diabetestalk.net

Dka And Heart Failure

Emergency Management Of Diabetic Ketoacidosis In Adults

Emergency Management Of Diabetic Ketoacidosis In Adults

Diabetic ketoacidosis (DKA) is a potentially fatal metabolic disorder presenting most weeks in most accident and emergency (A&E) departments.1 The disorder can have significant mortality if misdiagnosed or mistreated. Numerous management strategies have been described. Our aim is to describe a regimen that is based, as far as possible, on available evidence but also on our experience in managing patients with DKA in the A&E department and on inpatient wards. A literature search was carried out on Medline and the Cochrane Databases using “diabetic ketoacidosis” as a MeSH heading and as textword. High yield journals were hand searched. Papers identified were appraised in the ways described in the Users’ guide series published in JAMA. We will not be discussing the derangements in intermediary metabolism involved, nor would we suggest extrapolating the proposed regimen to children. Although some of the issues discussed may be considered by some to be outwith the remit of A&E medicine it would seem prudent to ensure that A&E staff were aware of the probable management of such patients in the hours after they leave the A&E department. AETIOLOGY AND DEFINITION DKA may be the first presentation of diabetes. Insulin error (with or without intercurrent illness) is the most common precipitating factor, accounting for nearly two thirds of cases (excluding those where DKA was the first presentation of diabetes mellitus).2 The main features of DKA are hyperglycaemia, metabolic acidosis with a high anion gap and heavy ketonuria (box 1). This contrasts with the other hyperglycaemic diabetic emergency of hyperosmolar non-ketotic hyperglycaemia where there is no acidosis, absent or minimal ketonuria but often very high glucose levels (>33 mM) and very high serum sodium levels (>15 Continue reading >>

Diabetic Ketoacidosis Causes, Symptoms, Treatment, And Complications

Diabetic Ketoacidosis Causes, Symptoms, Treatment, And Complications

Diabetic ketoacidosis definition and facts Diabetic ketoacidosis is a life-threatening complication of type 1 diabetes (though rare, it can occur in people with type 2 diabetes) that occurs when the body produces high levels of ketones due to lack of insulin. Diabetic ketoacidosis occurs when the body cannot produce enough insulin. The signs and symptoms of diabetic ketoacidosis include Risk factors for diabetic ketoacidosis are type 1 diabetes, and missing insulin doses frequently, or being exposed to a stressor requiring higher insulin doses (infection, etc). Diabetic ketoacidosis is diagnosed by an elevated blood sugar (glucose) level, elevated blood ketones and acidity of the blood (acidosis). The treatment for diabetic ketoacidosis is insulin, fluids and electrolyte therapy. Diabetic ketoacidosis can be prevented by taking insulin as prescribed and monitoring glucose and ketone levels. The prognosis for a person with diabetic ketoacidosis depends on the severity of the disease and the other underlying medical conditions. Diabetic ketoacidosis (DKA) is a severe and life-threatening complication of diabetes. Diabetic ketoacidosis occurs when the cells in our body do not receive the sugar (glucose) they need for energy. This happens while there is plenty of glucose in the bloodstream, but not enough insulin to help convert glucose for use in the cells. The body recognizes this and starts breaking down muscle and fat for energy. This breakdown produces ketones (also called fatty acids), which cause an imbalance in our electrolyte system leading to the ketoacidosis (a metabolic acidosis). The sugar that cannot be used because of the lack of insulin stays in the bloodstream (rather than going into the cell and provide energy). The kidneys filter some of the glucose (suga Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

The Facts Diabetic ketoacidosis (DKA) is a condition that may occur in people who have diabetes, most often in those who have type 1 (insulin-dependent) diabetes. It involves the buildup of toxic substances called ketones that make the blood too acidic. High ketone levels can be readily managed, but if they aren't detected and treated in time, a person can eventually slip into a fatal coma. DKA can occur in people who are newly diagnosed with type 1 diabetes and have had ketones building up in their blood prior to the start of treatment. It can also occur in people already diagnosed with type 1 diabetes that have missed an insulin dose, have an infection, or have suffered a traumatic event or injury. Although much less common, DKA can occasionally occur in people with type 2 diabetes under extreme physiologic stress. Causes With type 1 diabetes, the pancreas is unable to make the hormone insulin, which the body's cells need in order to take in glucose from the blood. In the case of type 2 diabetes, the pancreas is unable to make sufficient amounts of insulin in order to take in glucose from the blood. Glucose, a simple sugar we get from the foods we eat, is necessary for making the energy our cells need to function. People with diabetes can't get glucose into their cells, so their bodies look for alternative energy sources. Meanwhile, glucose builds up in the bloodstream, and by the time DKA occurs, blood glucose levels are often greater than 22 mmol/L (400 mg/dL) while insulin levels are very low. Since glucose isn't available for cells to use, fat from fat cells is broken down for energy instead, releasing ketones. Ketones accumulate in the blood, causing it to become more acidic. As a result, many of the enzymes that control the body's metabolic processes aren't able Continue reading >>

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 >>

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 >>

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 >>

Myocardial Injury With Biomarker Elevation In Diabetic Ketoacidosis

Myocardial Injury With Biomarker Elevation In Diabetic Ketoacidosis

Abstract We report of two patients with severe ketoacidosis, minute elevations of myocardial biomarkers (troponin T and CK-MB) and initial ECG changes compatible with myocardial infarction (MI). All successive investigations, including coronary arteriography, were normal, and the patients recovered fully without further evidence of ischemic heart disease. We suggest that acidosis and very high levels of free fatty acids could cause membrane instability and biomarker leakage. Regardless of the pathogenesis, these two case stories suggest that nonspecific myocardial injury may occur in severe diabetic ketoacidosis and that the presence of minute biomarker elevation and ECG changes does not necessarily signify MI. 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 >>

Lessons From Euroheart Failure Survey

Lessons From Euroheart Failure Survey

In some instances, acute myocardial infarction (AMI) may be the precipitating factor both for acute heart failure (AHF) and for diabetic ketoacidosis (DKA), with the consequence that the two disorders may occasionally co-exist in the same individual.1,2 When de novo AHF has cardiogenic pulmonary oedema as its presenting feature, its co-existence with DKA can pose unique diagnostic and therapeutic challenges. On the one hand, if the onset of AMI has escaped detection, due to a pain-free presentation, it may be difficult to differentiate between AMI-related cardiogenic pulmonary oedema and DKA-related adult respiratory distress syndrome, a diagnostic dilemna compounded by the fact that stigmata such as ST-segment elevation and a rise in cardiac troponin levels may be a feature, not only of AMI, but also of DKA per se.3 In the context of undisputable de novo AHF, the therapeutic challenge is one of managing cardiogenic pulmonary oedema and its aftermath, chronic heart failure, with minimal use of diuretics so as to reduce the risk of activation of the renin–angiotensin–aldosterone system (RAAS),4 with its attendant adverse sequelae.5 Although participants in the EuroHeart Failure study managed cardiogenic pulmonary oedema with intravenous diuretics and with intravenous nitrates, in 94 and 70.6% of instances, respectively,6 implying co-prescription of the two agents in some of those instances, the ideal strategy may well have been the sole use of intravenous nitrates7 given the fact that patients with new-onset cardiogenic pulmonary oedema are unlikely to have a net increase in blood volume, the latter eventuality rendered even less likely by the co-existence of DKA. Following the resolution of pulmonary oedema, the subsequent management of these patients should, theref Continue reading >>

Management Of Adult Diabetic Ketoacidosis

Management Of Adult Diabetic Ketoacidosis

Go to: Abstract Diabetic ketoacidosis (DKA) is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus. Due to its increasing incidence and economic impact related to the treatment and associated morbidity, effective management and prevention is key. Elements of management include making the appropriate diagnosis using current laboratory tools and clinical criteria and coordinating fluid resuscitation, insulin therapy, and electrolyte replacement through feedback obtained from timely patient monitoring and knowledge of resolution criteria. In addition, awareness of special populations such as patients with renal disease presenting with DKA is important. During the DKA therapy, complications may arise and appropriate strategies to prevent these complications are required. DKA prevention strategies including patient and provider education are important. This review aims to provide a brief overview of DKA from its pathophysiology to clinical presentation with in depth focus on up-to-date therapeutic management. Keywords: DKA treatment, insulin, prevention, ESKD Go to: Introduction In 2009, there were 140,000 hospitalizations for diabetic ketoacidosis (DKA) with an average length of stay of 3.4 days.1 The direct and indirect annual cost of DKA hospitalizations is 2.4 billion US dollars. Omission of insulin is the most common precipitant of DKA.2,3 Infections, acute medical illnesses involving the cardiovascular system (myocardial infarction, stroke) and gastrointestinal tract (bleeding, pancreatitis), diseases of the endocrine axis (acromegaly, Cushing’s syndrome), and stress of recent surgical procedures can contribute to the development of DKA by causing dehydration, increase in insulin counter-regulatory hor Continue reading >>

Diabetic Ketoacidosis

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 >>

Am I The Heart Attack?

Am I The Heart Attack?

A few weeks ago, I woke up at 3 a.m. with excruciating chest, arm, neck, and back pain. It was the kind of pain that resembled everything I’d ever read or heard about the pain which precedes a heart attack. I don’t know what the typical response is for a man who senses that he’s experiencing a cardiac emergency, but my response was probably a textbook example of what not to do: I stayed in bed and let my thoughts run wild. This can’t be a heart attack. I’m not breaking out in a cold sweat. I’m a healthy and well-controlled type 1 diabetic. I’m not short of breath. I exercised last night and felt fine. I had carrots and celery for my nighttime snack last night. I can’t afford to have a heart attack. What does a room in the cardiac ICU cost, ten thousand dollars a day? What if I die? What will my wife and son do without me? Why did I neglect my diabetes in my 20s? I ate too much pizza in college. God, I really can’t miss work today. I wonder if I can get to the emergency room and be out in time to get to work. After about 30 minutes of panicking and waiting for things to get better, I vomited. I remembered that my father-in-law had experienced the same symptoms when he’d had a heart attack two years ago – chest pains then vomiting. I woke my wife, Theresa. “I need to get to the hospital,” I said. We dressed quickly and as we were walking out the front door, my compulsive need to know my blood glucose level at all times (which apparently persists even under threat of cardiac arrest) forced me to test. It was 180 mg/dl, quite high for the middle of the night. Before we were out of our neighborhood, my chest pain had worsened. So had my state of mind. I was trying to convince Theresa to drive faster, but she was thinking clearly and decided we shoul 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 >>

Diabetes: Preventing Complications

Diabetes: Preventing Complications

Diabetes complications can be divided into two types: acute (sudden) and chronic (long-term). This article discusses these complications and strategies to prevent the complications from occurring in the first place. Acute complications Diabetic ketoacidosis (DKA) Hyperglycemic hyperosmolar non-ketotic syndrome (HHNS) Acute complications of diabetes can occur at any time in the course of the disease. Chronic complications Cardiovascular: Heart disease, peripheral vascular disease, stroke Eye: Diabetic retinopathy, cataracts, glaucoma Nerve damage: Neuropathy Kidney damage: Nephropathy Chronic complications are responsible for most illness and death associated with diabetes. Chronic complications usually appear after several years of elevated blood sugars (hyperglycemia). Since patients with Type 2 diabetes may have elevated blood sugars for several years before being diagnosed, these patients may have signs of complications at the time of diagnosis. Basic principles of prevention of diabetes complications: Take your medications (pills and/or insulin) as prescribed by your doctor. Monitor your blood sugars closely. Follow a sensible diet. Do not skip meals. Exercise regularly. See your doctor regularly to monitor for complications. Results from untreated hyperglycemia. Blood sugars typically range from 300 to 600. Occurs mostly in patients with Type 1 diabetes (uncommon in Type 2). Occurs due to a lack of insulin. Body breaks down its own fat for energy, and ketones appear in the urine and blood. Develops over several hours. Can cause coma and even death. Typically requires hospitalization. Nausea, vomiting Abdominal pain Drowsiness, lethargy (fatigue) Deep, rapid breathing Increased thirst Fruity-smelling breath Dehydration Inadequate insulin administration (not getting Continue reading >>

Diabetic Ketoacidosis: Evaluation And Treatment

Diabetic Ketoacidosis: Evaluation And Treatment

Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dL, a pH less than 7.3, a serum bicarbonate level less than 18 mEq per L, an elevated serum ketone level, and dehydration. Insulin deficiency is the main precipitating factor. Diabetic ketoacidosis can occur in persons of all ages, with 14 percent of cases occurring in persons older than 70 years, 23 percent in persons 51 to 70 years of age, 27 percent in persons 30 to 50 years of age, and 36 percent in persons younger than 30 years. The case fatality rate is 1 to 5 percent. About one-third of all cases are in persons without a history of diabetes mellitus. Common symptoms include polyuria with polydipsia (98 percent), weight loss (81 percent), fatigue (62 percent), dyspnea (57 percent), vomiting (46 percent), preceding febrile illness (40 percent), abdominal pain (32 percent), and polyphagia (23 percent). Measurement of A1C, blood urea nitrogen, creatinine, serum glucose, electrolytes, pH, and serum ketones; complete blood count; urinalysis; electrocardiography; and calculation of anion gap and osmolar gap can differentiate diabetic ketoacidosis from hyperosmolar hyperglycemic state, gastroenteritis, starvation ketosis, and other metabolic syndromes, and can assist in diagnosing comorbid conditions. Appropriate treatment includes administering intravenous fluids and insulin, and monitoring glucose and electrolyte levels. Cerebral edema is a rare but severe complication that occurs predominantly in children. Physicians should recognize the signs of diabetic ketoacidosis for prompt diagnosis, and identify early symptoms to prevent it. Patient education should include information on how to adjust insulin during times of illness and how to monitor glucose and ketone levels, as well as i Continue reading >>

More in ketosis