Diagnosis And Treatment Of Diabetic Ketoacidosis
85 Abstract Diabetic ketoacidosis (DKA) is the most frequent hyperglycaemic acute diabetic complication. Furthermore it carries a significant risk of death, which can be prevented by early and effective management. All physicians, irrespective of the discipline they are working in and whether in primary, secondary or tertiary care institutions, should be able to recognise DKA early and initiate management immediately. 86 Introduction Diabetic ketoacidosis (DKA) is a common complication of diabetes with an annual occurrence rate of 46 to 50 per 10 000 diabetic patients. The severity of this acute diabetic complication can be appreciated from the high death-to-case ratio of 5 to 10%.1 In Africa the mortality of DKA is unacceptably high with a reported death rate of 26 to 29% in studies from Kenya, Tanzania and Ghana.2 It is a complication of both type 1 and type 2 diabetes mellitus, although more commonly seen in type 1 diabetic patients. Of known diabetic patients presenting with DKA about one-quarter will be patients with type 2 diabetes. In patients presenting with a DKA as first manifestation of diabetes about 15% will be type 2.3 This correlates well with data from South Africa suggesting that one- quarter of patients with DKA will be type 2 with adequate C-peptide levels and the absence of anti-GAD antibodies.4 This review will focus on the principles of diagnosis, monitoring and treatment of DKA, with special mention of new developments and controversial issues. Clinical features DKA evolves over hours to days in both type 1 and type 2 diabetic patients, but the symptoms of poor control of blood glucose are usually present for several days before the onset or presentation of ketoacidosis.5 The clinical features of DKA are non-specific and patients may present with Continue reading >>
Ada Hospital Admission Guidelines For Diabetes Mellitus
[Diabetes Care 22(1):s80, 1999. © 1999 American Diabetes Association, Inc.] Introduction These guidelines are to be used for determining when a patient requires hospitalization for reasons related to diabetes. Inpatient care may be appropriate in the following situations: Life-threatening acute metabolic complications of diabetes. Newly diagnosed diabetes in children and adolescents. Substantial and chronic poor metabolic control that necessitates close monitoring of the patient to determine the etiology of the control problem, with subsequent modification of therapy. Severe chronic complications of diabetes that require intensive treatment or other severe conditions unrelated to diabetes that significantly affect its control or are complicated by diabetes. Uncontrolled or newly discovered insulin-requiring diabetes during pregnancy. Institution of insulin-pump therapy or other intensive insulin regimens. Modification of fixed insulin-treatment regimens or sulfonylurea treatment is not, by itself, an indication for hospital admission. Guidelines for hospital admission are given below. Guidelines are never a substitute for medical judgment, and each patient's total clinical and psychosocial circumstances must be considered in their application. Therefore, there may be situations in which admission is appropriate, although the patient's clinical profile does not comply with these guidelines. For example, inadequate family resources may dictate admission of newly diagnosed type 1 diabetic patients who otherwise do not meet the admission guidelines. Acute Metabolic Complications Of Diabetes Admission is appropriate for the following: Diabetic ketoacidosis Blood glucose >250 mg/dl (>13.9 mmol/l) with 1) arterial pH <7.35, venous pH <7.30, or serum bicarbonate level <15 mEq/ Continue reading >>
Hyperglycemic Crises In Diabetes
Ketoacidosis and hyperosmolar hyperglycemia are the two most serious acute metabolic complications of diabetes, even if managed properly. These disorders can occur in both type 1 and type 2 diabetes. The mortality rate in patients with diabetic ketoacidosis (DKA) is <5% in experienced centers, whereas the mortality rate of patients with hyperosmolar hyperglycemic state (HHS) still remains high at ∼15%. The prognosis of both conditions is substantially worsened at the extremes of age and in the presence of coma and hypotension (1–10). This position statement will outline precipitating factors and recommendations for the diagnosis, treatment, and prevention of DKA and HHS. It is based on a previous technical review (11), which should be consulted for further information. PATHOGENESIS Although the pathogenesis of DKA is better understood than that of HHS, the basic underlying mechanism for both disorders is a reduction in the net effective action of circulating insulin coupled with a concomitant elevation of counterregulatory hormones, such as glucagon, catecholamines, cortisol, and growth hormone. These hormonal alterations in DKA and HHS lead to increased hepatic and renal glucose production and impaired glucose utilization in peripheral tissues, which result in hyperglycemia and parallel changes in osmolality of the extracellular space (12,13). The combination of insulin deficiency and increased counterregulatory hormones in DKA also leads to the release of free fatty acids into the circulation from adipose tissue (lipolysis) and to unrestrained hepatic fatty acid oxidation to ketone bodies (β-hydroxybutyrate [β-OHB] and acetoacetate), with resulting ketonemia and metabolic acidosis. On the other hand, HHS may be caused by plasma insulin concentrations that are in Continue reading >>
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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 >>
Treatment Of Children With Diabetic Ketoacidosis Differs From Adult Treatment
Timing is crutial when a pediatric patient presents themselves with the symptoms for DKA Children with diabetic ketoacidosis (DKA) present differently and require different treatment than adults with DKA, according to newly published guidelines from the American Diabetes Association (ADA). "This is the first time that the ADA has had a position paper on childhood DKA separate from the adult position paper on DKA and nonketotic hyperglycemic coma, in recognition of the fact that children are not merely small adults — they have specific needs," Dr. Mark A. Sperling from Children’s Hospital of Pittsburgh, Pennsylvania told Diabetes In Control.com. Dr. Sperling and colleagues present a consensus statement on DKA in infants, children, and adolescents in the May issue of Diabetes Care. The younger the child, the less likely it is that the physician will be able to obtain the classical history of polyuria, polydipsia, and weight loss, the authors explain, and diabetes is often misdiagnosed as pneumonia or other conditions. For this reason, Dr. Sperling suggested that doctors "think of diabetes mellitus in any sick child whose cause of illness is not clear." In addition, the report indicates, differences in metabolic rate and surface area between children and adults dictate greater precision in managing fluids and electrolytes. Particular attention should be paid to the management of insulin, potassium, phosphate, and acid-base status. Because cerebral and other autoregulatory mechanisms may not be well developed in younger children, cerebral edema is a special concern, the statement points out. The most common cause of mortality in children with DKA, cerebral edema occurs in 0.5-1% of pediatric DKA episodes and leaves as many as one quarter of the survivors with permanent Continue reading >>
Impact Of Diabetic Ketoacidosis Management In The Medical Intensive Care Unit After Order Set Implementation
Abstract To determine the rate of compliance to the 2006 and 2009 ADA DKA guidelines in the medical intensive care unit (MICU) at a large academic medical centre after the implementation of a computerised DKA order set and protocol. Retrospective chart review of adult patients with DKA admitted to the MICU. Results of pre-order set (PRE) were compared to those of data post-order set (POST). The primary outcome was a composite administration of intravenous fluid resuscitation in the first 24 h, insulin bolus and initial insulin infusion rate. Key findings Twelve of 60 patients (20%) in the PRE group received treatment compliant with the 2006 guidelines versus 14 of 55 patients (25.5%) in the POST group (OR 1.22 95% CI 0.44 to 3.4, P = 0.51). Compliance to the 2009 guidelines was significantly higher in the POST group (31.7% versus 65.5%, OR 4.44 95% CI 1.8 to 10.92, P = 0.0004). Compliance for individual components was 26.7% versus 70.9% for fluid resuscitation (P = 0.0001), 55% versus 49.1% for insulin bolus (P = 0.58) and 60% versus 81.3% for initial insulin infusion rate (P = 0.014), respectively. Time to DKA resolution was decreased (P = 0.04), and hypoglycaemia was increased (P = 0.0022). Implementation of a computerised DKA order set and protocol was associated with improved compliance to the 2009 ADA DKA guidelines, 24-h fluid resuscitation, initial insulin infusion rate, time to DKA resolution and appropriate transition to subcutaneous insulin. However, patients in the POST implementation group were more likely to exhibit hypoglycaemia. Future assessment is warranted. Continue reading >>
Diabetic Ketoacidosis And Hyperosmolar Hyperglycemic State In Adults: Treatment
INTRODUCTION Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS, also known as hyperosmotic hyperglycemic nonketotic state [HHNK]) are two of the most serious acute complications of diabetes. They are part of the spectrum of hyperglycemia, and each represents an extreme in the spectrum. The treatment of DKA and HHS in adults will be reviewed here. The epidemiology, pathogenesis, clinical features, evaluation, and diagnosis of these disorders are discussed separately. DKA in children is also reviewed separately. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Epidemiology and pathogenesis".) (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis".) Continue reading >>
Type 1 Diabetes: Its Problems And Solutions
Formerly known as juvenile-onset diabetes, type 1 diabetes (T1D) is an endocrine disorder characterized by hyperglycemia due to insulin deficiency.1 Most cases of T1D are immune-mediated due to cellular-mediated autoimmune destruction of beta cells, resulting in inadequate insulin secretion and hyperglycemia via abnormal macronutrient metabolism.1,2 Acute hyperglycemia can cause metabolic emergencies such as diabetic ketoacidosis (DKA) and a hyperosmolar hyperglycemic state. Chronic hyperglycemia can cause vascular complications such as nephropathy, retinopathy, and cardiovascular disease. EPIDEMIOLOGY According to the American Diabetes Association (ADA), immune-mediated T1D accounts for 5% to 10% of diabetes cases. Although T1D may occur at any age, 50% to 60% of patients with T1D present at 16 years and younger.3-5 In a population- based cross-sectional study of children and adolescents in 2009, the overall prevalence of newly diagnosed cases of T1D was 1.93 per 1000 patients (95% CI, 1.88-1.97), with whites having the highest incidence of newly diagnosed T1D.6 RISK FACTORS A patient’s genome is a significant risk factor for T1D, as a case-control study of approximately 8000 patients with T1D identified 7 genetic variants associated with an increased risk of T1D and celiac disease.7 Other possible risk factors associated with an increased risk of T1D include high birth weight, childhood obesity, and a higher maternal age at birth.8-11 Childhood immunizations, however, are not associated with an increased risk for T1D.12,13 Conditions complicated by T1D include celiac disease and increased risk of hip fracture.14,15 HISTORY AND PHYSICAL Patients with T1D rarely present asymptomatically; the most common symptoms include polyuria and nocturia, enuresis, lethargy, fatig Continue reading >>
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Hospital Guidelines For Diabetes Management And The Joint Commission-american Diabetes Association Inpatient Diabetes Certification☆
Jump to Section Abstract Background The Joint Commission Advanced Inpatient Diabetes Certification Program is founded on the American Diabetes Association’s Clinical Practice Recommendations and is linked to the Joint Commission Standards. Diabetes currently affects 29.1 million people in the USA and another 86 million Americans are estimated to have pre-diabetes. On a daily basis at the Medical University of South Carolina (MUSC) Medical Center, there are approximately 130-150 inpatients with a diagnosis of diabetes. Methods The program encompasses all service lines at MUSC. Some important features of the program include: a program champion or champion team, written blood glucose monitoring protocols, staff education in diabetes management, medical record identification of diabetes, a plan coordinating insulin and meal delivery, plans for treatment of hypoglycemia and hyperglycemia, data collection for incidence of hypoglycemia, and patient education on self-management of diabetes. Results The major clinical components to develop, implement, and evaluate an inpatient diabetes care program are: I. Program management, II. Delivering or facilitating clinical care, III. Supporting self-management, IV. Clinical information management and V. performance measurement. The standards receive guidance from a Disease-Specific Care Certification Advisory Committee, and the Standards and Survey Procedures Committee of the Joint Commission Board of Commissioners. Conclusions The Joint Commission-ADA Advanced Inpatient Diabetes Certification represents a clinical program of excellence, improved processes of care, means to enhance contract negotiations with providers, ability to create an environment of teamwork, and heightened communication within the organization. Continue reading >>
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Dka Management In Children: Ada
Diabetic ketoacidosis (DKA) is considered to be a common presentation of Type 1 Diabetes Mellitus (T1DM) and occasionally, Type 2 Diabetes Mellitus (T2DM) in children and adolescents. DKA arises due to lack of adequate insulin in the body. Clinical Signs Dehydration (may be difficult to assess) Tachycardia, tachypnoea (may be mistaken for pneumonia or asthma) Kussmaul breathing with a typical fruity smell of ketones in the breath Nausea, vomiting (may be mistaken for gastroenteritis) Abdominal pain (may mimic an acute abdominal condition) Confusion, drowsiness, progressive reduction in level of consciousness, and eventually loss of consciousness. Investigations Serum glucose >200 mg/dL Serum bicarbonate <15 mEq/L or venous pH <7.3 Reduction in serum sodium of 2.4 mEq/L for every 100 mg/dL Potassium losses of 6–7 mEq/kg Negative phosphate balance Creatinine, BUN, blood gases, and hematocrit Blood Beta-hydroxybutyrate ≥31 mg/dL Urinalysis (for ketones) Electrocardiogram (ECG), if laboratory measurement of potassium status is delayed Diagnosis ISPAD in 2014 has defined the following biochemical criteria for the diagnosis of DKA: Hyperglycemia, blood glucose of >200 mg/dL, Metabolic acidosis, defined as a venous pH <7.3 or plasma bicarbonate <15 mEq/L, and Ketosis Severity of DKA: mild, moderate, or severe (pH 7.2–7.3; pH 7.1–7.2; or pH <7.1, respectively) Treatment Principles of DKA treatment: Replacement of fluid deficits Correction of dehydration Correction of acidosis and hyperglycemia Correction of electrolyte imbalance Treatment of any precipitating cause a. Fluid therapy: 0.9% normal saline or Ringer’s lactate, 10 mL/kg normal bolus for 1–2 hr. Continue ½ NS for 4–6 hr When the child becomes stable, switch to oral fluids After the first 48 hr, fluid ad Continue reading >>
My Site - Chapter 15: Hyperglycemic Emergencies In Adults
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) should be suspected in ill patients with diabetes. If either DKA or HHS is diagnosed, precipitating factors must be sought and treated. DKA and HHS are medical emergencies that require treatment and monitoring for multiple metabolic abnormalities and vigilance for complications. A normal blood glucose does not rule out DKA in pregnancy. Ketoacidosis requires insulin administration (0.1 U/kg/h) for resolution; bicarbonate therapy should be considered only for extreme acidosis (pH7.0). Note to readers: Although the diagnosis and treatment of diabetic ketoacidosis (DKA) in adults and in children share general principles, there are significant differences in their application, largely related to the increased risk of life-threatening cerebral edema with DKA in children and adolescents. The specific issues related to treatment of DKA in children and adolescents are addressed in the Type 1 Diabetes in Children and Adolescents chapter, p. S153. Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are diabetes emergencies with overlapping features. With insulin deficiency, hyperglycemia causes urinary losses of water and electrolytes (sodium, potassium, chloride) and the resultant extracellular fluid volume (ECFV) depletion. Potassium is shifted out of cells, and ketoacidosis occurs as a result of elevated glucagon levels and absolute insulin deficiency (in the case of type 1 diabetes) or high catecholamine levels suppressing insulin release (in the case of type 2 diabetes). In DKA, ketoacidosis is prominent, while in HHS, the main features are ECFV depletion and hyperosmolarity. Risk factors for DKA include new diagnosis of diabetes mellitus, insulin omission, infection, myocardial infarc Continue reading >>
Ispad Clinical Practice Consensus Guidelines 2014
Editor in Chief: Mark A. Sperling, Pittsburgh, USA. Guest Editors: Carlo Acerini, Maria E Craig, Carine de Beaufort, David M Maahs and Ragnar Hanas. Introduction Carlo Acerini, Maria E Craig, Carine de Beaufort, David M Maahs and Ragnar Hanas. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 1–3. Uploaded: 2. Sept 2014 Download Introduction Chapter 1: Definition, epidemiology, diagnosis and classification Craig ME, Jefferies C, Dabelea D, Balde N, Seth A, Donaghue KC. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 4–17. Uploaded: 2. Sept 2014 Download Chapter 1 Chapter 2: Phases of Type 1 Diabetes Couper JJ, Haller MJ, Ziegler A-G, KnipM, Ludvigsson J, Craig ME. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 18–25. Download Chapter 2 Chapter 3: Type 2 diabetes Zeitler P, Fu J, Tandon N, Nadeau K, Urakami T, Bartlett T, Maahs D. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 26-46. Uploaded: 2. Sept 2014 Download Chapter 3 Chapter 4: The Diagnosis and Management of Monogenic diabetes Rubio-Cabezas O, Hattersley AT, Njølstad PR, Mlynarski W, Ellard S,White N, Chi DV, Craig ME. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 47-64. Uploaded: 2. Sept 2014 Download Chapter 4 Chapter 5: Management of cystic fibrosis-related diabetes Moran A, Pillay K, Becker DJ, Acerini CL. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 65-76. Uploaded: 2. Sept 2014 Download Chapter 5 Chapter 6: Diabetes education Lange K, Swift P, Pankowska E, Danne T. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 77-85. Uploaded: 2. Sept 2014 Download Chapter 6 Chapter 7: The delivery of ambulatory diabetes care Pihoker C, Forsander G, Fantahun B, Virmani A, Luo X, Hallman M, Wolfsdorf J, Maahs DM. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 86-101. Up Continue reading >>
Pilot Study Of Guideline Adherence And Secondary Outcomes In Patients Presenting With Diabetic Ketoacidosis
Background: The 2010 American Diabetic Association (ADA) Guidelines for management of diabetic ketoacidosis (DKA) recommend treatment of DKA in a timely manner. Objective: We sought to explore the quality of emergency department (ED) DKA management by comparing ED DKA management with standard ADA guidelines beyond the initial management. Materials and Methods: This study was a retrospective study at an academic ED. Patients age ≥ 18 years who were evaluated and treated for DKA were included. We compared ED DKA management with standard ADA guidelines in four aspects: (1) fluid administration, (2) insulin administration, (3) electrolyte correction, and (4) ED disposition. Secondary outcomes were hypoglycemia, restarting of continuous insulin infusion (CII), and rebound hyperglycemia within 24 hours. Results: Of 75 enrolled patients, 29(39%) had mild, 16(21%) had moderate, and 30(40%) had severe DKA. All patients received intravenous fluid during their ED stay. Seventy five (100%) of cases received insulin administration in the ED. Twenty-four (44%) of cases received potassium supplement. Dextrose containing fluids was administered in 24/58(41%) of cases where blood glucose dropped <250 mg/dL. Only 14/30(47%) of severe DKA patients were admitted to ICU. Forty-six (61%) of the DKA cases treatment in the ED followed all components of the ADA guidelines. We found 12(16%) patients had hypoglycaemia. CII discontinued while still in the ED and restarted in 7/13(53%) of these patients. Conclusion: The ADA recommended guidelines were adhered to in only two third of the time. Further studies to assess the impact of educational programs and ED-specific DKA protocols beyond stabilization are planned. Keywords: Diabetic ketoacidosis (DKA); Guideline adherence; Emergency department ( Continue reading >>
Treatment Of Diabetic Ketoacidosis (dka)/hyperglycemic Hyperosmolar State (hhs): Novel Advances In The Management Of Hyperglycemic Crises (uk Versus Usa)
Go to: Diabetic Ketoacidosis Prior to the discovery and isolation of insulin in 1922 by Banting and Best, type 1 diabetes was universally fatal within a few months of initial diagnosis. Once mass production was started, the challenge to those early pioneers of insulin treatment was learning how to use this new wonder drug, e.g., how much to give and how often to give it, in order to treat the hyperglycemia without raising the inherent risk of hypoglycemia. In 1945, Howard Root in Boston described how they had improved the outcomes for people with diabetic ketoacidosis (DKA), reducing mortality to 12% by 1940 and to 1.6% by 1945 using high doses of insulin—giving an average of 83 units within the first 3 h of treatment in 1940 and 216 units by 1945 [3]. They described how in 1945, they used an average of 287 units in the first 24 h, but this ranged from 50 to 1770 units [3]. In Birmingham, UK, high-dose insulin was also being used with similar success—doses varying depending on the degree of consciousness, with those unarousable on admission given doses between 500 and 1400 units per 24 h [4]. DKA remains a medical emergency; over time, mortality has continued to fall but remains a significant risk, especially amongst the young, socially isolated and when care provision is fragmented [5•, 6•]. Overall, the diagnosis and treatment of DKA are very similar in the UK and USA with a few differences. The UK has separate guidelines on the management of DKA [7], while the USA has a position statement on DKA and HHS that was updated in 2009 [8]. The UK guideline differs in several ways from the US position statement. The concept of low-dose intravenous insulin was established in the late 1960s and early 1970s by teams on both sides of the Atlantic. The UK championed the u Continue reading >>
Hyperglycemic Crises: Diabetic Ketoacidosis (dka), And Hyperglycemic Hyperosmolar State (hhs)
Go to: Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management is key to the successful resolution of DKA and HHS. Critical components of the hyperglycemic crises management include coordinating fluid resuscitation, insulin therapy, and electrolyte replacement along with the continuous patient monitoring using available laboratory tools to predict the resolution of the hyperglycemic crisis. Understanding and prompt awareness of potential of special situations such as DKA or HHS presentation in comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA, and risk of brain edema during the therapy are important to reduce the risks of complications without affecting recovery from hyperglycemic crisis. Identification of factors that precipitated DKA or HHS during the index hospitalization should help prevent subsequent episode of hyperglycemic crisis. For extensive review of all related areas of Endocrinology, visit WWW.ENDOTEXT.ORG. Go to: INTRODUCTION Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) represent two extremes in the spectrum of decompensated diabetes. DKA and HHS remain important causes of morbidity and mortality among diabetic patients despite well developed diagnostic criteria and treatment protocols (1). The annual incidence of DKA from population-based studies is estimated to range from 4 to 8 episodes per 1,000 patient admissions with diabetes (2). The incidence of DKA continues to increase and it accounts for about 140,000 hospitalizations in the US in 2009 (Figure 1 a) (3). Continue reading >>
