Ebm Diabetic Ketoacidosis
Epidemiology New diagnosis of diabetes 10-27%. Infection ~ 35%, inadequate insulin ~ 30%, surgery, trauma, alcohol, cocaine and drugs such as steroids, thiazides, sympathomimetics, pentamidine. No cause in 19-38%, but poor compliance / economic reasons frequent. Mortality 1% in adults, but 5% if over 65 years. Also high 15% in patients with hyperglycaemic, hyperosmolar non-ketotic syndrome (HHNS), when BSL usually > 50 mmol/L, more dehydrated with osmolality is > 320 mosm/L – can calculate latter by (2[NA + K] + glucose). Diagnostic Criteria Raised glucose >11.1 mmol/L Acidosis with arterial / venous pH < 7.3, or venous bicarb < 15 mmol/L Ketonaemia or ketonuria (urinalysis may miss 3-beta hydroxybutyrate early). Management / Complications Hypoperfusion Rapid initial crystalloid, especially for significant circulatory insufficiency, at 15-20 mL/kg in first hour ie. 1-1.5 L. Possible role for bicarbonate is in patients with impending cardiovascular collapse, if pH < 6.9. Dilute 100 mmol 8.4% bicarbonate in 250-1000 mL 0.45% NS, and give over 30-60 minutes with 20 mmol K via infusion pump. (Note there are no prospective data concerning bicarbonate use below pH 6.9, and from 6.9-7.1 morbidity and mortality outcomes are equivocal ie. not proven). Fluid replacement Total body water deficit 100 mL/kg, and sodium deficit 7-10 mmol/kg. Restore normal hydration with 0.9% NS at 4-14 mL/kg/hr, to correct estimated fluid deficit over first 24 hours, without exceeding change in osmolality greater than 3 mOsm/kg per hour. One regime is NS 1000 mL in first hour, 500 mL/hr next 4 hours, then 250 mL/hr next 4 hours ie. around 4 L in first 9 hours. Aim to restore fluid deficits over 24 hours in adults, or up to 48 hours in children. Insulin infusion Insulin infusion at 0.1 units/kg/hr Continue reading >>
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 >>
Myths In Dka Management
Anand Swaminathan, MD, MPH (@EMSwami) is an assistant professor and assistant program director at the NYU/Bellevue Department of Emergency Medicine in New York City. Review questions are available at the end of this post. Background Each year, roughly 10,000 patients present to the Emergency Department in diabetic ketoacidosis (DKA). Prior to the advent of insulin, the mortality rate of DKA was 100% although in recent years, that rate has dropped to approximately 2-5%.1 Despite clinical advances, the mortality rate has remained constant over the last 10 years. With aggressive resuscitative measures and appropriate continued management this trend may change. DKA is defined as: Hyperglycemia (glucose > 250 mg/dl) Acidosis (pH < 7.3) Ketosis In the absence of insulin, serum glucose rises leading to osmotic diuresis. This diuresis leads to loss of electrolytes including sodium, magnesium, calcium and phosphorous. The resultant volume depletion leads to impaired glomerular filtration rate (GFR) and acute renal failure. In patients with DKA, fatty acid breakdown produces 2 different ketone bodies, first acetoacetate, which then further converts to beta-hydroxybutyrate, the latter being the ketone body largely produced in DKA patients. With this background in mind, let’s take a look at four urban legends in the management of DKA and the evidence that dispels these legends. Here’s our case: Although this presentation likely represents DKA, a blood gas is typically obtained to confirm the diagnosis. Often, the question arises as to whether an arterial or venous blood gas is adequate. Urban Legend #1 – An ABG is necessary for the diagnosis and treatment of DKA ABG gets you pH, PaO2, PaCO2, HCO3, Lactate, electrolytes and O2Sat VBG gets all this except for PaO2 (but we have Continue reading >>
Diabetic Ketoacidosis
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 >>
Dka (diabetic Ketoacidosis): Real Life In The Emergency Room
This is the first in a series from Susan Dupont RN BSN who is an Emergency Room Nurse and contributor at NRSNG.com . . . Click to View All Articles in the “Real Life in the ER Series” Every patient is a mystery that needs to be solved. Some are easy, some are complex, some aren’t solvable, but the thrill of a good challenge is what keeps me coming back for more. The emergency room is full of unsolved mystery’s. Every once in a while a mystery worth writing about comes along. Altered Mental Status? It was like any normal shift. I had just discharged a patient and walked them out of the ER to turn around and see an EMS stretcher waiting to enter my room. I hadn’t even cleaned the room yet. I grabbed a piece of paper and pen and walked into my favorite type of patient, Altered Mental Status. This patient, a 20-year-old female, had been found wandering around the streets and stumbling around. She didn’t know her name and when she attempted to talk, random words were coming out of her mouth. She would only respond to a sternal rub and her breath was fruity. Vital signs: BP 80/48 mmHg Respirations of 32 Heart rate 125 bpm (sinus tachycardia on her EKG). After getting a reading of >500 blood glucose on the glucometer, we started the search for an IV. This was the challenge of the night. This little girl had absolutely tiny veins that were hidden. Her first IV gave us blood but after starting a bolus of normal saline the line infiltrated, causing a grape sized lump on her forearm. The next IV was in her hand and it worked but was only a 22 gauge. We needed better IV access. After using the infrared goggles and ultrasound we got 2 IV’s, one in each antecubital. Suspicious of Diabetic Ketoacidosis, her lab work confirmed the diagnosis. Her blood work showed: Glucose Continue reading >>
Diabetic Ketoacidosis In Dogs
My dog is diabetic. He has been doing pretty well overall, but recently he became really ill. He stopped eating well, started drinking lots of water, and got really weak. His veterinarian said that he had a condition called “ketoacidosis,” and he had to spend several days in the hospital. I’m not sure I understand this disorder. Diabetic ketoacidosis is a medical emergency that occurs when there is not enough insulin in the body to control blood sugar (glucose) levels. The body can’t use glucose properly without insulin, so blood glucose levels get very high, and the body creates ketone bodies as an emergency fuel source. When these are broken down, it creates byproducts that cause the body’s acid/base balance to shift, and the body becomes more acidic (acidosis), and it can’t maintain appropriate fluid balance. The electrolyte (mineral) balance becomes disrupted which can lead to abnormal heart rhythms and abnormal muscle function. If left untreated, diabetic ketoacidosis is fatal. How could this disorder have happened? If a diabetic dog undergoes a stress event of some kind, the body secretes stress hormones that interfere with appropriate insulin activity. Examples of stress events that can lead to diabetic ketoacidosis include infection, inflammation, and heart disease. What are the signs of diabetic ketoacidosis? The signs of diabetic ketoacidosis include: Excessive thirst/drinking Increased urination Lethargy Weakness Vomiting Increased respiratory rate Decreased appetite Weight loss (unplanned) with muscle wasting Dehydration Unkempt haircoat These same clinical signs can occur with other medical conditions, so it is important for your veterinarian to perform appropriate diagnostic tests to determine if diabetic ketoacidosis in truly the issue at hand Continue reading >>
Diabetic Ketoacidosis
Print Overview Diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. The condition develops when your body can't produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated. If you have diabetes or you're at risk of diabetes, learn the warning signs of diabetic ketoacidosis — and know when to seek emergency care. Symptoms Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. For some, these signs and symptoms may be the first indication of having diabetes. You may notice: Excessive thirst Frequent urination Nausea and vomiting Abdominal pain Weakness or fatigue Shortness of breath Fruity-scented breath Confusion More-specific signs of diabetic ketoacidosis — which can be detected through home blood and urine testing kits — include: High blood sugar level (hyperglycemia) High ketone levels in your urine When to see a doctor If you feel ill or stressed or you've had a recent illness or injury, check your blood sugar level often. You might also try an over-the-counter urine ketones testing kit. Contact your doctor immediately if: You're vomiting and unable to tolerate food or liquid Your blood sugar level is higher than your target range and doesn't respond to home treatment Your urine ketone level is moderate or high Seek emergency care if: Your blood sugar level is consistently higher than 300 milligrams per deciliter (mg/dL), or 16.7 mill Continue reading >>
Emergency Management Of Diabetic Ketoacidosis In Adults
Diabetic ketoacidosis (DKA) is a potentially fatal metabolic disorder presenting most weeks in most accident and emergency (A&E) departments.1 The disorder can have significant mortality if misdiagnosed or mistreated. Numerous management strategies have been described. Our aim is to describe a regimen that is based, as far as possible, on available evidence but also on our experience in managing patients with DKA in the A&E department and on inpatient wards. A literature search was carried out on Medline and the Cochrane Databases using “diabetic ketoacidosis” as a MeSH heading and as textword. High yield journals were hand searched. Papers identified were appraised in the ways described in the Users’ guide series published in JAMA. We will not be discussing the derangements in intermediary metabolism involved, nor would we suggest extrapolating the proposed regimen to children. Although some of the issues discussed may be considered by some to be outwith the remit of A&E medicine it would seem prudent to ensure that A&E staff were aware of the probable management of such patients in the hours after they leave the A&E department. AETIOLOGY AND DEFINITION DKA may be the first presentation of diabetes. Insulin error (with or without intercurrent illness) is the most common precipitating factor, accounting for nearly two thirds of cases (excluding those where DKA was the first presentation of diabetes mellitus).2 The main features of DKA are hyperglycaemia, metabolic acidosis with a high anion gap and heavy ketonuria (box 1). This contrasts with the other hyperglycaemic diabetic emergency of hyperosmolar non-ketotic hyperglycaemia where there is no acidosis, absent or minimal ketonuria but often very high glucose levels (>33 mM) and very high serum sodium levels (>15 Continue reading >>
Diabetic Ketoacidosis: An Emergency Medicine Simulation Scenario
DOI: 10.7759/cureus.1286 Cite this article as: Addison R, Skinner T, Zhou F, et al. (May 29, 2017) Diabetic Ketoacidosis: An Emergency Medicine Simulation Scenario. Cureus 9(5): e1286. doi:10.7759/cureus.1286 Abstract Simulation provides a safe environment where learning is enhanced through the deliberate practice of skills and controlled management of a variety of clinical encounters. This is particularly important for core cases and low-frequency, high-stakes procedures and encounters. Competency-based medical education has seen widespread adoption in the field along with ongoing work in the areas of undergraduate and postgraduate training. Similarly, effective professional development activities stand to benefit greatly from a more stringent integration of simulation and competency-based approaches. This particularly makes sense when considering the goals of patient safety and achievement of optimal clinical outcomes. The current report describes a simulation training session designed to acquaint emergency medicine residents with the presentation and management of diabetic ketoacidosis (DKA) through the use of simulation. Continue reading >>
Treatment Of Diabetic Ketoacidosis In The Emergency Department Utilizing A Web Based Insulin Infusion Algorithm
American Association of Clinical Endocrinologists (AACE) Annual Scientific & Clinical Congress Authors Joseph Aloi,1 Raymie McFarland,2 Margaret Bachand,3 Courtenay Harrison3 Ongoing efforts at improving quality metrics in the care of persons with diabetes frequently focus on avoiding unnecessary hospitalizations, decreasing length of stay and avoiding readmission to hospital following discharge. Our prior experience with Glucommander, a web based insulin dosing algorithm, in inpatient insulin protocols suggested that its use in the emergency department (ED) would be safe. We previously studied the effectiveness of the Glucommander system for the treatment of mild to moderate Diabetic Ketoacidosis (DKA) in the ED and reported early data on 15 patients. We now report a full 1 year experience with 35 patients studied. DKA is a frequent cause for hospital admissions – accounting for up to 8% of general medicine admissions in some hospital studies.4 Current standard treatment protocols involves use of intravenous insulin infusions monitored in the intensive care unit (ICU); raising both the cost and complexity of care. Methods 35 Patients seen in the ED diagnosed with DKA during the 2012 calendar year were reviewed. All patients were studied at a single site – Virginia Beach General Hospital (VGBH) a 300 bed community hospital within the Sentara healthcare system. Patients seen in the ED with either significant hyperglycemia (glucose >300 mg/dL) or DKA were placed on the Glucomander protocol. Patients were then monitored for readiness to be discharged or need for admission. Adult patients with blood glucose >250 mg/dL, a positive anion gap and/or ketonuria were eligible to participate. Patients with severe acidosis (pH <7.0 or serum bicarbonate <10 nmol/L), or a concomi Continue reading >>
- Incidence and Risk Factors of Type 1 Diabetes: Implications for the Emergency Department
- Emergency Preparedness: Diabetes Emergency Kit
- Mutual Involvement in Families With Type 2 Diabetes Through Web-Based Health Care Solutions: Quantitative Survey Study of Family Preferences, Challenges, and Potentials
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 >>
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 (dka) - Topic Overview
Diabetic ketoacidosis (DKA) is a life-threatening condition that develops when cells in the body are unable to get the sugar (glucose) they need for energy because there is not enough insulin. When the sugar cannot get into the cells, it stays in the blood. The kidneys filter some of the sugar from the blood and remove it from the body through urine. Because the cells cannot receive sugar for energy, the body begins to break down fat and muscle for energy. When this happens, ketones, or fatty acids, are produced and enter the bloodstream, causing the chemical imbalance (metabolic acidosis) called diabetic ketoacidosis. Ketoacidosis can be caused by not getting enough insulin, having a severe infection or other illness, becoming severely dehydrated, or some combination of these things. It can occur in people who have little or no insulin in their bodies (mostly people with type 1 diabetes but it can happen with type 2 diabetes, especially children) when their blood sugar levels are high. Your blood sugar may be quite high before you notice symptoms, which include: Flushed, hot, dry skin. Feeling thirsty and urinating a lot. Drowsiness or difficulty waking up. Young children may lack interest in their normal activities. Rapid, deep breathing. A strong, fruity breath odor. Loss of appetite, belly pain, and vomiting. Confusion. Laboratory tests, including blood and urine tests, are used to confirm a diagnosis of diabetic ketoacidosis. Tests for ketones are available for home use. Keep some test strips nearby in case your blood sugar level becomes high. When ketoacidosis is severe, it must be treated in the hospital, often in an intensive care unit. Treatment involves giving insulin and fluids through your vein and closely watching certain chemicals in your blood (electrolyt Continue reading >>
Diabetic Emergencies – Diagnosis And Clinical Management: Diabetic Ketoacidosis In Adults
Diabetic ketoacidosis (DKA) is an acute complication of diabetes mellitus. It is characterized by the triad of hyperglycemia, ketosis, and metabolic acidosis.1 DKA complicates mainly patients with Type 1 diabetes mellitus, where it may be the first manifestation of the disease, and rarely people with Type 2 diabetes.1 A special heterogeneous syndrome of "ketosis – prone diabetes (KPD)," in usually adult patients who may lack the typical clinical phenotype of autoimmune Type 1 diabetes, has recently been identified. While initially the condition was thought to be limited to persons of non-Caucasian ethnicity (African-Americans and Hispanics), its prevalence appears to be increasing worldwide.2 DKA is an emergency situation and hospitalization of the patient is necessary for immediate treatment. Its frequency is reported as 4.8 – 8.0 episodes per 1000 diabetic patients.3,4 The mortality rate is 2.5 – 9% and increases along with age, level of consciousness on admission, degree of hyperosmolality and acidosis, as well as severity of azotemia.5,6 In the US, hospitalizations due to DKA reach 100,000 and the cost of treatment has been reported as 1 billion dollars per year.7… The criteria for the diagnosis of DKA are shown in Table 1.1.8,9 DKA can be mild, moderate, or severe. It is considered severe when the arterial blood pH is less than 7.0, the concentration of plasma bicarbonate is less than 10 mEq/L, and the anion gap is greater than 12 mEq/L. In severe DKA, the patient is in stupor or in coma. Notably, the severity of DKA does not necessarily coincide with the degree of hyperglycemia. DKA can rarely be seen without marked hyperglycemia (euglycemic DKA), and in one series of 722 consecutive episodes of DKA only 1.1% had blood glucose levels less than 180 mg/dl (1 Continue reading >>
Episode 63 – Pediatric Dka
Pediatric DKA was identified as one of key diagnoses that we need to get better at managing in a massive national needs assessment conducted by the fine folks at TREKK – Translating Emergency Knowledge for Kids – one of EM Cases’ partners who’s mission is to improve the care of children in non-pediatric emergency departments across the country. You might be wondering – why was DKA singled out in this needs assessment? It turns out that kids who present to the ED in DKA without a known history of diabetes, can sometimes be tricky to diagnose, as they often present with vague symptoms. When a child does have a known history of diabetes, and the diagnosis of DKA is obvious, the challenge turns to managing severe, life-threatening DKA, so that we avoid the many potential complications of the DKA itself as well as the complications of treatment – cerebral edema being the big bad one. The approach to these patients has evolved over the years, even since I started practicing, from bolusing insulin and super aggressive fluid resuscitation to more gentle fluid management and delayed insulin drips, as examples. There are subtleties and controversies in the management of DKA when it comes to fluid management, correcting serum potassium and acidosis, preventing cerebral edema, as well as airway management for the really sick kids. In this episode we‘ll be asking our guest pediatric emergency medicine experts Dr. Sarah Reid, who you may remember from her powerhouse performance on our recent episodes on pediatric fever and sepsis, and Dr. Sarah Curtis, not only a pediatric emergency physician, but a prominent pediatric emergency researcher in Canada, about the key historical and examination pearls to help pick up this sometimes elusive diagnosis, what the value of serum Continue reading >>
