Can Serum Β-hydroxybutyrate Be Used To Diagnose Diabetic Ketoacidosis?
Abstract OBJECTIVE—Current criteria for the diagnosis of diabetic ketoacidosis (DKA) are limited by their nonspecificity (serum bicarbonate [HCO3] and pH) and qualitative nature (the presence of ketonemia/ketonuria). The present study was undertaken to determine whether quantitative measurement of a ketone body anion could be used to diagnose DKA. RESEARCH DESIGN AND METHODS—A retrospective review of records from hospitalized diabetic patients was undertaken to determine the concentration of serum β-hydroxybutyrate (βOHB) that corresponds to a HCO3 level of 18 mEq/l, the threshold value for diagnosis in recently published consensus criteria. Simultaneous admission βOHB and HCO3 values were recorded from 466 encounters, 129 in children and 337 in adults. RESULTS—A HCO3 level of 18 mEq/l corresponded with βOHB levels of 3.0 and 3.8 mmol/l in children and adults, respectively. With the use of these threshold βOHB values to define DKA, there was substantial discordance (∼≥20%) between βOHB and conventional diagnostic criteria using HCO3, pH, and glucose. In patients with DKA, there was no correlation between HCO3 and glucose levels on admission and a significant but weak correlation between βOHB and glucose levels (P < 0.001). CONCLUSIONS—Where available, serum βOHB levels ≥3.0 and ≥3.8 mmol/l in children and adults, respectively, in the presence of uncontrolled diabetes can be used to diagnose DKA and may be superior to the serum HCO3 level for that purpose. The marked variability in the relationship between βOHB and HCO3 is probably due to the presence of other acid-base disturbances, especially hyperchloremic, nonanion gap acidosis. Recently published consensus criteria for diagnosing diabetic ketoacidosis (DKA) include a serum bicarbonate (HCO3) Continue reading >>
What Does A Doctor Do When A Patient Comes In For An Exam And Smells Really Bad?
I was a doctor in China, and grew up in a hospital because my father is a doctor too. (in the old days, the government run organizations usually have apartments for their employees, :) don't know if it's a good part of this communist country, at least you don't need to buy a house and maintain it, just kidding) So part of my childhood is weird compared to other kids.I usually did my homework with my father’s nurse in a small room next to my father’s office. I saw many things, people came here in a very severe health situation, people died here leaving their crying families alone. The most in my memory is crying, you can hear that everywhere in a hospital. About smell, I don't think they have time to think about this. Then, as a doctor, I don't care about that too. When I pick my friends or I teach my kids, an important thing is to “respect others”, that means I want them to be “appropriate” in normal life ( I don't know if I use this word correctly, English is not my native language) including a well dress style and being clean. But, a patient, not “normal”, sometimes they can't take a shower because they are very sick, sometimes they forgot taking a shower because they are too old, since they almost forget everything, how could you expect they still remember to shower? Sometimes they can't control pee or incontinece of fecal. I feel sorry for them, I lost my grandma before and I know “keep yourself alive” is the most important thing that time, smell, who cares? And, I have the “smell” sometimes too. When I have my babies, because of the surgery, I can not take a shower for several days, and I really sweat a lot. The doctors and the nurses, they are so nice. They help me changing my cloths many times a day and never a look on their faces sort of Continue reading >>
Diagnosis Of Diabetic Ketoacidosis
diagnostic criteria The diagnostic criteria for diabetic ketoacidosis are: 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 venous bicarbonate (HCO3 ) ) below 15 mmol /l and /or venous pH less than 7.3 (1) The American Diabetes Association diagnostic criteria for DKA are as follows: elevated serum glucose level (greater than 250 mg per dL [13.88 mmol per L]) an elevated serum ketone level a pH less than 7.3 and a serum bicarbonate level less than 18 mEq per L (18 mmol per L) (2) classification of diabetic ketoacidosis DKA can be classified according to the severity into mild, moderate and severe (2) criterion mild (serum glucose > 250 mg/dL [13.88 mmol/L]) moderate (serum glucose > 250 mg/dL) severe (serum glucose > 250 mg/dL) anion gap > 10 mEq/L (10 mmol/L) > 12 mEq/L (12 mmol/L) > 12 mEq/L (12 mmol/L) arterial pH 7.24 to 7.30 7.00 to < 7.24 < 7.00 effective serum osmolality variable variable variable mental status alert alert/drowsy stupor/coma serum bicarbonate 15 to 18 mEq/L (15 to 18 mmol/L) 10 to < 15 mEq/L (10 to < 15 mmol/L) < 10 mEq/L (10 mmol/L) serum ketone positive positive positive urine ketone positive positive positive Reference: Continue reading >>
A Preventable Crisis People who have had diabetic ketoacidosis, or DKA, will tell you it’s worse than any flu they’ve ever had, describing an overwhelming feeling of lethargy, unquenchable thirst, and unrelenting vomiting. “It’s sort of like having molasses for blood,” says George. “Everything moves so slow, the mouth can feel so dry, and there is a cloud over your head. Just before diagnosis, when I was in high school, I would get out of a class and go to the bathroom to pee for about 10–12 minutes. Then I would head to the water fountain and begin drinking water for minutes at a time, usually until well after the next class had begun.” George, generally an upbeat person, said that while he has experienced varying degrees of DKA in his 40 years or so of having diabetes, “…at its worst, there is one reprieve from its ill feeling: Unfortunately, that is a coma.” But DKA can be more than a feeling of extreme discomfort, and it can result in more than a coma. “It has the potential to kill,” says Richard Hellman, MD, past president of the American Association of Clinical Endocrinologists. “DKA is a medical emergency. It’s the biggest medical emergency related to diabetes. It’s also the most likely time for a child with diabetes to die.” DKA occurs when there is not enough insulin in the body, resulting in high blood glucose; the person is dehydrated; and too many ketones are present in the bloodstream, making it acidic. The initial insulin deficit is most often caused by the onset of diabetes, by an illness or infection, or by not taking insulin when it is needed. Ketones are your brain’s “second-best fuel,” Hellman says, with glucose being number one. If you don’t have enough glucose in your cells to supply energy to your brain, yo Continue reading >>
Print If your doctor suspects diabetic ketoacidosis, he or she will do a physical exam and various blood tests. In some cases, additional tests may be needed to help determine what triggered the diabetic ketoacidosis. Blood tests Blood tests used in the diagnosis of diabetic ketoacidosis will measure: Blood sugar level. If there isn't enough insulin in your body to allow sugar to enter your cells, your blood sugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugar level will continue to rise. Ketone level. When your body breaks down fat and protein for energy, acids known as ketones enter your bloodstream. Blood acidity. If you have excess ketones in your blood, your blood will become acidic (acidosis). This can alter the normal function of organs throughout your body. Additional tests Your doctor may order tests to identify underlying health problems that might have contributed to diabetic ketoacidosis and to check for complications. Tests might include: Blood electrolyte tests Urinalysis Chest X-ray A recording of the electrical activity of the heart (electrocardiogram) Treatment If you're diagnosed with diabetic ketoacidosis, you might be treated in the emergency room or admitted to the hospital. Treatment usually involves: Fluid replacement. You'll receive fluids — either by mouth or through a vein (intravenously) — until you're rehydrated. The fluids will replace those you've lost through excessive urination, as well as help dilute the excess sugar in your blood. Electrolyte replacement. Electrolytes are minerals in your blood that carry an electric charge, such as sodium, potassium and chloride. The absence of insulin can lower the level of several electrolytes in your blood. You'll receive electrolytes throu Continue reading >>
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: 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. 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. 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 >>
show all detail Diagnostic Tests 1st Tests To Order Test Result plasma glucose To access clinical pearls and in-depth diagnosis and treatment information, sign up for a FREE Epocrates Online account. Sign Up Now! Current Members - Sign In elevated ABG To access clinical pearls and in-depth diagnosis and treatment information, sign up for a FREE Epocrates Online account. Sign Up Now! Current Members - Sign In pH varies from 7.00 to 7.30 in DKA; arterial bicarbonate ranges from <10 mEq/L in severe DKA to >15 mEq/L in mild DKA capillary or serum ketones To access clinical pearls and in-depth diagnosis and treatment information, sign up for a FREE Epocrates Online account. Sign Up Now! Current Members - Sign In beta-hydroxybutyrate elevated ≥3.8 mmol/L in adults or ≥3.0 mmol/L in children U/A To access clinical pearls and in-depth diagnosis and treatment information, sign up for a FREE Epocrates Online account. Sign Up Now! Current Members - Sign In positive for glucose and ketones; positive for leukocytes and nitrites in the presence of infection serum BUN To access clinical pearls and in-depth diagnosis and treatment information, sign up for a FREE Epocrates Online account. Sign Up Now! Current Members - Sign In elevated serum creatinine To access clinical pearls and in-depth diagnosis and treatment information, sign up for a FREE Epocrates Online account. Sign Up Now! Current Members - Sign In elevated serum sodium To access clinical pearls and in-depth diagnosis and treatment information, sign up for a FREE Epocrates Online account. Sign Up Now! Current Members - Sign In usually low serum potassium To access clinical pearls and in-depth diagnosis and treatment information, sign up for a FREE Epocrates Online account. Sign Up Now! Current Members - Sign In usually el Continue reading >>
Point-of-care Screening For Diabetic Ketoacidosis
Summarized from Arora S, Henderson S, Long T, Menchine M. Diagnostic accuracy of point of care testing for diabetic ketoacidosis at Emergency Department triage. Diabetes Care 2011; 34: 852-54 Diabetic ketoacidosis (DKA), a common acute and potentially life-threatening complication of diabetes that results from insulin deficiency, is characterized by raised blood glucose (hyperglycemia) and metabolic acidosis. Metabolic acidosis occurs due to abnormal accumulation in blood of ketoacids, principally ß-hydroxybutyric acid and acetoacetic acid. In an emergency care setting it is common practice to screen all patients with hyperglycemia for DKA using urine dipstick testing for the presence of ketones (i.e. the two ketoacids and acetone, a metabolite of acetoacetic acid). An alternative approach is now available, made possible by the development of point-of-care analyzers that allow rapid (within 1 minute) estimation of serum ß-hydroxybutyrate concentration from a drop of venous blood. The latest of several studies comparing the reliability of traditional urine dipstick testing with that of the newer point-of-care blood testing to diagnose DKA is recently published. The study population comprised 516 patients who on routine triage testing following admission to the emergency department of a Californian hospital were found to have blood glucose in excess of 250 mg/dL (13.9 mmol/L). All were submitted for DKA screening using both urine dipstick testing for ketones and point-of-care blood measurement of serum ß-hydroxybutyrate concentration. A diagnosis of DKA was ultimately confirmed in 54 of the 516 hyperglycemic patients. Urine dipstick testing for ketones was positive in 53 of the 54 patients with DKA (sensitivity 98.1 %) but was also positive in 300 of the 462 patients w Continue reading >>
As fat is broken down, acids called ketones build up in the blood and urine. In high levels, ketones are poisonous. This condition is known as ketoacidosis. Diabetic ketoacidosis (DKA) is sometimes the first sign of type 1 diabetes in people who have not yet been diagnosed. It can also occur in someone who has already been diagnosed with type 1 diabetes. Infection, injury, a serious illness, missing doses of insulin shots, or surgery can lead to DKA in people with type 1 diabetes. People with type 2 diabetes can also develop DKA, but it is less common. It is usually triggered by uncontrolled blood sugar, missing doses of medicines, or a severe illness. Continue reading >>
The Facts Diabetic ketoacidosis (DKA) is a condition that may occur in people who have diabetes, most often in those who have type 1 (insulin-dependent) diabetes. It involves the buildup of toxic substances called ketones that make the blood too acidic. High ketone levels can be readily managed, but if they aren't detected and treated in time, a person can eventually slip into a fatal coma. 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. Although much less common, DKA can occasionally occur in people with type 2 diabetes under extreme physiologic stress. Causes 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 Continue reading >>
Delayed Diagnosis Of Diabetic Ketoacidosis In Children—a Cause For Concern
Abstract Diabetic ketoacidosis (DKA) is the major cause for mortality in children with diabetes mellitus (DM). Delayed diagnosis or missed diagnosis is common among children with DKA. This study was undertaken to identify the impact of delayed diagnosis on clinical presentation, complications, and mortality of DKA in children from a tertiary care center at Chennai. Among the 118 episodes of DKA in 100 children less than 12 years of age, delayed diagnosis was more common in new onset diabetes mellitus (DM). Forty-four out of 68 children with new onset DM with DKA (64.7 %) had delayed diagnosis. Thirty-two children with established diabetes presented with 50 episodes of DKA. Among these, eight episodes (16 %) had a delay in diagnosis; 85.7 % of infants, 76.9 % of toddlers, and 58 % of the preschool and school children had delayed diagnosis. Urinary tract infections, respiratory illness, vomiting, febrile illness, acute abdomen, and encephalopathy were the common diagnosis in children where DKA was missed. The causes for delay in diagnosis and management of DKA were lack of parental and physician awareness, improper referral, and delayed transport. Presence of shock, altered sensorium, severe DKA, lower PaCO2 at admission, and complications like renal failure and cerebral edema were higher in children with delayed diagnosis of DKA. This was found to be statistically significant. Delayed diagnosis was a significant risk factor for mortality in children with DKA (p = 0.00) in this study population. Continue reading >>
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 >>
Can I Expect Diabetes Patients Have Normal Life?
Sympler, Your Health Buddy says, After diabetes diagnosis, many type 1 and type 2 diabetics worry about their life expectancy. Death is never a pleasant subject but it's human nature to want to know 'how long can I expect to live'. There is no hard and fast answer to the question of ‘how long can I expect to live’ as a number of factors influence one’s life expectancy. How soon diabetes was diagnosed, the progress of diabetic complications and whether one has other existing conditions will all contribute to one’s life expectancy - regardless of whether the person in question has type 1 or type 2 diabetes. People with type 1 diabetes have traditionally lived shorter lives, with life expectancy having been quoted as being reduced by over 20 years. However, improvement in diabetes care in recent decades indicates that people with type 1 diabetes are now living significantly longer. According to the experts, people with type 1 diabetes born after 1965 had a life expectancy of 69 years. What causes a shorter life expectancy in diabetics? Higher blood sugars over a period of time allow diabetic complications to set in, such as: Diabetic retinopathy Kidney disease Cardiovascular disease (heart disease) Higher blood sugars can often be accompanied by associated conditions such as: Higher blood pressure High cholesterol Both help to contribute to poor circulation and further the damage to organs such as the heart, kidneys, eyes and nerves in particular. In some cases, short term complications such as hypoglycemia and diabetic ketoacidosis can also be fatal. What can a diabetic patient do to help increase his/her life expectancy? Maintaining good blood glucose control is a key way to prolong the length of your life. Keeping blood sugar levels within the recommended blood Continue reading >>
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 >>
Original Article The Value Of Venous Blood Gas Analysis In The Diagnosis Of Diabetic Ketoacidosis
Abstract Newer blood gas analyzers have the ability to report electrolyte values and glucose in addition to pH, so this diagnostic process could be condensed in diagnosing diabetic ketoacidosis (DKA). We aimed to assess the accuracy of the venous blood gas (VBG) analysis with electrolytes for diagnosing DKA. This study prospectively identified a convenience sample of (60 patients) presented with DKA and tested their VBG and serum electrolytes. The diagnosis of DKA was made according to American Diabetes Association criteria. Serum chemistry electrolyte values were considered to be the criterion standard. Sensitivity and specificity of VBG electrolytes results were compared against this standard. In addition, correlation coefficients for individual electrolytes between VBG electrolytes and laboratory chemistry electrolytes were calculated. Paired VBG and serum chemistry panels were available for 60 patients, only 49 patients were included, In this study; 20% of cases were newly diagnosed diabetes mellitus. The total number of diabetic ketoacidosis was 14 patients (28.5%). The sensitivity and specificity of the VBG and electrolytes for diagnosing DKA was 92.9% (95% confidence interval [CI] = 89% to 99%) and 97.1% (95% CI = 92% to 100%), respectively. Correlation coefficients between VBG and serum chemistry were 0.91, 0.47, 0.61, 0.65, and 0.58 for blood sugar, sodium, potassium, chloride, and creatinine respectively. Findings of this study offer preliminary support for the possibility of using VBG sample rather than VBG sample and serum chemistry electrolytes together to rule out diabetic ketoacidosis. Continue reading >>