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Dka Vs Hhs Differences

Question.... For Step 3 - Usmle Forum

Question.... For Step 3 - Usmle Forum

Hyperosmolar hyperglycemic nonketotic coma (HHNC) is a metabolic derangement that occurs principally in patients with adult-onset diabetes. The condition is characterized by hyperglycemia, hyperosmolarity, and an absence of significant ketosis Diabetic ketoacidosis (DKA) is a state of absolute or relative insulin deficiency aggravated by ensuing hyperglycemia, dehydration, and acidosis-producing derangements in intermediary metabolism. The most common causes are underlying infection, disruption of insulin treatment, and new onset of diabetes. DKA is typically characterized by hyperglycemia over 300 mg/dL, low bicarbonate (<15 mEq/L), and acidosis (pH <7.30) with ketonemia and ketonuria i mean how u make differnce in diagnosis DKA and HHS differ in presentation. If physical examination reveals dehydration along with a high capillary blood glucose level with or without urine or increased plasma ketone bodies, acute diabetic decompensation should be strongly suspected. A definitive diagnosis of DKA or HHS must be confirmed through laboratory investigation. The clinical presentation can provide helpful information for the preliminary bedside diagnosis.15 DKA usually occurs in younger, lean patients with type 1 diabetes and develops within a day or so, whereas HHS is more likely to occur in older, obese patients with type 2 diabetes and can take days or weeks to fully develop. In addition, HHS usually occurs in elderly diabetic patients, often those with decreased renal function who do not have access to water.16 Both DKA and HHS often present with polyuria and polydypsia, although polydypsia may be absent in elderly patients with HHS. In both conditions, abdominal pain with nausea and vomiting can develop owing to acidosis per se or to decreased mesenteric perfusion and ca Continue reading >>

Hyperosmolar Non Ketotic Hypergycaemic Coma (honk) - Deranged Physiology

Hyperosmolar Non Ketotic Hypergycaemic Coma (honk) - Deranged Physiology

Hyperosmolar Non Ketotic Hypergycaemic Coma (HONK) Though a distinction is being made between diabetic ketoacidosis and HONK, the two really form a part of the same disease spectrum. Some ketoacidosis is present in HONK, and some hyperosmolarity is present in DKA. However, different mechanisms are at play. HONK is distinct form DKA, and the distinction is not entirely arbitrary, at least from the management point of view. For instance, even though the conditions co-exist 30% of the time, it is possible to treat pure HONK without any supplemental insulin (because there is a satisfactory amount of it in circulation already).DKA is 3 times more common, but HONK has 3 times greater mortality. The chapter on DKA presents a table of discriminating features to help distinguish HONK from DKA. Past CICM SAQs involving HONk have included the following: Question 24 from the first paper of 2017 (management strategy) Question 1 from the second paper of 2016 (DKA vs HONK) Question 17 from the first paper of 2014 (DKA vs HONK) Question 18.1 from the second paper of 2008 (diagnosis and complications) Question 13 from the first paper of 2002 (pathophysiology, complications and treatment) Similarly to DKA, a stress response which mobilises metabolic substrates in a Type 2 diabetic will result in HONK. Precipitating Factors for Hyperosmolar Hyperglycaemia The key distinction between DKA and HONK seems to be the fact that in HONk, there is still enough insulin to overcome the ketogenic effects of glucagon. Glucagon inhibits acetyl-CoA carboxylase, which normally converts acetyl-CoA into malonyl-CoA. Malonyl CoA inhibits acyl-carnitine synthesis; if this is uninhibited, it results in a stream of fatty acids being sucked up into the mitochondria to be converted into ketones. Thus, we have a Continue reading >>

Hyperosmolar Hyperglycemic State

Hyperosmolar Hyperglycemic State

Hyperosmolar hyperglycemic state (HHS) is a complication of diabetes mellitus in which high blood sugar results in high osmolarity without significant ketoacidosis.[4] Symptoms include signs of dehydration, weakness, legs cramps, trouble seeing, and an altered level of consciousness.[2] Onset is typically over days to weeks.[3] Complications may include seizures, disseminated intravascular coagulopathy, mesenteric artery occlusion, or rhabdomyolysis.[2] The main risk factor is a history of diabetes mellitus type 2.[4] Occasionally it may occur in those without a prior history of diabetes or those with diabetes mellitus type 1.[3][4] Triggers include infections, stroke, trauma, certain medications, and heart attacks.[4] Diagnosis is based on blood tests finding a blood sugar greater than 30 mmol/L (600 mg/dL), osmolarity greater than 320 mOsm/kg, and a pH above 7.3.[2][3] Initial treatment generally consists of intravenous fluids to manage dehydration, intravenous insulin in those with significant ketones, low molecular weight heparin to decrease the risk of blood clotting, and antibiotics among those in whom there is concerns of infection.[3] The goal is a slow decline in blood sugar levels.[3] Potassium replacement is often required as the metabolic problems are corrected.[3] Efforts to prevent diabetic foot ulcers are also important.[3] It typically takes a few days for the person to return to baseline.[3] While the exact frequency of the condition is unknown, it is relatively common.[2][4] Older people are most commonly affected.[4] The risk of death among those affected is about 15%.[4] It was first described in the 1880s.[4] Signs and symptoms[edit] Symptoms of high blood sugar including increased thirst (polydipsia), increased volume of urination (polyurea), and i Continue reading >>

Dka Vs Hhs (hhns) Nclex Review

Dka Vs Hhs (hhns) Nclex Review

Diabetic ketoacidosis vs hyperglycemic hyperosmolar nonketotic syndrome (HHNS or HHS): What are the differences between these two complications of diabetes mellitus? This NCLEX review will simplify the differences between DKA and HHNS and give you a video lecture that easily explains their differences. Many students get these two complications confused due to their similarities, but there are major differences between these two complications. After reviewing this NCLEX review, don’t forget to take the quiz on DKA vs HHNS. Lecture on DKA and HHS DKA vs HHNS Diabetic Ketoacidosis Affects mainly Type 1 diabetics Ketones and Acidosis present Hyperglycemia presents >300 mg/dL Variable osmolality Happens Suddenly Causes: no insulin present in the body or illness/infection Seen in young or undiagnosed diabetics Main problems are hyperglycemia, ketones, and acidosis (blood pH <7.35) Clinical signs/symptoms: Kussmaul breathing, fruity breath, abdominal pain Treatment is the same as in HHNS (fluids, electrolyte replacement, and insulin) Watch potassium levels closely when giving insulin and make sure the level is at least 3.3 before administrating. Hyperglycemic Hyperosmolar Nonketotic Syndrome Affects mainly Type 2 diabetics No ketones or acidosis present EXTREME Hyperglycemia (remember heavy-duty hyperglycemia) >600 mg/dL sometimes four digits High Osmolality (more of an issue in HHNS than DKA) Happens Gradually Causes: mainly illness or infection and there is some insulin present which prevents the breakdown of ketones Seen in older adults due to illness or infection Main problems are dehydration & heavy-duty hyperglycemia and hyperosmolarity (because the glucose is so high it makes the blood very concentrated) More likely to have mental status changes due to severe dehydrat Continue reading >>

Diabetic Ketoacidosis And Hyperosmolar Hyperglycemic State In Adults: Clinical Features, Evaluation, And Diagnosis

Diabetic Ketoacidosis And Hyperosmolar Hyperglycemic State In Adults: Clinical Features, Evaluation, And Diagnosis

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. DKA is characterized by ketoacidosis and hyperglycemia, while HHS usually has more severe hyperglycemia but no ketoacidosis (table 1). Each represents an extreme in the spectrum of hyperglycemia. The precipitating factors, clinical features, evaluation, and diagnosis of DKA and HHS in adults will be reviewed here. The epidemiology, pathogenesis, and treatment 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".) Continue reading >>

Dka And Hhs Flashcards | Quizlet

Dka And Hhs Flashcards | Quizlet

synthesis of NEW glucose (not from storage) from the liver and skeletal muscle; occurs during prolonged fasting and glycogen depletion; alanine, glycerol and lactate are precursors occurs in 'fed' state when high amounts of glucose and ATP are available Where/when is insulin synthesized/released? How is it innervated? inhibits glycogenolysis and gluconeogenesis; increases glucose transport into fat and muscle; Where/when is glucagon synthesized/released? How is it innervated? What does the release of glucagon do? (4) stimulation of amino acid uptake into liver; inhibition of glycolysis and fatty acid synthesis diabetic ketoacidosis: absence of insulin causing an increase in glucose and fatty acid breakdown with subsequent hyperglycemia and metabolic acidosis; gluconeogenesis and ketogenesis hyperosmolar hyperglycemic state: reduced insulin causing drastically elevated glucose levels and hyperosmolarity leading to severe volume depletion without acidosis A --> metabolic acidosis with increased anion gap (HCO3- <15; pH <7.3; anion gap >12) What are types of ketoacidosis? What is the major difference between them? starvation: requires 3-14 days of starvation; acidosis remains minimal (~7.3 at worst) alcoholic: chronic alcohol intake + fasting; severe acidosis (pH ~7) What causes dehydration and electrolyte deficiencies? hyperglycemia causes an increase in serum osmolarity; osmotic diuresis leads to excess water/electrolyte loss and potential for renal injury ketone testing: positive for ketones in serum or urine suggest DKA serum beta hydroxybutyrate (BHB) level: increase from 1:1 to 10:1 of BHB: acetoacetate; >3 mmol/L shows ketoacidosis What are differences between DKA and HHS? expansion of intravascular and intracellular volume What is the replacement rate for fluids? Continue reading >>

Hyperosmolar Hyperglycemic State

Hyperosmolar Hyperglycemic State

Author: Dipa Avichal, DO; Chief Editor: George T Griffing, MD more... Hyperosmolar hyperglycemic state (HHS) isone of two serious metabolic derangements that occurs in patients with diabetes mellitus (DM). [ 1 ] It is alife-threatening emergency that, although less common than its counterpart, diabetic ketoacidosis (DKA), has a much higher mortality rate, reaching up to 5-10%. (See Epidemiology.) HHS was previously termed hyperosmolar hyperglycemic nonketotic coma (HHNC); however, the terminology was changed because coma is found in fewer than 20% of patients with HHS. [ 2 ] HHS is most commonly seen in patients with type 2DM who have some concomitant illness that leads to reduced fluid intake, as seen, for example, in elderly institutionalizedpersons with decreased thirst perception andreduced ability to drink water. [ 3 ] Infection is the most common preceding illness, but many other conditions, such as stroke or myocardial infarction, can cause this state. [ 3 ] Once HHS has developed, it may be difficult to identify or differentiate it from the antecedent illness. (See Etiology.) HHS is characterized by hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis. Most patients present with severe dehydration and focal or global neurologic deficits. [ 2 , 4 , 5 ] The clinical features of HHS and DKA overlap and are observed simultaneously (overlap cases) in up toone thirdof cases. According to the consensus statement published by the American Diabetes Association, diagnostic features of HHS may include the following (see Workup) [ 4 , 6 ] : Plasma glucose level of 600 mg/dL or greater Effective serum osmolality of 320 mOsm/kg or greater Profound dehydration, up to an average of 9L Bicarbonate concentration greater than 15 mEq/L Small ketonuria a Continue reading >>

Difference Between Dka And Hhs

Difference Between Dka And Hhs

DKA vs HHS “DKA” means “diabetic ketoacidosis” and “HHS” means “Hyperosmolar Hyperglycemic Syndrome.” Both DKA and HHS are the two complications of diabetes mellitus. Though there are many differences between DKA and HHS, the basic problem is associated with insulin deficiency. When comparing the two, HHS has a higher mortality rate. When DKA has a mortality rate of 2 to 5 per cent, HHS has a 15 per cent mortality rate. Diabetic ketoacidosis is seen mainly in type 1 diabetic patients but is also seen in some type 2 diabetic patients. Hyperosmolar Hyperglycemic Syndrome is mainly seen in older patients having type 2 diabetes. DKA is mainly characterized by hyperglycemia, acidosis-producing derangements, and dehydration. Infection, disruption of insulin, and onset of diabetes are some of the common causes of DKA. Hyperglycemia, dehydration and hyperosmolarity are some of the common characteristics of Hyperosmolar Hyperglycemic Syndrome. But HHS does not have ketoacidosis. Some of the early symptoms of diabetic ketoacidosis include increased thirst and increased urination. Other symptoms include malaise, weakness, and fatigue. Bacterial infection, illness, insulin deficiency, stress, and insulin infusion catheter blockage are some of the causes that lead to DKA. When compared to diabetic ketoacidosis, the Hyperosmolar Hyperglycemic Syndrome develops only over the course of a week. Diabetic ketoacidosis develops rapidly. Increased dehydration, acute illness, vomiting, dementia, pneumonia, immobility, and urinary tract infections are some of the common causes of Hyperosmolar Hyperglycemic Syndrome. One of the main goals of treatment of DKA involves correcting high blood glucose levels by injecting insulin as well as replacing fluid lost because of vomiting an Continue reading >>

Diabetic Emergencies, Diagnosis And Clinical Management: Hyperosmolar Non-ketotic Hyperglycemia, Part 1

Diabetic Emergencies, Diagnosis And Clinical Management: Hyperosmolar Non-ketotic Hyperglycemia, Part 1

Konstantinos Makrilakis, MD, PhD Nikolaos Katsilambros, MD, PhD. Hyperosmolar non-ketotic hyperglycemia (also called hyperosmolar hyperglycemic state [HHS]) is one of the most serious acute complications of diabetes, with significant morbidity and mortality. Together with diabetic ketoacidosis (DKA) it represents an extreme in the spectrum of hyperglycemic states, and in fact significant overlap between these two conditions has been reported in more than one third of cases.1…. HHS is characterized by usually extreme hyperglycemia (serum glucose >600 mg/dl [33.3 mmol/L]), hyperosmolality, and profound dehydration, without significant ketoacidosis.2 The essential difference from DKA is that in HHS there is little or no ketoacid accumulation (most patients with HHS have an admission pH >7.30, a serum bicarbonate >18 mEq/L, and test negative for ketones in serum and urine, although mild ketonemia may be present); the serum glucose concentration is usually much higher (frequently exceeding 1000 mg/dl [56 mmol/L]); the plasma osmolality is high (it may reach 380 mOsm/kg); and neurological abnormalities are frequently present (including coma in 25-50% of cases). Summary box HHS is usually characterized by: extreme hyperglycemia (serum glucose >600 mg/dl [33.3 mmol/L]) hyperosmolality (serum osmolality >320 mOsm/kg H 2 O) profound dehydration lack of significant ketoacidosis HHS is most commonly seen in older individuals (> 65 years of age) with Type 2 diabetes. 4 The incidence of HHS is difficult to determine because of the lack of population-based studies and the multiple combined illnesses often found in these patients. In general, it is estimated that the rate of hospital admissions due to HHS is lower than the rate due to DKA and accounts for <1% of all primary diabetic Continue reading >>

Diabetic Hyperglycemic Hyperosmolar Syndrome

Diabetic Hyperglycemic Hyperosmolar Syndrome

HHS is a condition of: Extremely high blood sugar (glucose) level Decreased alertness or consciousness (in many cases) Buildup of ketones in the body (ketoacidosis) may also occur. But it is unusual and is often mild compared with diabetic ketoacidosis. HHS is more often seen in people with type 2 diabetes who don't have their diabetes under control. It may also occur in those who have not been diagnosed with diabetes. The condition may be brought on by: Infection Other illness, such as heart attack or stroke Medicines that decrease the effect of insulin in the body Medicines or conditions that increase fluid loss Normally, the kidneys try to make up for a high glucose level in the blood by allowing the extra glucose to leave the body in the urine. But this also causes the body to lose water. If you do not drink enough water, or you drink fluids that contain sugar and keep eating foods with carbohydrates, the kidneys may become overwhelmed. When this occurs, they are no longer able to get rid of the extra glucose. As a result, the glucose level in your blood can become very high. The loss of water also makes the blood more concentrated than normal. This is called hyperosmolarity. It is a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances. This draws the water out of the body's other organs, including the brain. Risk factors include: Impaired thirst Limited access to water (especially in people with dementia or who are bedbound) Older age Poor kidney function Poor management of diabetes, not following the treatment plan as directed Stopping insulin or other medicines that lower glucose level Continue reading >>

Hyperosmolar Hyperglycemic State (hhs)

Hyperosmolar Hyperglycemic State (hhs)

By Erika F. Brutsaert, MD, Assistant Professor, Albert Einstein College of Medicine; Attending Physician, Montefiore Medical Center Hyperosmolar hyperglycemic state is a metabolic complication of diabetes mellitus (DM) characterized by severe hyperglycemia, extreme dehydration, hyperosmolar plasma, and altered consciousness. It most often occurs in type 2 DM, often in the setting of physiologic stress. HHS is diagnosed by severe hyperglycemia and plasma hyperosmolality and absence of significant ketosis. Treatment is IV saline solution and insulin. Complications include coma, seizures, and death. Hyperosmolar hyperglycemic state (HHSpreviously referred to as hyperglycemic hyperosmolar nonketotic coma [HHNK] and nonketotic hyperosmolar syndrome) is a complication of type 2 diabetes mellitus and has an estimated mortality rate of up to20%, which is significantly higher than the mortality for diabetic ketoacidosis (currently < 1%). It usually develops after a period of symptomatic hyperglycemia in which fluid intake is inadequate to prevent extreme dehydration due to the hyperglycemia-induced osmotic diuresis. Acute infections and other medical conditions Drugs that impair glucose tolerance (glucocorticoids) or increase fluid loss (diuretics) Serum ketones are not present because the amounts of insulin present in most patients with type 2 DM are adequate to suppress ketogenesis. Because symptoms of acidosis are not present, most patients endure a significantly longer period of osmotic dehydration before presentation, and thus plasma glucose (> 600 mg/dL [> 33.3 mmol/L]) and osmolality (> 320 mOsm/L) are typically much higher than in diabetic ketoacidosis (DKA). The primary symptom of HHS is altered consciousness varying from confusion or disorientation to coma, usually as Continue reading >>

Diabetic Ketoacidosis And Hyperosmolar Hyperglycemic State In Adults: Clinical Features, Evaluation, And Diagnosis

Diabetic Ketoacidosis And Hyperosmolar Hyperglycemic State In Adults: Clinical Features, Evaluation, And Diagnosis

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. DKA is characterized by ketoacidosis and hyperglycemia, while HHS usually has more severe hyperglycemia but no ketoacidosis (table 1). Each represents an extreme in the spectrum of hyperglycemia. The precipitating factors, clinical features, evaluation, and diagnosis of DKA and HHS in adults will be reviewed here. The epidemiology, pathogenesis, and treatment 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".) Continue reading >>

Hyperosmolar Hyperglycemic State (hhs)

Hyperosmolar Hyperglycemic State (hhs)

By Erika F. Brutsaert, MD, Assistant Professor, Albert Einstein College of Medicine; Attending Physician, Montefiore Medical Center Hyperosmolar hyperglycemic state is a metabolic complication of diabetes mellitus (DM) characterized by severe hyperglycemia, extreme dehydration, hyperosmolar plasma, and altered consciousness. It most often occurs in type 2 DM, often in the setting of physiologic stress. HHS is diagnosed by severe hyperglycemia and plasma hyperosmolality and absence of significant ketosis. Treatment is IV saline solution and insulin. Complications include coma, seizures, and death. Hyperosmolar hyperglycemic state (HHSpreviously referred to as hyperglycemic hyperosmolar nonketotic coma [HHNK] and nonketotic hyperosmolar syndrome) is a complication of type 2 diabetes mellitus and has an estimated mortality rate of up to20%, which is significantly higher than the mortality for diabetic ketoacidosis (currently < 1%). It usually develops after a period of symptomatic hyperglycemia in which fluid intake is inadequate to prevent extreme dehydration due to the hyperglycemia-induced osmotic diuresis. Acute infections and other medical conditions Drugs that impair glucose tolerance (glucocorticoids) or increase fluid loss (diuretics) Serum ketones are not present because the amounts of insulin present in most patients with type 2 DM are adequate to suppress ketogenesis. Because symptoms of acidosis are not present, most patients endure a significantly longer period of osmotic dehydration before presentation, and thus plasma glucose (> 600 mg/dL [> 33.3 mmol/L]) and osmolality (> 320 mOsm/L) are typically much higher than in diabetic ketoacidosis (DKA). The primary symptom of HHS is altered consciousness varying from confusion or disorientation to coma, usually as Continue reading >>

Treatment Of Diabetic Ketoacidosis (dka)/hyperglycemic Hyperosmolar State (hhs): Novel Advances In The Management Of Hyperglycemic Crises (uk Versus Usa)

Treatment Of Diabetic Ketoacidosis (dka)/hyperglycemic Hyperosmolar State (hhs): Novel Advances In The Management Of Hyperglycemic Crises (uk Versus Usa)

#The Author(s) 2017. This article is published with open access at Springerlink.com Purpose of Review Diabetic ketoacidosis (DKA) and hyper- glycemic hyperosmolar state (HHS) are diabetic emergencies that cause high morbidity and mortality. Their treatment dif- fers in the UK and USA. This review delineates the differ- ences in diagnosis and treatment between the two countries. Recent Findings Large-scale studies to determine optimal man- agement of DKA and HHS are lacking. The diagnosis of DKA is based on disease severity in the USA, which differs from the UK. The diagnosis of HHS in the USA is based on total rather than effective osmolality. Unlike the USA, the UK has separate guidelines for DKA and HHS. Treatment of DKA and HHS also differs with respect to timing of fluid and insulin initiation. Summary There is considerable overlap but important differ- ences between the UK and USA guidelines for the manage- ment of DKA and HHS. Further research needs to be done to delineate a unifying diagnostic and treatment protocol. Keywords Diabetic ketoacidosis .Management .Survey . Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are hyperglycemic emergencies that continue to account for increased burden of hospitaliza- tions in both the USA [1] and UK [2]. Historically, both DKA and HHS were initially described as one entity but subse- quently recognized as separate conditions. Since the advent of insulin, mortality has fallen for DKA and HHS, but the risk remains high. Previous work from the UK and seminal ran- domized controlled studies performed in the USA by Abbas Kitabchi form the basis of treatment of DKA and HHS. However, only a few of these were randomized studies to guide clinicians on the best way to manage DKA and HHS. Whilst the principles Continue reading >>

Acute Complications Of Diabetes - Hyperosmolar Hyperglycemic Nonketotic State

Acute Complications Of Diabetes - Hyperosmolar Hyperglycemic Nonketotic State

- [Voiceover] Diabetes mellitus and its associated complications are the 8th leading cause of death worldwide. Now normally we think of both type 1 and type 2 diabetes as being more chronic conditions that result in complications such as kidney disease and cardiovascular disease over years to decades. And this is true, but there are also a couple of very important acute complications of diabetes mellitus. And these are known as diabetic ketoacidosis, or DKA for short, and hyperosmolar hyperglycemic non-ketotic state, or HHNS for short. And unfortunately these acute complications can be very serious, especially HHNS, which has a mortality rate of eight to 20%. In this video, let's discuss hyperosmolar hyperglycemic non-ketotic state. Now the name hyperosmolar hyperglycemic non-ketotic state is pretty descriptive in regards to the metabolism that underlies the disease. However, it does not really describe the clinical presentation of the condition. So let's start with that. And most commonly, someone with HHNS has already been diagnosed with diabetes, and this occurs sometime after their initial diagnosis. And since they have diabetes, they likely will have hyperglycemia, which is one of the defining characteristics of diabetes mellitus. And as we'll discuss in just a minute, it's this hyperglycemia that's driving a lot of the events that are occurring in HHNS. Now over a period of days to weeks, someone with HHNS is gonna become pretty sick, and they're gonna have symptoms of fatigue, maybe some weight loss. They're gonna have extreme thirst and frequent urination. On physical exam they'll have signs of dehydration, such as a high heart rate, known as tachycardia, a low blood pressure known as hypotension, the mucus membranes in their mouth may be dry, and their skin may Continue reading >>

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