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How Does Ketoacidosis Cause Hypotension

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 >>

Possible Side Effects Of Farxiga

Possible Side Effects Of Farxiga

FARXIGA can cause serious side effects, including: See the What is the most important information I should know about FARXIGA? section. Dehydration (the loss of body water and salt), which may cause you to feel dizzy, faint, lightheaded, or weak, especially when you stand up (orthostatic hypotension). You may be at a higher risk of dehydration if you have low blood pressure; take medicines to lower your blood pressure, including water pills (diuretics); are 65 years of age or older; are on a low salt diet, or have kidney problems Ketoacidosis occurred in people with type 1 and type 2 diabetes during treatment with FARXIGA. Ketoacidosis is a serious condition which may require hospitalization and may lead to death. Symptoms may include nausea, tiredness, vomiting, trouble breathing, and abdominal pain. If you get any of these symptoms, stop taking FARXIGA and call your healthcare provider right away. If possible, check for ketones in your urine or blood, even if your blood sugar is less than 250 mg/dL Kidney problems. Sudden kidney injury occurred in people taking FARXIGA. Talk to your doctor right away if you reduce the amount you eat or drink, or if you lose liquids; for example, from vomiting, diarrhea, or excessive heat exposure The most common side effects of FARXIGA (far-SEE-guh) include: Vaginal yeast infections and yeast infections of the penis Stuffy or runny nose and sore throat Changes in urination, including urgent need to urinate more often, in larger amounts, or at night These are not all the possible side effects of FARXIGA. For more information, please read the Medication Guide; ask your healthcare provider or pharmacist. Call your healthcare provider for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088. Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetes mellitus is the name given to a group of conditions whose common hallmark is a raised blood glucose concentration (hyperglycemia) due to an absolute or relative deficiency of the pancreatic hormone insulin. In the UK there are 1.4 million registered diabetic patients, approximately 3 % of the population. In addition, an estimated 1 million remain undiagnosed. It is a growing health problem: In 1998, the World Health Organization (WHO) predicted a doubling of the worldwide prevalence of diabetes from 150 million to 300 million by 2025. For a very tiny minority, diabetes is a secondary feature of primary endocrine disease such as acromegaly (growth hormone excess) or Cushing’s syndrome (excess corticosteroid), and for these patients successful treatment of the primary disease cures diabetes. Most diabetic patients, however, are classified as suffering either type 1 or type 2 diabetes. Type 1 diabetes Type 1 diabetes, which accounts for around 15 % of the total diabetic population, is an autoimmune disease of the pancreas in which the insulin-producing β-cells of the pancreas are selectively destroyed, resulting in an absolute insulin deficiency. The condition arises in genetically susceptible individuals exposed to undefined environmental insult(s) (possibly viral infection) early in life. It usually becomes clinically evident and therefore diagnosed during late childhood, with peak incidence between 11 and 13 years of age, although the autoimmune-mediated β-cell destruction begins many years earlier. There is currently no cure and type 1 diabetics have an absolute life-long requirement for daily insulin injections to survive. Type 2 diabetes This is the most common form of diabetes: around 85 % of the diabetic population has type 2 diabetes. The primary prob 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 >>

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 >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Patient professional reference Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Pre-diabetes (Impaired Glucose Tolerance) article more useful, or one of our other health articles. See also the separate Childhood Ketoacidosis article. Diabetic ketoacidosis (DKA) is a medical emergency with a significant morbidity and mortality. It should be diagnosed promptly and managed intensively. DKA is characterised by hyperglycaemia, acidosis and ketonaemia:[1] Ketonaemia (3 mmol/L and over), or significant ketonuria (more than 2+ on standard urine sticks). Blood glucose over 11 mmol/L or known diabetes mellitus (the degree of hyperglycaemia is not a reliable indicator of DKA and the blood glucose may rarely be normal or only slightly elevated in DKA). Bicarbonate below 15 mmol/L and/or venous pH less than 7.3. However, hyperglycaemia may not always be present and low blood ketone levels (<3 mmol/L) do not always exclude DKA.[2] Epidemiology DKA is normally seen in people with type 1 diabetes. Data from the UK National Diabetes Audit show a crude one-year incidence of 3.6% among people with type 1 diabetes. In the UK nearly 4% of people with type 1 diabetes experience DKA each year. About 6% of cases of DKA occur in adults newly presenting with type 1 diabetes. About 8% of episodes occur in hospital patients who did not primarily present with DKA.[2] However, DKA may also occur in people with type 2 diabetes, although people with type 2 diabetes are much more likely to have a hyperosmolar hyperglycaemic state. Ketosis-prone type 2 diabetes tends to be more common in older, overweight, non-white people with type 2 diabetes, and DKA may be their 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: 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

Diabetic Ketoacidosis

What Is It? Diabetic ketoacidosis is a potentially fatal complication of diabetes that occurs when you have much less insulin than your body needs. This problem causes the blood to become acidic and the body to become dangerously dehydrated. Diabetic ketoacidosis can occur when diabetes is not treated adequately, or it can occur during times of serious sickness. To understand this illness, you need to understand the way your body powers itself with sugar and other fuels. Foods we eat are broken down by the body, and much of what we eat becomes glucose (a type of sugar), which enters the bloodstream. Insulin helps glucose to pass from the bloodstream into body cells, where it is used for energy. Insulin normally is made by the pancreas, but people with type 1 diabetes (insulin-dependent diabetes) don't produce enough insulin and must inject it daily. Subscribe to Harvard Health Online for immediate access to health news and information from Harvard Medical School. Continue reading >>

What Is Type 2 Diabetes?

What Is Type 2 Diabetes?

INVOKANA® can cause important side effects, including: Amputations. INVOKANA® may increase your risk of lower-limb amputations. Amputations mainly involve removal of the toe or part of the foot; however, amputations involving the leg, below and above the knee, have also occurred. Some people had more than one amputation, some on both sides of the body. You may be at a higher risk of lower-limb amputation if you: have a history of amputation, have heart disease or are at risk for heart disease, have had blocked or narrowed blood vessels (usually in leg), have damage to the nerves (neuropathy) in the leg, or have had diabetic foot ulcers or sores. Call your doctor right away if you have new pain or tenderness, any sores, ulcers, or infections in your leg or foot. Your doctor may decide to stop your INVOKANA® for a while if you have any of these signs or symptoms. Talk to your doctor about proper foot care Dehydration. INVOKANA® can cause some people to become dehydrated (the loss of too much body water), which may cause you to feel dizzy, faint, lightheaded, or weak, especially when you stand up (orthostatic hypotension). You may be at higher risk of dehydration if you have low blood pressure, take medicines to lower your blood pressure (including diuretics [water pills]), are on a low sodium (salt) diet, have kidney problems, or are 65 years of age or older Vaginal yeast infection. Women who take INVOKANA® may get vaginal yeast infections. Symptoms include: vaginal odor, white or yellowish vaginal discharge (discharge may be lumpy or look like cottage cheese), or vaginal itching Yeast infection of the penis (balanitis or balanoposthitis). Men who take INVOKANA® may get a yeast infection of the skin around the penis. Symptoms include: redness, itching, or swelling o Continue reading >>

Hypovolemic And Hemorrhagic Shock

Hypovolemic And Hemorrhagic Shock

A A A Shock (cont.) Hypovolemic Shock There needs to be enough red blood cells and water in the blood for the heart to push the fluids around within the blood vessels. When the body becomes dehydrated, there may be enough red blood cells, but the total volume of fluid is decreased, and pressure within the system decreases. Cardiac output is the amount of blood that the heart can pump out in one minute. It is calculated as the stroke volume (how much blood each heart beat can push out) multiplied by the heart rate (how fast the heart beats each minute). If there is less blood in the system to be pumped, the heart speeds up to try to keep its output steady. Water makes up 90% of blood. If the body becomes dehydrated because water is lost or fluid intake is inadequate, the body tries to maintain cardiac output by making the heart beat faster. But as the fluid losses mount, the body's compensation mechanisms fail, and shock may ensue. Hypovolemic (hypo=low + volemic=volume) shock due to water loss can be the endpoint of many illnesses, but the common element is the lack of fluid within the body. Gastroenteritis can cause significant water loss from vomiting and diarrhea, and is a common cause of death in third world countries. Heat exhaustion and heat stroke is caused by excessive water loss through sweating as the body tries to cool itself. Patients with infections can lose significant amounts of water from sweating. People with diabetes who have diabetic ketoacidosis lose significant water because of because of elevated blood sugar that cause excess water to be excreted in the urine. Ultimately in hypovolemic shock, the patient cannot replace the amount of fluid that was lost by drinking enough water, and the body is unable to maintain blood pressure and cardiac output. I Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Introduction Diabetic ketocacidosis (DKA) is a medical emegency caused by insufficient levels of insulin and increased levels of counter-regulatory hormones such as glucagon, epinephrine, and cortisol. This leads to significant, potentially life-threatening metabolic abnormalities, including hyperglycemia, anion gap metabolic acidosis, hyperketonemia, ketonuria. The Case of Rachel R Rachel is a 34 year-old woman with type I diabetes. She has poor control of her sugars during the best of days, and she has not been counting her dietary intake or monitoring her blood glucose over the past two days, as she has been ill with a bad cold. She feels increasingly unwell and comes to the emergency department with nausea, vomiting, and blurred vision. What are the symptoms of DKA? How is it diagnosed? How do you treat someone like Rachel? return to top Causes and Risk Factors DKA is more common in Type 1 DM than type II, due to complete insulin deficiency and counter-regulatory hormones. It is precipitated by the 7 I’s: infection (pneumonia, UTI) insulin nonadherence/insufficiency (as can occur with pregnancy) initial presentation with DMI ischemia/infarct (myocardial, stroke, gut) inflammation (pancreatitis, cholecystitis) iatrogenic (glucocorticoids, dieuretics, surgery) intoxication (alcohol, atypical antipsychotics, cocaine) return to top Pathophysiology Insufficient insulin levels lead to a change in metabolism. An increase in fatty acid oxidation leads to ketones such as acetone, beta-hydroxybutyrate, and aceto-acetate. This, in turn, leads to an anion gap metabolic acidosis. Acidemia leads to a shift of potassium from cells into the extra-cellular space. Increased glucose production in liver leads to hyperglycemia and osmotic diuresis, with glycosuria and ketonuria. Dehyd 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 >>

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

DKA is an acute complication of diabetes mellitus (usually type 1 diabetes) characterized by hyperglycemia, ketonuria, acidosis, and dehydration. Insulin deficiency prevents glucose from being used for energy, forcing the body to metabolize fat for fuel. Free fatty acids, released from the metabolism of fat, are converted to ketone bodies in the liver. Increase in the secretion of glucagon, catecholamines, growth hormone, and cortisol, in response to the hyperglycemia caused by insulin deficiency, accelerates the development of DKA. Osmotic diuresis caused by hyperglycemia creates a shift in electrolytes, with losses in potassium, sodium, phosphate, and water. Serum glucose level is usually elevated over 300 mg/dL; may be as high as 1,000 mg/dL. Serum bicarbonate and pH are decreased due to metabolic acidosis, and partial pressure of carbon dioxide is decreased as a respiratory compensation mechanism. Serum sodium and potassium levels may be low, normal, or high due to fluid shifts and dehydration, despite total body depletion. Urine glucose is present in high concentration and specific gravity is increased, reflecting osmotic diuresis and dehydration. Observe for cardiac changes reflecting dehydration, metabolic acidosis, and electrolyte imbalance- hypotension; tachycardia; weak pulse; electrocardiographic changes, including elevated P wave, flattened T wave or inverted, prolonged QT interval. Administer replacement electrolytes and insulin as ordered. Flush the entire I.V. infusion set with solution containing insulin and discard the first 50 mL because plastic bags and tubing may absorb some insulin and the initial solution may contain decreased concentration of insulin. Continue reading >>

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