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Acid–base Problems In Diabetic Ketoacidosis

Acid–base Problems In Diabetic Ketoacidosis

Disorders of Fluids and Electrolytes The case description below highlights issues raised in an upcoming article about acid–base disturbance and its clinical implications in patients with diabetic ketoacidosis in the series “Disorders of Fluids and Electrolytes.” A 15-year-old boy with nephrotic syndrome presented with abdominal pain and vomiting. Lab data include: blood glucose 849 mg/dL, blood pH 7.19, PCO2 18 mm Hg, PO2 40 mm Hg, bicarbonate 7 mmol/L, sodium 125 mmol/L, potassium 6.2 mmol/L, chloride 81 mmol/L, and total carbon dioxide 8 mmol/L. What is the best strategy to support this patient? Polling and commenting are now closed. The editor’s recommendations appear below. The next challenge appears on March 5. Share: A 15-year-old boy with a history of glucocorticoid-dependent nephrotic syndrome since 5 years of age arrives in a community emergency department because of chest pain and nausea that has progressed to abdominal pain over the preceding 16 hours. The nephrotic syndrome was in remission while the patient was receiving glucocorticoids and cyclosporine. The patient and his mother stated that he had become very thirsty and had been drinking huge amounts of water over the past week. On the day of admission, he had several episodes of vomiting. There was no fever, cough, rhinorrhea, or diarrhea, and no family member, friend, or associate had been ill. The patient’s usual medications at the time of presentation included prednisone (at a dose of 50 mg daily), cyclosporine (125 mg twice daily), enalapril (10 mg daily), and ranitidine (75 mg daily). In addition, treatment with recombinant human growth hormone had been initiated for glucocorticoid-induced short stature. The patient and his family said that the urinary albumin level had been negative on a Continue reading >>

Blood Ketones

Blood Ketones

On This Site Tests: Urine Ketones (see Urinalysis - The Chemical Exam); Blood Gases; Glucose Tests Elsewhere On The Web Ask a Laboratory Scientist Your questions will be answered by a laboratory scientist as part of a voluntary service provided by one of our partners, the American Society for Clinical Laboratory Science (ASCLS). Click on the Contact a Scientist button below to be re-directed to the ASCLS site to complete a request form. If your question relates to this web site and not to a specific lab test, please submit it via our Contact Us page instead. Thank you. Continue reading >>

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Snap Shot A 12 year old boy, previously healthy, is admitted to the hospital after 2 days of polyuria, polyphagia, nausea, vomiting and abdominal pain. Vital signs are: Temp 37C, BP 103/63 mmHg, HR 112, RR 30. Physical exam shows a lethargic boy. Labs are notable for WBC 16,000, Glucose 534, K 5.9, pH 7.13, PCO2 is 20 mmHg, PO2 is 90 mmHg. Introduction Complication of type I diabetes result of ↓ insulin, ↑ glucagon, growth hormone, catecholamine Precipitated by infections drugs (steroids, thiazide diuretics) noncompliance pancreatitis undiagnosed DM Presentation Symptoms abdominal pain vomiting Physical exam Kussmaul respiration increased tidal volume and rate as a result of metabolic acidosis fruity, acetone odor severe hypovolemia coma Evaluation Serology blood glucose levels > 250 mg/dL due to ↑ gluconeogenesis and glycogenolysis arterial pH < 7.3 ↑ anion gap due to ketoacidosis, lactic acidosis ↓ HCO3- consumed in an attempt to buffer the increased acid hyponatremia dilutional hyponatremia glucose acts as an osmotic agent and draws water from ICF to ECF hyperkalemia acidosis results in ICF/ECF exchange of H+ for K+ moderate ketonuria and ketonemia due to ↑ lipolysis β-hydroxybutyrate > acetoacetate β-hydroxybutyrate not detected with normal ketone body tests hypertriglyceridemia due to ↓ in capillary lipoprotein lipase activity activated by insulin leukocytosis due to stress-induced cortisol release H2PO4- is increased in urine, as it is titratable acid used to buffer the excess H+ that is being excreted Treatment Fluids Insulin with glucose must prevent resultant hypokalemia and hypophosphatemia labs may show pseudo-hyperkalemia prior to administartion of fluid and insulin due to transcellular shift of potassium out of the cells to balance the H+ be Continue reading >>

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Diabetic ketoacidosis is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. Hyperglycemia causes an osmotic diuresis with significant fluid and electrolyte loss. DKA occurs mostly in type 1 diabetes mellitus (DM). It causes nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death. DKA is diagnosed by detection of hyperketonemia and anion gap metabolic acidosis in the presence of hyperglycemia. Treatment involves volume expansion, insulin replacement, and prevention of hypokalemia. Diabetic ketoacidosis (DKA) is most common among patients with type 1 diabetes mellitus and develops when insulin levels are insufficient to meet the body’s basic metabolic requirements. DKA is the first manifestation of type 1 DM in a minority of patients. Insulin deficiency can be absolute (eg, during lapses in the administration of exogenous insulin) or relative (eg, when usual insulin doses do not meet metabolic needs during physiologic stress). Common physiologic stresses that can trigger DKA include Some drugs implicated in causing DKA include DKA is less common in type 2 diabetes mellitus, but it may occur in situations of unusual physiologic stress. Ketosis-prone type 2 diabetes is a variant of type 2 diabetes, which is sometimes seen in obese individuals, often of African (including African-American or Afro-Caribbean) origin. People with ketosis-prone diabetes (also referred to as Flatbush diabetes) can have significant impairment of beta cell function with hyperglycemia, and are therefore more likely to develop DKA in the setting of significant hyperglycemia. SGLT-2 inhibitors have been implicated in causing DKA in both type 1 and type 2 DM. Continue reading >>

Venous Blood Gases And Other Alternatives To Arterial Blood Gases

Venous Blood Gases And Other Alternatives To Arterial Blood Gases

INTRODUCTION An arterial blood gas (ABG) is the traditional method of estimating the systemic carbon dioxide tension and pH, usually for the purpose of assessing ventilation and/or acid-base status. However, the necessary sample of arterial blood can be difficult to obtain due to diminished pulses or patient movement. Diminished pulses may reflect poor peripheral circulation or low blood pressure, while patient movement is frequently caused by the pain associated with arterial puncture. A venous blood gas (VBG) is an alternative method of estimating systemic carbon dioxide and pH that does not require arterial blood sampling. Performing a VBG rather than an ABG is particularly convenient in the intensive care unit, since many patients have a central venous catheter from which venous blood can be quickly and easily obtained. The sites from which venous blood can be sampled, measurements that can be performed on venous blood, and correlation of venous measurements with arterial measurements are reviewed here. Other alternatives to ABGs for estimating systemic carbon dioxide and pH are also described, including end-tidal carbon dioxide and transcutaneous carbon dioxide. ABGs, capnography, and mechanisms of oxygenation are reviewed separately. (See "Arterial blood gases" and "Carbon dioxide monitoring (capnography)" and "Oxygenation and mechanisms of hypoxemia".) VENOUS BLOOD GASES Sampling sites — A VBG can be performed using: A peripheral venous sample (obtained by venipuncture) Continue reading >>

(pdf) Predictive Value Of Capnography For Suspected Diabetic Ketoacidosis In The Emergency Department

(pdf) Predictive Value Of Capnography For Suspected Diabetic Ketoacidosis In The Emergency Department

All content in this area was uploaded by Hassan Soleimanpour eScholarship provides open access, scholarly publishing services to the University of California and delivers a dynamic Predictive Value of Capnography for Diagnosis in Patients with Suspected Diabetic Ketoacidosis Western Journal of Emergency Medicine, Articles In Press Soleimanpour, Hassan, Cardiovascular Research Center, Tabriz University of Medical Sciences, Taghizadieh, Ali, Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Niafar, Mitra, Bone Research Center, Endocrine Section, Imam Reza Medical Research & Training Rahmani, Farzad, Students Research Committee, Tabriz University of Medical Sciences, Tabriz, Golzari, Samad EJ, 1- Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran 2-Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. Mehdizadeh Esfanjani, Robab, Neurosciences Research Center, Tabriz University of Medical Western Journal of Emergency Medicine, Department of Emergency Medicine (UCI), UC Irvine The authors are grateful to all the health personnel and patients who participated in the study, in addition to the data collectors, supervisors and administrative staff of Emergency Department of Imam Reza Hospital. Special thanks to Research Vice Chancellor Tabriz University of Medical Sciences for all the material and financial support in our study. This article was written based on a dataset of MD thesis, registered in Tabriz University of Medical Sciences. Associate Professor of Anesthesiology and Critical Care at the Department of Emergency Medicine, Tabriz University of Medical Sciences, Tabriz, Iran. Fellowship in Trauma Critical Care and CPR, MD. Editorial board mem Continue reading >>

Anion Gap In Diabetes Ketoacidosis

Anion Gap In Diabetes Ketoacidosis

When I left the Cardiac-Surgical ICU to go to a Medical Cardiac ICU at a Level I Trauma center, it was a big change for me. It was a whole new regime of policies, protocols, and procedures. And, it was a big chance for growth for me as a nurse. I remember one of the first patients I had when I got to the new unit. I was caring for a DKA patient and the doctors continually asking me has her gap closed? I thought to myself, What the heck are they talking about? Diabetic ketoacidosis is an EMERGENCY! It must be treated as quickly as possible to prevent coma and/or death. The patients insulin needs are unable to match their insulin supply. The body metabolizes glucose for energy, so it begins to metabolize fats and acids, which in turn, create ketones. The ketones create keto acids, which create a state of acidosis. Watch this video for an in-depth conversation about DKA: Irregular pattern of deep & rapid breathing. Patients are trying to blow off CO2 to lower acid levels DKA can often be the first manifestation of Type 1 diabetes. Chronic hyperglycemia causes damage to tissues & organs over time. The body can (for the most part) tolerate and compensate while the person is young. Additionally, younger people and children burn more calories (thus, lowering their glucose levels) than adults due to: What converts the person from a state of tolerance to a state of DKA, is an injury. Injuries are not just a physical injury like a cut or something, but any type of injury which causes the body to develop a stress response to repair itself, like infection. An Anion Gap is the difference between the measured cations and anions in the serum. There are some formulas where potassium is not added to the sodium. The rational behind that is potassium is usually a small number and may not 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 >>

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Diabetic ketoacidosis is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. Hyperglycemia causes an osmotic diuresis with significant fluid and electrolyte loss. DKA occurs mostly in type 1 diabetes mellitus (DM). It causes nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death. DKA is diagnosed by detection of hyperketonemia and anion gap metabolic acidosis in the presence of hyperglycemia. Treatment involves volume expansion, insulin replacement, and prevention of hypokalemia. Diabetic ketoacidosis (DKA) is most common among patients with type 1 diabetes mellitus and develops when insulin levels are insufficient to meet the body’s basic metabolic requirements. DKA is the first manifestation of type 1 DM in a minority of patients. Insulin deficiency can be absolute (eg, during lapses in the administration of exogenous insulin) or relative (eg, when usual insulin doses do not meet metabolic needs during physiologic stress). Common physiologic stresses that can trigger DKA include Some drugs implicated in causing DKA include DKA is less common in type 2 diabetes mellitus, but it may occur in situations of unusual physiologic stress. Ketosis-prone type 2 diabetes is a variant of type 2 diabetes, which is sometimes seen in obese individuals, often of African (including African-American or Afro-Caribbean) origin. People with ketosis-prone diabetes (also referred to as Flatbush diabetes) can have significant impairment of beta cell function with hyperglycemia, and are therefore more likely to develop DKA in the setting of significant hyperglycemia. SGLT-2 inhibitors have been implicated in causing DKA in both type 1 and type 2 DM. Continue reading >>

Exam Shows Diffuse Abdominal Tenderness With Guarding.

Exam Shows Diffuse Abdominal Tenderness With Guarding.

A 14 y/o female is brought to the emergency department by her mother after being found unresponsive at home. She had been ill the day before with nausea and vomiting, but was not running a fever. Her parents had kept her home from school that day. When her mother came home at lunchtime to check on her, she was very lethargic and not responding coherently. By the time she arrived at the hospital, she had to be brought in to the ED on a gurney. Initial evaluation showed O2 sat 100% on room air, pulse 126, respirations 30, BP 92/68, temperature 101.2 F. She appears pale, mucous membranes are dry and she only responds to painful stimuli. Exam shows diffuse abdominal tenderness with guarding. Differential diagnosis? What initial treatment would you suggest? What labs would you order? Any xrays or additional studies? CBC WBC 23,500 Hgb 14.2 g/dL Hct 45% Platelets 425,000 BMP Sodium 126 Potassium 5.2 Chloride 87 CO2 <5 BUN 32 Creatinine 1.5 Glucose 1,376 Arterial Blood Gases pH 7.19 Po2 100 mm Hg HCO3 7.5 mmo/L Pco2 20 mm Hg Sao2 98% (room air) Urine Specific gravity 1.015 Ketones 4+ Leukocytes few Glucose 4+ Nitrates 0 RBCs many Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. DKA occurs mostly in type 1 diabetics. It causes nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death. DKA is diagnosed by detection of hyperketonemia and anion gap metabolic acidosis in the presence of hyperglycemia. Treatment involves volume expansion, insulin replacement, and prevention of hypokalemia. Symptoms and signs of DKA Nausea & vomiting Abdominal pain--particularly in children Lethargy and somnolence Kussmaul respirations Hypotension Tachycardia Fruity breath Continue reading >>

Co2 Blood Test

Co2 Blood Test

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Arterial Blood Gases (blood Gases), Acidosis And Alkalosis

Arterial Blood Gases (blood Gases), Acidosis And Alkalosis

Sample The better choice is the Radial artery. The sample may be taken from the femoral artery or brachial. The tests are done immediately because oxygen and carbon dioxide are unstable. Arterial blood is better than the venous blood. For arterial blood don't use the tourniquet and no pull on the syringe plunger. For venous blood syringe or tubes are completely filled and apply a tourniquet for few seconds. Arterial VS Venous blood Arterial blood gives good mixture of blood from various areas of the body. Venous blood gives information of the local area from where the blood sample is taken. Metabolism of the extremity varies from area to area. Arterial blood measurement gives the better status of the lung oxygenating the blood. Arterial blood gives information about the ability of the lung to regulate the acid-base balance through retention or release of CO2. Precautions for the collection of blood Avoid pain and anxiety to the patient which will lead to hyperventilation. Hyperventilation due to any cause leads to decreased CO2 and increased pH. Keep blood cool during transit. Don't clench finger or fist. This will leads to lower CO2 and increased acid metabolites. pCO2 values are lower in the sitting or standing position in comparison with the supine position. Don't delay the performance of the test. Avoid air bubbles in the syringe. Excess of heparin decreases the pCO2 may be 40% less. Not proper mixing of the blood before running the test. Purpose of the test This test is done on the mostly hospitalized patient. Mostly the patients are on ventilator or unconscious. For patients in pulmonary distress. To assess the metabolic (renal) acid-base and electrolytes imbalance. Its primary use is to monitor arterial blood gases and pH of blood. Also used to monitor oxygenatio Continue reading >>

An Error Occurred Setting Your User Cookie

An Error Occurred Setting Your User Cookie

An Error Occurred Setting Your User Cookie This site uses cookies to improve performance. If your browser does not accept cookies, you cannot view this site. There are many reasons why a cookie could not be set correctly. Below are the most common reasons: You have cookies disabled in your browser. You need to reset your browser to accept cookies or to ask you if you want to accept cookies. Your browser asks you whether you want to accept cookies and you declined. To accept cookies from this site, use the Back button and accept the cookie. Your browser does not support cookies. Try a different browser if you suspect this. The date on your computer is in the past. If your computer's clock shows a date before 1 Jan 1970, the browser will automatically forget the cookie. To fix this, set the correct time and date on your computer. You have installed an application that monitors or blocks cookies from being set. You must disable the application while logging in or check with your system administrator. This site uses cookies to improve performance by remembering that you are logged in when you go from page to page. To provide access without cookies would require the site to create a new session for every page you visit, which slows the system down to an unacceptable level. This site stores nothing other than an automatically generated session ID in the cookie; no other information is captured. In general, only the information that you provide, or the choices you make while visiting a web site, can be stored in a cookie. For example, the site cannot determine your email name unless you choose to type it. Allowing a website to create a cookie does not give that or any other site access to the rest of your computer, and only the site that created the cookie can read it. Continue reading >>

Co2 Blood Test

Co2 Blood Test

What is a CO2 blood test? A CO2 blood test measures the amount of carbon dioxide (CO2) in the blood serum, which is the liquid part of blood. A CO2 test may also be called: a carbon dioxide test a TCO2 test a total CO2 test bicarbonate test an HCO3 test a CO2 test-serum You may receive a CO2 test as a part of a metabolic panel. A metabolic panel is a group of tests that measures electrolytes and blood gases. The body contains two major forms of CO2: HCO3 (bicarbonate, the main form of CO2 in the body) PCO2 (carbon dioxide) Your doctor can use this test to determine if there’s an imbalance between the oxygen and carbon dioxide in your blood or a pH imbalance in your blood. These imbalances can be signs of a kidney, respiratory, or metabolic disorder. Blood gas test » Your doctor will order a CO2 blood test based on your symptoms. Signs of an imbalance of oxygen and carbon dioxide or a pH imbalance include: shortness of breath other breathing difficulties nausea vomiting These symptoms may point to lung dysfunction involving the exchange between oxygen and carbon dioxide. You will need to have your blood’s oxygen and carbon dioxide levels measured frequently if you’re on oxygen therapy or having certain surgeries. Blood samples for a CO2 blood test may be taken from either a vein or an artery. Venipuncture blood sample Venipuncture is the term used to describe a basic blood sample taken from a vein. Your doctor will order a simple venipuncture blood sample if they only want to measure HCO3. To get a venipuncture blood sample, a healthcare provider: cleans the site (often the inside of the elbow) with a germ-killing antiseptic wraps an elastic band around your upper arm to cause the vein to swell with blood gently inserts a needle into the vein and collect blood in Continue reading >>

Vbg Versus Abg

Vbg Versus Abg

OVERVIEW Venous blood gases (VBG) are widely used in the emergency setting in preference to arterial blood gases (ABG) as a result of research published since 2001 The weight of data suggests that venous pH has sufficient agreement with arterial pH for it to be an acceptable alternative in clinical practice for most patients Nevertheless acceptance of this strategy has been limited by some specialties and maybe inappropriate in some settings; for instance there is no data to confirm that this level of agreement is maintained in shock states or mixed acid-base disturbances Clinically acceptable limits of agreement for blood gas parameters remains poorly defined ARTERIAL BLOOD GAS PROS AND CONS Advantages gold standard test for determining the arterial metabolic millieu (pH, PaCO2, HCO3) can determine PaO2 Disadvantages pH, PCO2 (if normocapnic), HCO3 and base excess from a VBG are usually adequate for clinical decision making SpO2 is usually sufficient for clinical decision making unless pulse oximetry is unreliable for other reasons (e.g. shock state, poor pick up) painful (should be performed with local anaesthetic in conscious patients) increased risk of bleeding and hematoma risk of pseudo aneurysm and AV fistula infection nerve injury digital ischemia injury to staff delays in care serial exams may be needed venous sampling may better represent the tissue milieu CORRELATION BETWEEN VBG AND ABG pH Good correlation pooled mean difference: +0.035 pH units pCO2 good correlation in normocapnia non-correlative in severe shock 100% sensitive in detecting arterial hypercarbia in COPD exacerbations using cutoff of PaCO2 45 mmHg and laboratory based testing (McCanny et al, 2012), i.e. if VBG PCO2 is normal then hypercapnia ruled out (PaCO2 will be normal), though this conflic Continue reading >>

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