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How Does Ketoacidosis Cause Hypotension

Sodium Bicarbonate And Diabetic Ketoacidosis

Sodium Bicarbonate And Diabetic Ketoacidosis

OVERVIEW The correction of the acidaemia in DKA is achieved by correcting the underlying pathophysiology with fluid replacement and insulin The role of sodium bicarbonate (NaHCO3) as a therapy for diabetic ketoacidosis (DKA) is controversial Different sources have different values for the cut off pH which requires treatment, and other sources advise against NaHCO3 use in DKA completely — there is no consensus RATIONALE Reasons proposed for use of sodium bicarbonate in DKA: treatment of severe acidaemia, which causes catecholamine resistance and myocardial depression treatment of severe hyperkalemia replacement of bicarbonate loss from Renal or GI tract — theoretical potential for giving HCO3- with renal wasting of HCO3- or GI loss if delta ratio is <1 (as is usual for DKA) ketoacids lost in urine (hence delta ratio <1) cannot be converted into HCO3- DISADVANTAGES Side effects of sodium bicarbonate Worsening of intracellular acidaemia hypernatraemia (1mmol of Na+ for every 1mmol of HCO3-) hyperosmolality (cause arterial vasodilation and hypotension) volume overload rebound or ‘overshoot’ alkalosis hypokalaemia ionised hypocalcaemia impaired oxygen unloading due to left shift of the oxyhaemoglobin dissociation curve removal of acidotic inhibition of glycolysis by increased activity of PFK CSF acidosis hypercapnia (CO2 readily passes intracellularly and worsens intracellular acidosis) severe tissue necrosis if extravasation takes place bicarbonate increases lactate production by: — increasing the activity of the rate limiting enzyme phosphofructokinase and removal of acidotic inhibition of glycolysis — shifts Hb-O2 dissociation curve, increased oxygen affinity of haemoglobin and thereby decreases oxygen delivery to tissues EVIDENCE A 2011 systematic review by C Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Practice Essentials Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but it is not uncommon in some patients with type 2 diabetes. This condition is a complex disordered metabolic state characterized by hyperglycemia, ketoacidosis, and ketonuria. Signs and symptoms The most common early symptoms of DKA are the insidious increase in polydipsia and polyuria. The following are other signs and symptoms of DKA: Nausea and vomiting; may be associated with diffuse abdominal pain, decreased appetite, and anorexia History of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons or history of mechanical failure of insulin infusion pump Altered consciousness (eg, mild disorientation, confusion); frank coma is uncommon but may occur when the condition is neglected or with severe dehydration/acidosis Signs and symptoms of DKA associated with possible intercurrent infection are as follows: See Clinical Presentation for more detail. Diagnosis On examination, general findings of DKA may include the following: Characteristic acetone (ketotic) breath odor In addition, evaluate patients for signs of possible intercurrent illnesses such as MI, UTI, pneumonia, and perinephric abscess. Search for signs of infection is mandatory in all cases. Testing Initial and repeat laboratory studies for patients with DKA include the following: Serum electrolyte levels (eg, potassium, sodium, chloride, magnesium, calcium, phosphorus) Note that high serum glucose levels may lead to dilutional hyponatremia; high triglyceride levels may lead to factitious low glucose levels; and high levels of ketone bodies may lead to factitious elevation of creatinine levels. Continue reading >>

Diabetic Ketoacidosis: A Serious Complication

Diabetic Ketoacidosis: A Serious Complication

A balanced body chemistry is crucial for a healthy human body. A sudden drop in pH can cause significant damage to organ systems and even death. This lesson takes a closer look at a condition in which the pH of the body is severely compromised called diabetic ketoacidosis. Definition Diabetic ketoacidosis, sometimes abbreviated as DKA, is a condition in which a high amount of acid in the body is caused by a high concentration of ketone bodies. That definition might sound complicated, but it's really not. Acidosis itself is the state of too many hydrogen ions, and therefore too much acid, in the blood. A pH in the blood leaving the heart of 7.35 or less indicates acidosis. Ketones are the biochemicals produced when fat is broken down and used for energy. While a healthy body makes a very low level of ketones and is able to use them for energy, when ketone levels become too high, they make the body's fluids very acidic. Let's talk about the three Ws of ketoacidosis: who, when, and why. Type one diabetics are the group at the greatest risk for ketoacidosis, although the condition can occur in other groups of people, such as alcoholics. Ketoacidosis usually occurs in type one diabetics either before diagnosis or when they are subjected to a metabolic stress, such as a severe infection. Although it is possible for type two diabetics to develop ketoacidosis, it doesn't happen as frequently. To understand why diabetic ketoacidosis occurs, let's quickly review what causes diabetes. Diabetics suffer from a lack of insulin, the protein hormone responsible for enabling glucose to get into cells. This inability to get glucose into cells means that the body is forced to turn elsewhere to get energy, and that source is fat. As anyone who exercises or eats a low-calorie diet knows, fa 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 >>

Dizziness (dizzy)

Dizziness (dizzy)

Dizziness is a symptom that is often applies to a variety of sensations including lightheadedness and vertigo. Vertigo is the sensation of spinning, while lightheadedness is typically described as near fainting, and weakness. Some of the conditions that may cause lightheadedness in a patient include low blood pressure, high blood pressure, dehydration, medications, postural or orthostatic hypotension, diabetes, endocrine disorders, hyperventilation, heart conditions, and vasovagal syncope. Vertigo is most often caused by a problem in the balance centers of the inner ear called the vestibular system and causes the sensation of the room spinning. It may be associated with vomiting. Symptoms often are made worse with position changes. Those with significant symptoms and vomiting may need intravenous medication and hospitalization. Vertigo is also the presenting symptom in patients with Meniere's Disease and acoustic neuroma, conditions that often require referral to an ENT specialist. Vertigo may also be a symptom of stroke. Most often, dizziness or lightheadedness is a temporary situation that resolves spontaneously without a specific diagnosis being made. Introduction to dizziness (feeling dizzy) Dizziness is one of the most common symptoms that will prompt a person to seek medical care. The term dizziness is sometimes difficult to understand since it means different things to different people. It is either the sensation of feeling lightheaded as if the individual is weak and will pass out, or it describes vertigo or the sensation of spinning, as if the affected person just got off a merry-go-round. Lightheadedness is often caused by a decrease in blood supply to the brain, while vertigo may be caused by disturbances of the inner ear and the balance centers of the brain. Continue reading >>

Poisoning-related Hypotension

Poisoning-related Hypotension

Introduction Hypotension is a frequently encountered problem in patients with poisoning or drug overdose. Toxicological causes of hypotension are usually due to a drug’s or toxin’s ability to induce one or more of the following: decrease cardiac contractility; decrease peripheral vasculature resistance; decrease intravascular volume; or depress the central nervous system. Yet, determining the specific cause of hypotension is often complex as its medical differential is vast. While medications are commonly implicated as a direct cause of hypotension, a fall in blood pressure may be associated with other coexisting medical conditions. An understanding of the pharmacologic effects of drugs and knowledge of the patient’s underlying medical conditions are crucial for the effective management of hypotension. Hypotension is frequently seen in the overdose population. During 2004, hypotension was present in over 20% of all cases reported to poison centers across California. In 2003, the American Association of Poison Control Centers (AAPCC) reported 12,710 cases of hypotension associated with tricyclic antidepressant poisoning; 15,350 cases from beta-receptor antagonist poisoning; 9,650 cases from calcium antagonist poisoning; and 2,850 cases from cardiac glycoside intoxication. Case presentation A 46 year-old man with a history of diabetes, hypertension, and ethanol abuse was brought to the emergency department after being found with decreased responsiveness. He had become increasingly despondent after losing his job. His medications were unknown. His blood pressure was 85/62 mm Hg, and the heart rate was 55 beats/min. The blood glucose was elevated at 250 mg/dL without evidence of ketoacidosis. He had an ethanol level of 180 mg/dL. An electrocardiogram showed sinus brad 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 >>

Postural Hypotension

Postural Hypotension

Tweet Postural hypotension is lower than normal blood pressure more commonly seen in the elderly and in some patients with conditions such as diabetes and Parkinson's disease. Postural hypotension, also referred to orthostatic hypotension, can cause people to feel dizzy or light-headed upon standing. What is postural hypotension? Postural or orthostatic hypotension is defined as a fall in systolic blood pressure (the top number in a typical BP reading) by 20mmHg or more after changing position or posture, typically from lying to standing. Such a drop in blood pressure after changing posture can reduce the flow of blood to your brain, causing dizzy spells and in some cases loss of consciousness and falls. How is it linked to diabetes? When you stand up, the build-up of blood in your legs causes blood pressure to decrease as there's less blood circulating back to your heart to pump. The body naturally counteracts this by increasing your heart rate so that more blood is pumped around the body to help stabilise blood pressure. Postural hypotension occurs when something interrupts this natural response, such as dehydration, which is a common problem for people with less well controlled diabetes as a result of frequent urination. Diabetes can also damage the nerves supplying your blood vessels, which in turn can lead to a drop in blood pressure upon standing up or any other sudden movements where your blood vessels may find it hard to adjust. What else can cause postural hypotension? In addition to diabetes, postural hypotension can be bought on by the following conditions: Anaemia Heart problems Hypovolaemia (severe blood and fluid loss) Parkinson’s disease Postural hypotension can also be caused by various medications, including antidepressants, diuretics (water medicatio Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Abbas E. Kitabchi, PhD., MD., FACP, FACE Professor of Medicine & Molecular Sciences and Maston K. Callison Professor in the Division of Endocrinology, Diabetes & Metabolism UT Health Science Center, 920 Madison Ave., 300A, Memphis, TN 38163 Aidar R. Gosmanov, M.D., Ph.D., D.M.Sc. Assistant Professor of Medicine, Division of Endocrinology, Diabetes & Metabolism, The University of Tennessee Health Science Center, 920 Madison Avenue, Suite 300A, Memphis, TN 38163 Clinical Recognition Omission of insulin and infection are the two most common precipitants of DKA. Non-compliance may account for up to 44% of DKA presentations; while infection is less frequently observed in DKA patients. Acute medical illnesses involving the cardiovascular system (myocardial infarction, stroke, acute thrombosis) and gastrointestinal tract (bleeding, pancreatitis), diseases of endocrine axis (acromegaly, Cushing`s syndrome, hyperthyroidism) and impaired thermo-regulation or recent surgical procedures can contribute to the development of DKA by causing dehydration, increase in insulin counter-regulatory hormones, and worsening of peripheral insulin resistance. Medications such as diuretics, beta-blockers, corticosteroids, second-generation anti-psychotics, and/or anti-convulsants may affect carbohydrate metabolism and volume status and, therefore, could precipitateDKA. Other factors: psychological problems, eating disorders, insulin pump malfunction, and drug abuse. It is now recognized that new onset T2DM can manifest with DKA. These patients are obese, mostly African Americans or Hispanics and have undiagnosed hyperglycemia, impaired insulin secretion, and insulin action. A recent report suggests that cocaine abuse is an independent risk factor associated with DKA recurrence. Pathophysiology In 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 >>

When Blood Pressure Is Too Low

When Blood Pressure Is Too Low

Talk around blood pressure typically centers on what to do if blood pressure is too high. We know that high blood pressure is more common in people with diabetes than people without diabetes. We also know that uncontrolled high blood pressure is a risk factor for stroke, heart disease, and kidney disease. The American Diabetes Association recommends a blood pressure goal of less than 140/80 for most people with diabetes. But what if your blood pressure is too low? Is it cause for concern? And what do you do about it? Low blood pressure defined Low blood pressure is also known as “hypotension.” You might be thinking that low blood pressure is a good thing, especially if yours tends to run on the high side. But the reality is that low blood pressure can be a serious condition for some people. For people without diabetes, the American Heart Association recommends a blood pressure of less than 120 over 80 (written as 120/80). Low blood pressure is generally defined as a blood pressure of less than 90/60. If your blood pressure tends to hover in that area without any symptoms, then there’s likely no cause for concern. But if symptoms occur, that’s a signal that something is amiss. Symptoms of low blood pressure Low blood pressure may be a sign that there’s an underlying medical condition, especially if your blood pressure drops suddenly or if you have the following symptoms: • Dizziness or lightheadedness • Fainting • Fast or irregular heartbeat • Feeling weak • Feeling confused • Lack of concentration • Blurred vision • Cold, clammy skin • Nausea • Rapid, shallow breathing • Depression • Dehydration That’s quite a list. Some of the above symptoms can occur if you have, say, the flu, a stomach bug, or have been outside for a long time in h Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic ketoacidosis is a medical emergency that typically occurs as a complication of type 1 diabetes. It can occur in people with undiagnosed type 1 diabetes or in diabetics with: decreased insulin intake intercurrent illness stress of any form (e.g.infection, surgery, MI) Pathophysiology The pathophysiology (see image) of diabetic ketoacidosis must be considered to help understand its presentation and the necessary management. There are 3 main biochemical features: hyperglycaemia hyperketonaemia metabolic acidosis Firstly, lack of insulin causes glucose to remain in the blood rather than be transferred into cells for utilisation. The body therefore responds as if it were in starvation and hepatic glucose production becomes increased. Osmotic diuresis occurs as a consequence of this glucose rich blood being filtered by the kidneys. Glucose is normally reabsorbed by the proximal tubule but in DKA the amount of glucose filtered exceeds the renal threshold for reabsorbtion. The presence of glucose in the tubules causes water retention in the lumen, thus increasing urine output and decreasing reabsorption into the body, leading to dehydration and electrolyte depletion. Secondly, an absence of insulin together with elevated stress hormones such as catecholamines, leads to lipolysis, resulting in numerous free fatty acids available for hepatic ketogenesis. Consequently, there is increased ketone body formation by fatty acid oxidation in the liver, leading to an elevated level in the blood. These ketones give a distinct smell to the urine and breath. Thirdly, the ketone bodies lower the pH of the blood resulting in metabolic acidosis. This causes nausea and vomiting resulting in further dehydration. The body compensates for the acidosis by hyperventilation (Kussmals respira Continue reading >>

The Dangers In Bulimia Are Real - This Illness Can Kill!

The Dangers In Bulimia Are Real - This Illness Can Kill!

People often overlook the dangers in bulimia. They think that because bulimics are often within a healthy weight range, that it's a 'safe' eating disorder. The truth could not be more different... I was bulimic for over 10 years. The illness ravaged my body and I knew that it was close to killing me. But thankfully, I got help and I recovered... Too many people don't seek help for their bulimia and suffer from it for years on end, sometimes for many decades. Too often, bulimia kills. To help you realize the dangers in bulimia, I've listed the 10 most worrying ones below. TOP 10 Terrifying Dangers in Bulimia Please click on the links below to jump to that part of the 'dangers in bulimia' page, or just scroll down. Suicide Ketoacidosis Malnutrition and then see... Seizures or Fits If you suffer from bulimia you have an increased risk of having seizures or fits. The seizures may be caused by dehydration, hyperglycemia or ketoacidosis. Seizures are one of the serious dangers in bulimia because they can cause brain damage. Electrolyte Imbalance Electrolytes are important chemicals in your body. Having the right balance of electrolytes is essential for your nerves, muscles and organs to work properly. Electrolyte imbalances are caused by a mix of dehydration and the loss of potassium and sodium. This can be caused by excessive vomiting or laxative abuse. Bulimics often develop electrolyte abnormalities... Which can lead to sudden cardiac arrest and death. Because of the stress that electrolyte imbalances place on the organs - this is one of the most deadly dangers in bulimia. When I was bulimic, my electrolyte balance was so messed up that my heartbeat became very irregular. I am lucky that bulimia didn't kill me. Terri Schiavo had a heart attack, which was caused by a massiv Continue reading >>

How Does Diabetic Ketoacidosis Cause Vomiting?

How Does Diabetic Ketoacidosis Cause Vomiting?

DKA can occur in people who are newly diagnosed with type 1 diabetes and have had ketones building up in their blood prior to the start of treatment. It can also occur in people already diagnosed with type 1 diabetes that have missed an insulin dose, have an infection, or have suffered a traumatic event or injury. With type 1 diabetes, the pancreas is unable to make the hormone insulin, which the body’s cells need in order to take in glucose from the blood. In the case of type 2 diabetes, the pancreas is unable to make sufficient amounts of insulin in order to take in glucose from the blood. Glucose, a simple sugar we get from the foods we eat, is necessary for making the energy our cells need to function. People with diabetes can’t get glucose into their cells, so their bodies look for alternative energy sources. Meanwhile, glucose builds up in the bloodstream, and by the time DKA occurs, blood glucose levels are often greater than 22 mmol/L (400 mg/dL) while insulin levels are very low. Since glucose isn’t available for cells to use, fat from fat cells is broken down for energy instead, releasing ketones. Ketones accumulate in the blood, causing it to become more acidic. As a result, many of the enzymes that control the body’s metabolic processes aren’t able to function as well. A higher level of ketones also affects levels of sugar and electrolytes in the body. As ketones accumulate in the blood, more ketones will be passed in the urine, taking sodium and potassium salts out with them. Over time, levels of sodium and potassium salts in the body become depleted, which can cause nausea and vomiting. The result is a vicious cycle. The most important prevention strategies are to monitor blood glucose levels routinely, keep blood glucose levels controlled (e.g., Continue reading >>

Testicular Failure Following Severe Diabetic Ketoacidosis Complicated By Hypotensive Shock

Testicular Failure Following Severe Diabetic Ketoacidosis Complicated By Hypotensive Shock

Go to: Case Presentation A 14‐year‐old Caucasian boy with no significant past medical history presented to the emergency department when his mother was unable to wake him up. The family reported a 3 day history of flu‐like symptoms with polyuria and polydipsia but no vomiting. On exam, the patient was unresponsive but had no localizing neurological findings. Physical exam was remarkable for Kussmaul breathing, hypotension, and poor perfusion. Exam by the consulting endocrine team at presentation documented normal body mass index, no acanthosis, and sexual maturity staging of Tanner 4 for pubic hair with testicular volume of 15 mL bilaterally. The patient was diagnosed with severe DKA based on labs which showed pH 6.89, bicarbonate 4.5 mmol/L, blood glucose 1493 mg/dL, and ketonuria. He had acute renal failure with initial blood urea nitrogen (BUN) of 59 and serum creatinine 3.4 mg/dL. Fluid resuscitation and insulin infusion were initiated. The patient was transferred to the pediatric intensive care unit (PICU) for further management. Additional labs drawn at presentation are shown in Table 2. While in the PICU, in spite of biochemical resolution of DKA, the patient had persistent hypotension and developed multi‐system organ failure. He had a normal serum cortisol level in response to a 1 mcg cosyntropin stimulation test performed on day 3 of admission (baseline 15 mcg/dL, t = 60 min 25 mcg/dL; 4–20 mcg/dL), and blood cultures drawn at presentation were negative. Brain imaging did not disclose cerebral edema. Management included mechanical ventilation, both conventional (for 10 days) and high‐frequency oscillatory (for 5 days), pressor therapy, and additional supportive care. After 25 days in the PICU, the patient improved and was discharged on multiple dail Continue reading >>

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