Diabetic Emergencies-diagnosis And Clinical Management: Diabetic Ketoacidosis In Adults, Part 2
Hyperglycemia Hyperglycemia in DKA is the result of reduced glucose uptake and utilization from the liver, muscle, and fat tissue and increased gluconeogenesis as well as glycogenolysis. The lack of insulin results in an increase in gluconeogenesis, primarily in the liver but also in the kidney, and increased glycogenolysis in liver and muscle.8,9 In addition, the inhibitory effect of insulin on glucagon secretion is abolished and plasma glucagon levels increase. The increase of glucagon aggravates hyperglycemia by enhancing gluconeogenesis and glycogenolysis. In parallel, the increased concentrations of the other counter-regulatory hormones enhance further gluconeogenesis. In addition to increased gluconeogenesis, in DKA there is excess production of substances which are used as a substrate for endogenous glucose production. Thus, the amino acids glutamine and alanine increase because of enhanced proteolysis and reduced protein synthesis.8,9 Hyperglycemia-induced osmotic diuresis leads to dehydration, hyperosmolality, electrolyte loss (Na+, K +, Mg 2 +, PO 4 3+, Cl−, and Ca+), and eventually decline in glomerular filtration rate. With decline in renal function, glucosuria diminishes and hyperglycemia worsens. Dehydration results in augmentation of plasma osmolality, which results in water movement out of the cells to the extracellular space. Osmotic diuresis caused by hyperglycemia results in loss of sodium in urine; in addition, the excess of glucagon aggravates hyponatremia because it inhibits reabsorption of sodium in the kidneys. With impaired insulin action and hyperosmolality, utilization of potassium by skeletal muscles is markedly decreased leading to intracellular potassium deficiency. Potassium is also lost due to osmotic diuresis. In addition, metabolic ac Continue reading >>
Initial Evaluation Initial evaluation of patients with DKA includes diagnosis and treatment of precipitating factors (Table 14–18). The most common precipitating factor is infection, followed by noncompliance with insulin therapy.3 While insulin pump therapy has been implicated as a risk factor for DKA in the past, most recent studies show that with proper education and practice using the pump, the frequency of DKA is the same for patients on pump and injection therapy.19 Common causes by frequency Other causes Selected drugs that may contribute to diabetic ketoacidosis Infection, particularly pneumonia, urinary tract infection, and sepsis4 Inadequate insulin treatment or noncompliance4 New-onset diabetes4 Cardiovascular disease, particularly myocardial infarction5 Acanthosis nigricans6 Acromegaly7 Arterial thrombosis, including mesenteric and iliac5 Cerebrovascular accident5 Hemochromatosis8 Hyperthyroidism9 Pancreatitis10 Pregnancy11 Atypical antipsychotic agents12 Corticosteroids13 FK50614 Glucagon15 Interferon16 Sympathomimetic agents including albuterol (Ventolin), dopamine (Intropin), dobutamine (Dobutrex), terbutaline (Bricanyl),17 and ritodrine (Yutopar)18 DIFFERENTIAL DIAGNOSIS Three key features of diabetic acidosis are hyperglycemia, ketosis, and acidosis. The conditions that cause these metabolic abnormalities overlap. The primary differential diagnosis for hyperglycemia is hyperosmolar hyperglycemic state (Table 23,20), which is discussed in the Stoner article21 on page 1723 of this issue. Common problems that produce ketosis include alcoholism and starvation. Metabolic states in which acidosis is predominant include lactic acidosis and ingestion of drugs such as salicylates and methanol. Abdominal pain may be a symptom of ketoacidosis or part of the inci Continue reading >>
With What Diet Can I Lose A Lot Of Weight Fast?
Look, almost any diet will make you lose weight. But what are you going to do when you’re finished with them? If you’re like most people, you’ll fall back on your old habits—the same ones that made you fat in the first place. That’s why most diets end in failure. It’s not that they’re ineffective—although some are complete rubbish; it’s that they’re a temporary answer to a semi-permanent problem. Here’s what you need to find out: what’s the healthiest form of food consumption you can enjoy for the rest of your life? Maybe you like veganism? Or paleo, or keto, or whatever. Perhaps you don’t end up in any diet camp and instead create your own habits. That’s great too. But here’s what matters for right now: if you want to lose weight, then you must consume food at a caloric deficit. This means eating less calories than you burn. I lost eighty pounds a number of years ago. About fifty to sixty pounds of that came without any exercise; I simply ate at a caloric deficit and tracked everything on MyFitnessPal—an online food journal with a mobile app. Similar stories can be found daily on forums like Reddit’s /r/loseit. You can literally achieve this eating junk food. (although I don’t recommend it!) A professor at Kansas State University lost 27lbs in 2 months eating Twinkies, chips, Oreos, and other junk. More recently, I lost 6lbs after eating exclusively at gas stations for 30 days. I traveled across 9 states and visited more than 200 stores—all in an effort to prove that you can “eat out” and still be healthy. But to be fair, the convenience store industry is working hard to make healthful food available on-the-go. Finding fruit, veggies, and good made-to-order options was easier than I thought it would be. So here’s the point: d Continue reading >>
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Will Obese People Starve To Death Before Their Fat Runs Out?
Treating obesity by total starvation is not advised as it can be very dangerous. There are many reports of total starvation leading to death. Some people have died of heart failure during the fast. Some people have died during the re-feeding period after the fast from lactic acidosis. There was a case of a successful medically managed fast in Scotland in 1965. A 27-year-old man weighing 207 kilograms, described as "grossly obese" turned up at the Department of Medicine at the Royal Infirmary in Dundee. He said he was sick of being fat and wanted to lose weight by eating nothing and living off his body fat. Doctors advised against this but told them he was going to fast flat out, whatever they said, so they may as well monitor him along the way. The staff gave him yeast tablets, multi-vitamins and essential minerals. Potassium is essential for the proper working of the heart, and when his potassium levels got a little low around the 100-day mark, he was given potassium tablets for about 70 days. He defecated infrequently, roughly every 40 to 50 days. He ended up fasting for one year and 17 days. Apart from water and the vitamin and mineral supplements he lived entirely off his copious body fat. He lost about 125 kilograms of weight over 382 days. Link below to paper about the case from BMJ Publishing Group: Features of a successful therapeutic fast of 382 days' duration: 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 >>
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 >>
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 >>
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 >>
Diabetes With Ketone Bodies In Dogs
Studies show that female dogs (particularly non-spayed) are more prone to DKA, as are older canines. Diabetic ketoacidosis is best classified through the presence of ketones that exist in the liver, which are directly correlated to the lack of insulin being produced in the body. This is a very serious complication, requiring immediate veterinary intervention. Although a number of dogs can be affected mildly, the majority are very ill. Some dogs will not recover despite treatment, and concurrent disease has been documented in 70% of canines diagnosed with DKA. Diabetes with ketone bodies is also described in veterinary terms as diabetic ketoacidosis or DKA. It is a severe complication of diabetes mellitus. Excess ketone bodies result in acidosis and electrolyte abnormalities, which can lead to a crisis situation for your dog. If left in an untreated state, this condition can and will be fatal. Some dogs who are suffering from diabetic ketoacidosis may present as systemically well. Others will show severe illness. Symptoms may be seen as listed below: Change in appetite (either increase or decrease) Increased thirst Frequent urination Vomiting Abdominal pain Mental dullness Coughing Fatigue or weakness Weight loss Sometimes sweet smelling breath is evident Slow, deep respiration. There may also be other symptoms present that accompany diseases that can trigger DKA, such as hypothyroidism or Cushing’s disease. While some dogs may live fairly normal lives with this condition before it is diagnosed, most canines who become sick will do so within a week of the start of the illness. There are four influences that can bring on DKA: Fasting Insulin deficiency as a result of unknown and untreated diabetes, or insulin deficiency due to an underlying disease that in turn exacerba Continue reading >>
What You Should Know About Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA) is a serious condition that can occur in diabetes. DKA happens when acidic substances, called ketones, build up in your body. Ketones are formed when your body burns fat for fuel instead of sugar, or glucose. That can happen if you don’t have enough insulin in your body to help you process sugars. Learn more: Ketosis vs. ketoacidosis: What you should know » Left untreated, ketones can build up to dangerous levels. DKA can occur in people who have type 1 or type 2 diabetes, but it’s rare in people with type 2 diabetes. DKA can also develop if you are at risk for diabetes, but have not received a formal diagnosis. It can be the first sign of type 1 diabetes. DKA is a medical emergency. Call your local emergency services immediately if you think you are experiencing DKA. Symptoms of DKA can appear quickly and may include: frequent urination extreme thirst high blood sugar levels high levels of ketones in the urine nausea or vomiting abdominal pain confusion fruity-smelling breath a flushed face fatigue rapid breathing dry mouth and skin It is important to make sure you consult with your doctor if you experience any of these symptoms. If left untreated, DKA can lead to a coma or death. All people who use insulin should discuss the risk of DKA with their healthcare team, to make sure a plan is in place. If you think you are experiencing DKA, seek immediate medical help. Learn more: Blood glucose management: Checking for ketones » If you have type 1 diabetes, you should maintain a supply of home urine ketone tests. You can use these to test your ketone levels. A high ketone test result is a symptom of DKA. If you have type 1 diabetes and have a glucometer reading of over 250 milligrams per deciliter twice, you should test your urine for keton Continue reading >>
Diabetic Ketoacidosis - Symptoms
A A A Diabetic Ketoacidosis Diabetic ketoacidosis (DKA) results from dehydration during a state of relative insulin deficiency, associated with high blood levels of sugar level and organic acids called ketones. Diabetic ketoacidosis is associated with significant disturbances of the body's chemistry, which resolve with proper therapy. Diabetic ketoacidosis usually occurs in people with type 1 (juvenile) diabetes mellitus (T1DM), but diabetic ketoacidosis can develop in any person with diabetes. Since type 1 diabetes typically starts before age 25 years, diabetic ketoacidosis is most common in this age group, but it may occur at any age. Males and females are equally affected. Diabetic ketoacidosis occurs when a person with diabetes becomes dehydrated. As the body produces a stress response, hormones (unopposed by insulin due to the insulin deficiency) begin to break down muscle, fat, and liver cells into glucose (sugar) and fatty acids for use as fuel. These hormones include glucagon, growth hormone, and adrenaline. These fatty acids are converted to ketones by a process called oxidation. The body consumes its own muscle, fat, and liver cells for fuel. In diabetic ketoacidosis, the body shifts from its normal fed metabolism (using carbohydrates for fuel) to a fasting state (using fat for fuel). The resulting increase in blood sugar occurs, because insulin is unavailable to transport sugar into cells for future use. As blood sugar levels rise, the kidneys cannot retain the extra sugar, which is dumped into the urine, thereby increasing urination and causing dehydration. Commonly, about 10% of total body fluids are lost as the patient slips into diabetic ketoacidosis. Significant loss of potassium and other salts in the excessive urination is also common. The most common 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 >>
As A Doctor, What Is The Biggest Mistake That You've Made?
My biggest mistake was giving too much naloxone to a patient with opioid tolerance because she as bradypneic. For non medical people browsing: Naloxone is an opioid reversal drug (an antidote). When people overdose on opioids, such as morphine, you can inject that drug to quickly “wake them up”. People overdosing on morphine breath slowly. They can even stop breathing (which isn’t optimal, obviously). My patient was breathing slowly (6 per minute) and her blood oxygen level was low (low 80%). She had been on morphine for a long time for chronic pain, so she was taking impressive doses of morphine. She wouldn’t wake up, so I thought I’d give her a little naloxone to help with her breathing. I went for the lowest dose recommended in the monograph (1/10 of a full dose), because I knew I just needed to control her breathing. It turns out that in order to do that, the dose is 1/10 of what I gave her (1/100 of the full dose). She woke up a few seconds after the injection. Then she started screaming. She was in agony. I had completely reversed her morphine. The unfortunate thing with naloxone is that the only way to “fix it” is to wait. 30 minutes of a woman screaming on the ward. We tried hard to help her through it, but it was terrifying. I wrote about that experience on my blog. That story is one of the main reason why I wrote my app, MD on Call after my first year of residency. We rarely talk about our mistakes, but we should. People learn from others mistakes. On top of that, everyone makes mistakes. Everyone. 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 >>
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 >>