated. If you have diabetes or you're at risk of diabetes, learn the warning signs of diabetic ketoacidosis — and know when to seek emergency care. Symptoms Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. For some, these signs and symptoms may be the first indication of having diabetes. You may notice: Excessive thirst Frequent urination Nausea and vomiting Abdominal pain Weakness or fatigue Shortness of breath Fruity-scented breath Confusion More-specific signs of diabetic ketoacidosis — which can be detected through home blood and urine testing kits — include: High blood sugar level (hyperglycemia) High ketone levels in your urine When to see a doctor If you feel ill or stressed or you've had a recent illness or injury, check your blood sugar level often. You might also try an over-the-counter urine ketones testing kit. Contact your doctor immediately if: You're vomiting and unable to tolerate food or liquid Your blood sugar level is higher than your target range and doesn't respond to home treatment Your urine ketone level is moderate or high Seek emergency care if: Your blood sugar level is consistently higher than 300 milligrams per deciliter (mg/dL), or 16.7 mill Continue reading >>

Diabetic Ketoacidosis (dka) - Topic Overview

Diabetic Ketoacidosis (dka) - Topic Overview

Diabetic ketoacidosis (DKA) is a life-threatening condition that develops when cells in the body are unable to get the sugar (glucose) they need for energy because there is not enough insulin. When the sugar cannot get into the cells, it stays in the blood. The kidneys filter some of the sugar from the blood and remove it from the body through urine. Because the cells cannot receive sugar for energy, the body begins to break down fat and muscle for energy. When this happens, ketones, or fatty acids, are produced and enter the bloodstream, causing the chemical imbalance (metabolic acidosis) called diabetic ketoacidosis. Ketoacidosis can be caused by not getting enough insulin, having a severe infection or other illness, becoming severely dehydrated, or some combination of these things. It can occur in people who have little or no insulin in their bodies (mostly people with type 1 diabetes but it can happen with type 2 diabetes, especially children) when their blood sugar levels are high. Your blood sugar may be quite high before you notice symptoms, which include: Flushed, hot, dry skin. Feeling thirsty and urinating a lot. Drowsiness or difficulty waking up. Young children may lack interest in their normal activities. Rapid, deep breathing. A strong, fruity breath odor. Loss of appetite, belly pain, and vomiting. Confusion. Laboratory tests, including blood and urine tests, are used to confirm a diagnosis of diabetic ketoacidosis. Tests for ketones are available for home use. Keep some test strips nearby in case your blood sugar level becomes high. When ketoacidosis is severe, it must be treated in the hospital, often in an intensive care unit. Treatment involves giving insulin and fluids through your vein and closely watching certain chemicals in your blood (electrolyt Continue reading >>

Practical Management Of Diabetes In Critically Ill Patients

Practical Management Of Diabetes In Critically Ill Patients

According to the American Diabetes Association and the World Health Organization, the diagnosis of diabetes requires one of the following: (1) random plasma glucose ⩾ 200 mg% with symptoms of diabetes (polyuria, polydipsia, etc.), (2) fasting plasma glucose ⩾ 126 mg% (confirmed on a second occasion), or (3) plasma glucose ⩾ 200 mg% 2 h after an oral glucose load (2). These criteria were developed for outpatients. Diagnostic criteria for diabetes in the hospitalized patient are not available; however, hyperglycemia (random plasma glucose > 180–200 mg%) warrants treatment. Measurement of the hemoglobin A1c, a reflection of glycemia for the prior 2–3 mo, is useful in determining the chronicity of hyperglycemia and, if elevated, indicates the presence of hyperglycemia prior to hospital admission. The nomenclature for diabetes classification is divided into type 1 diabetes (replaces insulin-dependent diabetes mellitus or IDDM), type 2 diabetes (replaces non-insulin-dependent diabetes mellitus or NIDDM), and other forms such as gestational diabetes or forms of diabetes secondary to other diseases (2). Accurate classification of diabetes in a patient assists in glycemic management in the hospital setting and alerts the physician to associated conditions. Type 1 diabetes refers to hyperglycemia that results primarily from insulin deficiency. Although the prototypical patient is a young child or adolescent, the onset of type 1 diabetes may occur over the age of 20 yr in more than one-third of patients. Because type 1 diabetes is an autoimmune disorder, autoimmune thyroid disease (hyperthyroidism or hypothyroidism) and adrenal insufficiency should be considered in patients with unexplained hypotension, persistent tachycardia, or prolonged respiratory failure. Type 2 dia Continue reading >>

Severe Diabetic Ketoacidosis Associated With Acute Myocardial Necrosis

Severe Diabetic Ketoacidosis Associated With Acute Myocardial Necrosis

We describe a case of a 28-year-old woman who was admitted to our hospital with severe diabetic ketoacidosis. She was known to have had type 1 diabetes for 10 years. During the previous 2 days, she had gone to a party, drank a considerable amount of alcohol, and did not administer her regular dose of insulin. On admission, she was semicomatose and tachypnoic, her blood pressure was 90/70 mmHg, and her heart rate 80 bpm. Laboratory tests showed severe metabolic acidosis (pH 6.92, bicarbonate 2.2 mmol/l, pCO2 1.49 kPa), very high blood glucose (75 mmol/l), hyponatremia (104.3 mmol/l), hypochloremia (70 mmol/l), severe hyperkalemia (8.5 mmol/l), and elevated blood urea (20.3 mmol/l) and creatinine (317 μmol/l). Blood ethanol level was 0.2 g/l. Screening for possible intoxication, including cocaine, opiates, and amphetamines, was negative. Electrocardiogram (ECG) showed sinus rhythm with wide QRS complexes and diffuse nonspecific ST changes. The patient was treated with continuous intravenous saline and insulin infusion. After 12 h, her blood glucose decreased to 17.5 mmol/l (pH 7.23, bicarbonate 12.0 mmol/l, potassium 5.12 mmol/l, and sodium 127.8 mmol/l). Blood urea decreased to 14.6 mmol/l and creatinine to 154 μmol/l. ECG was also normalized. After 36 h, the patient experienced transient stabbing chest pain, which was partially relieved by the change of body position. Complex ventricular arrhythmias, including short runs of ventricular tachycardia, were noticed. Repeat ECG revealed mild ST elevations in leads II, III, and aVF with negative T-waves in leads V2–V4. Echocardiography revealed somewhat depressed left ventricular systolic function (LVEF 45%) with hypokinesis of the posterior and inferior walls. Serum troponin I increased to 343 ng/ml (normal value ≤0.4 Continue reading >>

Cardiac Contractility During Severe Ketoacidosis

Cardiac Contractility During Severe Ketoacidosis

To the Editor: Experimental studies suggest that metabolic acidosis impairs the contractile function of the heart, but whether this occurs in humans is uncertain.1,2 During a six-month period, we measured fractional shortening of the left ventricle during systole in 10 consecutive patients (6 women and 4 men; mean [±SD] age, 42±18 years), 7 of whom were admitted for treatment of diabetic ketoacidosis and 3 of whom were admitted for alcoholic ketoacidosis. We focused on these conditions because the ketoacidosis associated with them, although frequently severe, is usually rapidly reversible. Treatment included intravenous rehydration (mean volume of fluid infused, 3.1±1.6 liters), insulin administration in the patients with diabetes, and antibiotic therapy as needed (in two patients). No alkali therapy was administered. Fractional shortening of the left ventricle was measured by transthoracic echocardiography (with a 2.5- or 3.5-MHz probe, Sonos 100, Hewlett–Packard, Orsay, France) before treatment and 24 to 36 hours later, after correction of the ketoacidosis. No patient had a systolic blood pressure of less than 90 mm Hg on admission or during follow-up, and none received plasma expanders or vasopressors. Echocardiography revealed no regional wall-motion abnormalities, and the fractional shortening of the left ventricle was normal at both times in all patients (Table 1Table 1), including three patients who had extremely severe acidosis (pH, 6.90, 6.76, and 6.75). Although cardiac contractility is a multifactorial function, we think that it can be reliably evaluated by measurements of left ventricular fractional shortening. For this reason, it seems unlikely that ketoacidosis had a clinically important effect in our patients. Our findings do not support the notion t Continue reading >>

Cardiovascular Complications Of Ketoacidosis

Cardiovascular Complications Of Ketoacidosis

US Pharm. 2016;41(2):39-42. ABSTRACT: Ketoacidosis is a serious medical emergency requiring hospitalization. It is most commonly associated with diabetes and alcoholism, but each type is treated differently. Some treatments for ketoacidosis, such as insulin and potassium, are considered high-alert medications, and others could result in electrolyte imbalances. Several cardiovascular complications are associated with ketoacidosis as a result of electrolyte imbalances, including arrhythmias, ECG changes, ventricular tachycardia, and cardiac arrest, which can be prevented with appropriate initial treatment. Acute myocardial infarction can predispose patients with diabetes to ketoacidosis and worsen their cardiovascular outcomes. Cardiopulmonary complications such as pulmonary edema and respiratory failure have also been seen with ketoacidosis. Overall, the mortality rate of ketoacidosis is low with proper and urgent medical treatment. Hospital pharmacists can help ensure standardization and improve the safety of pharmacotherapy for ketoacidosis. In the outpatient setting, pharmacists can educate patients on prevention of ketoacidosis and when to seek medical attention. Metabolic acidosis occurs as a result of increased endogenous acid production, a decrease in bicarbonate, or a buildup of endogenous acids.1 Ketoacidosis is a metabolic disorder in which regulation of ketones is disrupted, leading to excess secretion, accumulation, and ultimately a decrease in the blood pH.2 Acidosis is defined by a serum pH <7.35, while a pH <6.8 is considered incompatible with life.1,3 Ketone formation occurs by breakdown of fatty acids. Insulin inhibits beta-oxidation of fatty acids; thus, low levels of insulin accelerate ketone formation, which can be seen in patients with diabetes. Extr Continue reading >>

New Safety Warnings For Two Classes Of Diabetes Drugs: What Pharmacists Should Know

New Safety Warnings For Two Classes Of Diabetes Drugs: What Pharmacists Should Know

This spring, FDA called attention to two classes of diabetes drugs and potential serious risks associated with them. In April, the Endocrinologic and Metabolic Drugs Advisory Committee advised FDA to add a heart failure warning to labels on dipeptidyl peptidase–4 (DPP-4) inhibitors, also known as gliptins. A month later, FDA issued a drug safety communication warning that another diabetes drug, sodium–glucose linked transporter–2 (SGLT-2) inhibitors, could cause euglycemic diabetic ketoacidosis. When FDA has new information on the safety of a drug, the agency may issue a drug safety communication, or it could deem a label change necessary. In some but not all cases, these warnings warrant a change in the way pharmacists advise prescribers and counsel patients. “All medications come with benefits and risks, and every decision for type 2 diabetes should be based on the patient-specific advantages and disadvantages of the different options available. The potential risks with these two medication classes are something we must consider,” said Jennifer Trujillo, PharmD, BCPS, CDE, Associate Professor of Clinical Pharmacy at University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. New drug safety information FDA has issued 15 drug safety communications this year. There were 16 in 2014 and twice that many in each of the two preceding years. Health care providers learn about these warnings on FDA’s website or through MedWatch Safety Alerts, the Drug Information Listserv, e-mail newsletters, podcasts, and social and traditional media. The communications are distributed to about 573,000 subscribers to e-mail distribution listservs and 451,000 followers to FDA social media accounts. (APhA’s DrugInfoLine at www.aphadruginfoline.com also publishes F Continue reading >>

Diabetes Complications In Dogs And Cats: Diabetes Ketoacidosis (dka)

Diabetes Complications In Dogs And Cats: Diabetes Ketoacidosis (dka)

Unfortunately, we veterinarians are seeing an increased prevalence of diabetes mellitus in dogs and cats. This is likely due to the growing prevalence of obesity (secondary to inactive lifestyle, a high carbohydrate diet, lack of exercise, etc.). So, if you just had a dog or cat diagnosed with diabetes mellitus, what do you do? First, we encourage you to take a look at these articles for an explanation of the disease: Diabetes Mellitus (Sugar Diabetes) in Dogs Once you have a basic understanding of diabetes mellitus (or if you already had one), this article will teach you about life-threatening complications that can occur as a result of the disease; specifically, I discuss a life-threatening condition called diabetes ketoacidosis (DKA) so that you know how to help prevent it! What is DKA? When diabetes goes undiagnosed, or when it is difficult to control or regulate, the complication of DKA can occur. DKA develops because the body is so lacking in insulin that the sugar can’t get into the cells -- resulting in cell starvation. Cell starvation causes the body to start breaking down fat in an attempt to provide energy (or a fuel source) to the body. Unfortunately, these fat breakdown products, called “ketones,” are also poisonous to the body. Symptoms of DKA Clinical signs of DKA include the following: Weakness Not moving (in cats, hanging out by the water bowl) Not eating to complete anorexia Large urinary clumps in the litter box (my guideline? If it’s bigger than a tennis ball, it’s abnormal) Weight loss (most commonly over the back), despite an overweight body condition Excessively dry or oily skin coat Abnormal breath (typically a sweet “ketotic” odor) In severe cases DKA can also result in more significant signs: Abnormal breathing pattern Jaundice Ab Continue reading >>

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