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How Does Ketoacidosis Cause Confusion

When There Are Acute Changes In Mental Status In Patients With Diabetes

When There Are Acute Changes In Mental Status In Patients With Diabetes

Author(s): Adam Lang, BS, and Kathleen Satterfield, DPM, FACFAOM As podiatric physicians in 2010, we are better trained than ever to manage patients’ problems. Even more importantly, we are well versed in making appropriate, well-timed referrals when needed. In the following case study, that particular acumen was critically important. A 78-year-old male with type 2 diabetes underwent resection of the first metatarsophalangeal base and debridement of an underlying ulcer, which has at times been infected. The plan was to inspect the bone for osteomyelitis, place the patient on oral antibiotics and not primarily close the plantar lesion, but pack it open instead. Resection of the phalangeal base would ease the deforming hallux interphalangeus. Examination revealed a hallux limitus and the physician determined that at the patient’s age and activity level, a Keller arthroplasty would serve him well, preventing further breakdown and possible osteomyelitis. The plantar lesion did not undergo primary closure but physicians packed it instead. The hospital discharged the patient within a week after bone cultures and histology showed no evidence of osteomyelitis. He received a prescription for oral antibiotics and received instruction to keep a clinic appointment in 48 hours. However, he was a no-show for his appointment. Phone calls to his home, all of which were documented, went unanswered over a period of two weeks. About a month after his discharge from the hospital, the patient went to the emergency department of the hospital accompanied by his wife. His extremity was in the same dressing he received upon preparation for discharge although now it was soiled and loose. His wife reported that they had never filled the prescription for antibiotics because they “did not und Continue reading >>

Understanding The Presentation Of Diabetic Ketoacidosis

Understanding The Presentation Of Diabetic Ketoacidosis

Hypoglycemia, diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) must be considered while forming a differential diagnosis when assessing and managing a patient with an altered mental status. This is especially true if the patient has a history of diabetes mellitus (DM). However, be aware that the onset of DKA or HHNS may be the first sign of DM in a patient with no known history. Thus, it is imperative to obtain a blood glucose reading on any patient with an altered mental status, especially if the patient appears to be dehydrated, regardless of a positive or negative history of DM. In addition to the blood glucose reading, the history — particularly onset — and physical assessment findings will contribute to the formulation of a differential diagnosis and the appropriate emergency management of the patient. Pathophysiology of DKA The patient experiencing DKA presents significantly different from one who is hypoglycemic. This is due to the variation in the pathology of the condition. Like hypoglycemia, by understanding the basic pathophysiology of DKA, there is no need to memorize signs and symptoms in order to recognize and differentiate between hypoglycemia and DKA. Unlike hypoglycemia, where the insulin level is in excess and the blood glucose level is extremely low, DKA is associated with a relative or absolute insulin deficiency and a severely elevated blood glucose level, typically greater than 300 mg/dL. Due to the lack of insulin, tissue such as muscle, fat and the liver are unable to take up glucose. Even though the blood has an extremely elevated amount of circulating glucose, the cells are basically starving. Because the blood brain barrier does not require insulin for glucose to diffuse across, the brain cells are rece Continue reading >>

The Scary Experience Of Diabetic Ketoacidosis

The Scary Experience Of Diabetic Ketoacidosis

Today, we’re excited to share with you another guest blog from Katie Janowiak, who works for the Medtronic Foundation, our company’s philanthropic arm. When she first told me her story about food poisoning and Diabetic Ketoacidosis (DKA), I knew others could benefit from hearing it as well. Thanks Katie for your openness and allowing us to share your scary story so that the LOOP community can learn from it. Throughout this past year, I’ve had the honor of sharing with you, the amazing LOOP community, my personal journey and the often humorous sequence of events that is my life with T1. Humor is, after all, the best (and cheapest) therapy. Allow me to pause today to share with you the down and dirty of what it feels like to have something that is not the slightest bit humorous: diabetic ketoacidosis.You are hot. You are freezing. You are confused. You are blacked out but coherent. You go to talk but words fail you. Time flies and goes in slow motion simultaneously. You will likely smell and look like death. In my instance, this was brought on by the combination of excessive vomiting and dehydration caused by food poisoning and the diabetic ketoacidosis that followed after my body had gone through so much. In hindsight, I was lucky, my husband knew that I had food poisoning because I began vomiting after our meal. But I had never prepped him on diabetic ketoacidosis and the symptoms (because DKA was for those other diabetics.) Upon finding me in our living room with a bowl of blood and bile by my side (no, I am not exaggerating), he got me into the car and took me to emergency care. It was 5:30 p.m. – and I thought it was 11:00 a.m. The series of events that led up to my stay in the ICU began innocently enough. It was a warm summer night and my husband and I walke Continue reading >>

Diabetic Ketoacidosis Clinical Presentation

Diabetic Ketoacidosis Clinical Presentation

History Insidious increased thirst (ie, polydipsia) and urination (ie, polyuria) are the most common early symptoms of diabetic ketoacidosis (DKA). Malaise, generalized weakness, and fatigability also can present as symptoms of DKA. Nausea and vomiting usually occur and may be associated with diffuse abdominal pain, decreased appetite, and anorexia. A history of rapid weight loss is a symptom in patients who are newly diagnosed with type 1 diabetes. Patients may present with a history of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons. Decreased perspiration is another possible symptom of DKA. Altered consciousness in the form of mild disorientation or confusion can occur. Although frank coma is uncommon, it may occur when the condition is neglected or if dehydration or acidosis is severe. Among the symptoms of DKA associated with possible intercurrent infection are fever, dysuria, coughing, malaise, chills, chest pain, shortness of breath, and arthralgia. Acute chest pain or palpitation may occur in association with myocardial infarction. Painless infarction is not uncommon in patients with diabetes and should always be suspected in elderly patients. A study by Crossen et al indicated that in children with type 1 diabetes, those who have had a recent emergency department visit and have undergone a long period without visiting an endocrinologist are more likely to develop DKA. The study included 5263 pediatric patients with type 1 diabetes. [15] 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 >>

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

Introduction Diabetic ketoacidosis (DKA) is a dangerous complication of diabetes caused by a lack of insulin in the body. Diabetic ketoacidosis occurs when the body is unable to use blood sugar (glucose) because there isn't enough insulin. Instead, it breaks down fat as an alternative source of fuel. This causes a build-up of a by-product called ketones. Most cases of diabetic ketoacidosis occur in people with type 1 diabetes, although it can also be a complication of type 2 diabetes. Symptoms of diabetic ketoacidosis include: passing large amounts of urine feeling very thirsty vomiting abdominal pain Seek immediate medical assistance if you have any of these symptoms and your blood sugar levels are high. Read more about the symptoms of diabetic ketoacidosis. Who is affected by diabetic ketoacidosis? Diabetic ketoacidosis is a relatively common complication in people with diabetes, particularly children and younger adults who have type 1 diabetes. Younger children under four years of age are thought to be most at risk. In about 1 in 4 cases, diabetic ketoacidosis develops in people who were previously unaware they had type 1 diabetes. Diabetic ketoacidosis accounts for around half of all diabetes-related hospital admissions in people with type 1 diabetes. Diabetic ketoacidosis triggers These include: infections and other illnesses not keeping up with recommended insulin injections Read more about potential causes of diabetic ketoacidosis. Diagnosing diabetic ketoacidosis This is a relatively straightforward process. Blood tests can be used to check your glucose levels and any chemical imbalances, such as low levels of potassium. Urine tests can be used to estimate the number of ketones in your body. Blood and urine tests can also be used to check for an underlying infec Continue reading >>

Is Keto Healthy? Ketosis Vs Ketoacidosis

Is Keto Healthy? Ketosis Vs Ketoacidosis

Is Keto Healthy? Ketosis vs Ketoacidosis When looking at a ketogenic diet and ketosis, it’s common for some people to confuse the process with a harmful, more extreme version of this state known as diabetic ketoacidosis. But there are a lot of misconceptions out there about ketosis vs ketoacidosis, and it’s time to shed some light on the subject by looking at the (very big) differences between the two. An Overview of Ketosis A ketogenic, or keto, diet is centered around the process of ketosis, so it’s important to understand exactly what ketosis is first before we get into whether or not it’s safe (spoiler: it is): Ketosis is a metabolic state where the body is primarily using fat for energy instead of carbohydrates. Burning carbohydrates (glucose) for energy is the default function of the body, so if glucose is available, the body will use that first. But during ketosis, the body is using ketones instead of glucose. This is an amazing survival adaptation by the body for handling periods of famine or fasting, extreme exercise, or anything else that leaves the body without enough glucose for fuel. Those eating a ketogenic diet purposely limit their carb intake (usually between 20 and 50 grams per day) to facilitate this response. That’s why the keto diet focuses on very low carb intake, moderate to low protein intake, and high intakes of dietary fats. Lower protein is important because it prevents the body from pulling your lean muscle mass for energy and instead turns to fat. Ketone bodies are released during ketosis and are created by the liver from fatty acids. These ketones are then used by the body to power all of its biggest organs, including the brain, and they have many benefits for the body we’ll get into later. But first, let’s address a common mi Continue reading >>

Diabetes Update: Acute Complications

Diabetes Update: Acute Complications

"Diabetes update: Acute complications" CE credit is no longer available for this article. Originally posted April 2001 MARJORIE CYPRESS, MS, C-ANP, CDE MARJORIE CYPRESS is a nurse practitioner and certified diabetes educator for Lovelace Health Systems, Albuquerque, N.M. Series Editor: Carolyn Robertson, RN, MSN, CDE KEY WORDS: acute complications, hyperglycemia, hypoglycemia, diabetic ketoacidosis, hyperosmolar hyperglycemic state, ketosis Critically high or low blood sugar in a patient with diabetes is a medical emergency. You'll need to be able to quickly identify and know how to manage the acute complications of diabetes to help a patient avoid a tragic outcome. Here's how. Jump to: Choose article section... Emergency treatment of acute complications of diabetes demands quick recognition of the problem and immediate intervention. High blood sugar can progress to diabetic ketoacidosis (DKA) in Type 1 diabetics, and hyperosmolar hyperglycemic state (HHS) in those with Type 2. But every diabetic patient taking a hypoglycemic agent is at risk for hypoglycemia, the most common—and most feared—complication. Here we'll review the pathophysiology behind DKA, HHS, and hypoglycemia; provide assessments that help distinguish one complication from another; and discuss emergency treatments and nursing strategies that can prevent a potentially fatal outcome. Too much sugar, too little insulin DKA, often referred to as diabetic coma, occurs when there's a profound lack of insulin in the body. Without insulin, the body can't use glucose for fuel. Cells starve as sugar accumulates. The blood becomes thick with sugar, which promotes osmotic diuresis. As the body loses water, the excess sugar spills into the urine, taking important electrolytes with it. Patients become thirsty and Continue reading >>

How Can Diabetic Ketoacidosis Cause Cerebral Edema In Infants?

How Can Diabetic Ketoacidosis Cause Cerebral Edema In Infants?

Diabetic Ketoacidosis (DKA) in and of itself does not cause cranial edema. What happens with DKA is the excess glucose in the blood changes the osmolarity of the blood, and causes fluid shift from intracelluar to extracellular. This causes the cells to shrink somewhat. Upon finding the patient in the DKA state, the teatment is insulin and IV fluids. Insulin and the hydration IV fluids reverse the DKA state, and also the osmolarity of the extracellular fluid, causing a fluid shift back into the cell. With the osmolarity reversed, the cells begin swelling—sometimes sometimes larger than before: this is what causes the edema in the cerebrum. This is particularly dangerous because the brain cells have nowhere to go, being encased within the skull. Even though infants have fontanelles and the skull has not fused solid, the extra fluid causes compression within the brain, which in turn can adversely affect the brain function. Continue reading >>

Diabetic Ketoacidosis (dka) - Topic Overview

Diabetic Ketoacidosis (dka) - Topic Overview

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

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (DKA) Diabetic ketoacidosis (DKA) occurs when the body does not have enough insulin. Insulin is what breaks down sugar into energy. When insulin is not present to break down sugars, our body begins to break down fat. Fat break down produces ketones which spill into the urine and cause glucose build up in the blood, thus acidifying the body. Because sugar is not entering into our body’s cells for energy breakdown, the sugar is being processed by the kidneys and excreted through the urine; as a result, we become dehydrated and our blood becomes even more acidic. This leads to sickness and hospitalization if not treated. If a person’s blood sugar is over 240, they should start checking their blood for ketones. If you have diabetes, or love someone who does, being aware of warning signs of diabetic ketoacidosis (DKA) can help save a life. Early Symptoms of DKA: High blood glucose level, usually > 300 High volume to ketones present in blood or urine Frequent urination or thirst that lasts for a day or more Dry skin and mouth Rapid shallow breathing Abdominal pain (especially in children) Muscle stiffness or aches Flushed face As DKA Worsens: Decreases alertness, confusion – brain is dehydrating Deep, labored, and gasping breathing Headache Breath that smells fruity or like fingernail polish remover Nausea and/or vomiting Abdomen may be tender and hurt if touched Decreased consciousness, coma, death If you think you might have DKA, test for ketones. If ketones are present, call your health care provider right away. To treat high blood sugar, hydrate with water or sugar free, caffeine free drinks. Sugar free popsicles and snacks are also good alternatives. Always call the doctor if vomiting goes on for more than two hours. Symptoms can go from mild Continue reading >>

What Is The Difference Between Hyperglycemia And Hypoglycemia?

What Is The Difference Between Hyperglycemia And Hypoglycemia?

By Debra A. Sokol-McKay, MS, CVRT, CDE, CLVT, OTR/L, SCLV What Is Hyperglycemia? In relation to diabetes, hyperglycemia refers to chronically high blood glucose levels. Most medical professionals define hyperglycemia by using the blood glucose goals that you and your physician have established and combining those goals with the blood glucose target ranges set by the American Diabetes Association. It's important to understand that you'll probably experience high blood glucose levels from time to time, despite your best efforts at control. As with any chronic disease, talk with your physician and diabetes care team if the pattern of your blood glucose readings is consistently higher or lower than your blood glucose goals. Complications from Hyperglycemia Persistent hyperglycemia can cause a wide range of chronic complications that affect almost every system in your body. When large blood vessels are affected, it can lead to: Stroke (cerebral vascular disease) Heart attack or Congestive Heart Failure (coronary heart disease) Circulation disorders and possible amputation (peripheral vascular disease) When smaller blood vessels are affected, it can lead to: Kidney disease (nephropathy) Nerve damage (neuropathy) Diabetic eye disease (retinopathy) Joseph Monks: Writer, Producer, and Film Director Joseph Monks, who has diabetic retinopathy, creates and produces films for his production company Sight Unseen Pictures. He is also the first blind filmmaker to direct a feature film. Says Joe, "I'm not uncomfortable with the term 'blind.' I'm not thrilled about it, of course, but it's accurate. The lights went out for me in early 2002 as a result of diabetic retinopathy—the death of my retinas. It is what it is, so when it happened, I decided that I wasn't going to let it put an en Continue reading >>

Type 1 Diabetes Complications

Type 1 Diabetes Complications

Type 1 diabetes is complicated—and if you don’t manage it properly, there are complications, both short-term and long-term. “If you don’t manage it properly” is an important if statement: by carefully managing your blood glucose levels, you can stave off or prevent the short- and long-term complications. And if you’ve already developed diabetes complications, controlling your blood glucose levels can help you manage the symptoms and prevent further damage. Diabetes complications are all related to poor blood glucose control, so you must work carefully with your doctor and diabetes team to correctly manage your blood sugar (or your child’s blood sugar). Short-term Diabetes Complications Hypoglycemia: Hypoglycemia is low blood glucose (blood sugar). It develops when there’s too much insulin—meaning that you’ve taken (or given your child) too much insulin or that you haven’t properly planned insulin around meals or exercise. Other possible causes of hypoglycemia include certain medications (aspirin, for example, lowers the blood glucose level if you take a dose of more than 81mg) and alcohol (alcohol keeps the liver from releasing glucose). There are three levels of hypoglycemia, depending on how low the blood glucose level has dropped: mild, moderate, and severe. If you treat hypoglycemia when it’s in the mild or moderate stages, then you can prevent far more serious problems; severe hypoglycemia can cause a coma and even death (although very, very rarely). The signs and symptoms of low blood glucose are usually easy to recognize: Rapid heartbeat Sweating Paleness of skin Anxiety Numbness in fingers, toes, and lips Sleepiness Confusion Headache Slurred speech For more information about hypoglycemia and how to treat it, please read our article on hy Continue reading >>

High And Low Blood Sugar Levels & Symptoms

High And Low Blood Sugar Levels & Symptoms

It is important for people with diabetes to know the symptoms of high and low sugar levels so appropriate action can be taken to prevent health problems occurring in either the short or long term. In the case of low blood glucose levels, it is generally only people on certain medications such as insulin and tablets which directly stimulate insulin production that need to be actively aware of low blood sugar symptoms. Symptoms of high sugar levels (hyperglycemia) One or more of the following symptoms are common when blood glucose levels are too high: Increased urination Increased thirst Increased hunger Fatigue Dry mouth Dry eyes Blurred vision If sugar levels are regularly too high for a number of days or weeks, the following symptoms may also be recognised: Loss of weight, particularly muscle mass Regular urinary tract infections (UTIs) Regular episodes of thrush (yeast infections) Note that in people that are overweight, loss of weight may sometimes be more recognisable as a loss of muscle mass. High blood sugar can be uncomfortable and can increase the risk of developing long term complications if extended periods of hyperglycemia become a regular occurrence. Read more about hyperglycemia. Symptoms of low sugar levels (hypoglycemia) One or more of the following symptoms may be recognised if blood glucose levels become too low: Increased hunger Pale appearance Feeling weak Lethargy Faster heart rate Sweating Blurred vision Dizzy spells Reduced co-ordination Impaired ability to make decisions Hypoglycemia, or hypos for short, can be dangerous for people on the following anti-diabetic medications: Insulin Sulphonylureas Prandial glucose regulators (glinides) People with diabetes on these medications need to be able to spot the signs of low blood sugar levels quickly and Continue reading >>

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