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Pediatric Dka Guidelines 2017

Update Regarding Diabetic Ketoacidosis In Children And Controversies In Management

Update Regarding Diabetic Ketoacidosis In Children And Controversies In Management

Update Regarding Diabetic Ketoacidosis In Children And Controversies In Management King Abdullah Specialized Childrens Hospital, King Abdullah International Medical and Research Center, King Abdulaziz Medical City Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia King Abdullah International Medical and Research Center King Abdullah Specialized Childrens Hospital King Abdulaziz Medical City Ministry of National Guard Health Affairs Submitted date: February 21, 2018; Accepted date: March 09, 2018; Published date: March 16, 2018 Visit for more related articles at Quality in Primary Care Diabetic ketoacidosis (DKA) is a serious complication among pediatric population suffering from Diabetes Mellitus and it is associated with significant risk of life threatening complications resulting in increased morbidity and mortality. Overall the DKA management is well harmonized through recommended guidelines with a few emerging concerns relevant to the management and location of admissions for patients with different levels of severity of DKA , i.e. mild, moderate, severe. With emerging suggestions of revising the guidelines it is important to maintain the quality of care by careful evaluation of existing literature and properly designed future researches in pediatric population. Then to define the correct population of pediatric DKA patients who might be benefitted from the proposed revisions. Additionally, continuing awareness of primary health care providers is crucially important about the latest concepts as this can remarkably improve care in children having DM and DKA. Here is presented some literature review relevant to the emerging concerns with the aim to help improve quality of care. The aim of this article is to identify the controversies in manage Continue reading >>

Pem Pearls: Treatment Of Pediatric Diabetic Ketoacidosis And The Two-bag Method

Pem Pearls: Treatment Of Pediatric Diabetic Ketoacidosis And The Two-bag Method

Insulin does MANY things in the body, but the role we care about in the Emergency Department is glucose regulation. Insulin allows cells to take up glucose from the blood stream, inhibits liver glucose production, increases glycogen storage, and increases lipid production. When insulin is not present, such as in patients with Type 1 diabetes mellitus (DM), all of the opposite effects occur. A lack of insulin causes the following downstream effects: Prevents glucose from being used as an energy source – Free fatty acids are used instead and produce ketoacids during metabolism. Causes a surge of stress hormones and induces gluconeogenesis – When blood glucose levels are elevated, the kidneys cannot absorb all of the glucose from the urine, and the extra glucose in the urine causes polyuria, even in the setting of dehydration. In addition, acidosis causes potassium to shift out of cells into the blood, and the combination of this with dehydration causes the body to preferentially retain sodium at the expense of potassium.1,2 When insulin homeostasis is disrupted and decompensates, patients are at risk for developing diabetic ketoacidosis (DKA). All of the following criteria are required for a diagnosis of DKA: Hyperglycemia (glucose >200 mg/dL) Acidosis (pH <7.3 or bicarb <15 mmol/L) Ketosis (by urine or blood test) Treatment is based on a simple principle: return the body’s glucose regulation to its normal state and replace all of the things the body consumed while insulin-deficient. While bolus insulin is common in the treatment of DKA in adults, it is relatively contraindicated in the pediatric patient. Dehydration and secondary sympathetic activation can interfere with local tissue perfusion and may cause irregular and unpredictable absorption. Step 1: Correction Continue reading >>

Children's Hospital Of Philadelphia

Children's Hospital Of Philadelphia

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact us. ©2017 by Children's Hospital of Philadelphia, all rights reserved. Use of this site is subject to the Terms of Use. The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located. Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient. Continue reading >>

My Site - Chapter 34: Type 1 Diabetes In Children And Adolescents

My Site - Chapter 34: Type 1 Diabetes In Children And Adolescents

Screen all children with type 1 diabetes at least twice a year There are important age-related considerations regarding surveillance for diabetes complications and interpretation of investigations ( Table5 ). Risk for microvascular complications accelerates through puberty (152,153) . In an observational study, children with type 1 diabetes with a mean duration of 7.9 years were found to have an age-adjusted prevalence of diabetic nephropathy of 5.8%, retinopathy 5.6%, peripheral neuropathy 8.5%, arterial stiffness 11.6%, hypertension 10.1% and cardiovascular (CV) autonomic neuropathy 14.4% (154) . Prepubertal children and those in the first 5 years of diabetes should be considered at very low risk for albuminuria (152,155) . A first morning urine albumin to creatinine ratio (ACR) has high sensitivity and specificity for the detection of albuminuria (156,157) . Although screening with a random ACR is associated with greater compliance than with a first morning sample, its specificity may be compromised in adolescents due to their higher frequency of exercise-induced proteinuria and benign postural proteinuria. Abnormal random ACRs (i.e. >2.5 mg/mmol) require confirmation with a first morning ACR or timed overnight urine collection (158) . The likelihood of transient or intermittent albuminuria is higher during the early peripubertal years (155) . Individuals with intermittent albuminuria may progress to overt nephropathy (159) . Abnormal screening results require confirmation and follow up to demonstrate persistent abnormalities, as albuminuria can and is more likely to regress in youth compared to older adults (160162) . Treatment is indicated only for those adolescents with persistent albuminuria. One short-term randomized controlled trial in adolescents demonstrated Continue reading >>

Pediatric Diabetic Ketoacidosis – Guideline From Royal Children’s Hospital Melbourne

Pediatric Diabetic Ketoacidosis – Guideline From Royal Children’s Hospital Melbourne

Our goal as primary care physicians is to make the diagnosis of Type 1 Diabetes or Diabetic Ketoacidosis at the earliest opportunity and then immediately arrange for inpatient expert follow up at a tertiary care center. Twenty-five percent of patients with a new diagnosis of diabetes present with diabetic ketoacidosis; a missed diagnosis of diabetes is the most common cause, especially in young children. [from Pediatric Diabetic Ketoacidosis Emergency Department Care of emedicine.medscape.com] What follows are excerpts of Pediatric Type 1 Diabetes Mellitus Clinical Presentation Updated: Apr 27, 2017 from emedicine.medscape.com: Symptoms of ketoacidosis These symptoms include the following: What follows are only excerpts from the Diabetes Mellitus Guideline. Please see the complete protocol] on diabetic ketoacidosis from the Royal Children’s Hospital Melbourne: Background: Diabetic ketoacidosis (DKA) is the combination of hyperglycemia, metabolic acidosis, and ketonaemia. It may be the first presentation for a child with previously undiagnosed diabetes. It can also be precipitated by illness, or poor compliance with taking insulin. All patients presenting with a blood glucose level (BGL) ≥ 11.1mmol/l [200 mg/dl] should have blood ketones tested on a capillary sample using a bedside OptiumTM meter. If this test is positive (>0.6 mmol/l), assess for acidosis to determine further management. Urinalysis can be used for initial assessment if blood ketone testing is not available. The biochemical criteria for DKA are: 1. Venous pH < 7.3 or bicarbonate <15 mmol/l 2. Presence of blood or urinary ketones If ketones are negative, or the pH is normal in the presence of ketones, patients can be managed with subcutaneous (s.c.) insulin (see ‘ new presentation, mildly ill‘ bel Continue reading >>

Managing Diabetes In Preschool Children Ispad Guidelines. Pediatric Diabetes. 2017;119.

Managing Diabetes In Preschool Children Ispad Guidelines. Pediatric Diabetes. 2017;119.

Managing diabetes in preschool children ISPAD Guidelines. Pediatric Diabetes. 2017;119. Frida Sundberg1,2 | Katharine Barnard3 | Allison Cato4 | Carine de Beaufort5,6 | Linda A DiMeglio7 | Greg Dooley8 | Tamara Hershey9,10 | Jeff Hitchcock11 | Vandana Jain12 | Jill Weissberg-Benchell13,14 | Birgit Rami-Merhar15 | The target hemoglobin A1c (HbA1c) for all children with type 1 diabetes, including preschool children, is recommended to be This target is chosen with the aim of minimizing hyperglycemia, severe hypoglycemia, hypoglycemic unawareness, and reducing the likelihood of development of long-term complications Intensive insulin therapy, i.e. as close to physiological insulin replacement as possible with preprandial insulin doses and basal insulin, should be used, with frequent glucose monitoring and Insulin pump therapy is the preferred method of insulin administration for young children (aged <7 years) with type 1 diabetes (E). If pump therapy is not available, multiple daily injections (MDIs), with consideration of use of an injection port, should be For preschool children using intensive insulin therapy, preprandial administration of bolus insulin given for correction if blood glucose is high and for at least part of the meal is preferable to giving the whole dose during or after the meal (C). Greg Dooley is parent of a child with type 1 diabetes diagnosed at age 2, cofounder of the type 1 diabetes blog Inspired by Isabella (www. inspiredbyisabella.com); Jeff Hitchcock is parent of a child with diabetes diagnosed at age 2, founder and president of Children with Diabetes (www. This article is a new chapter in the ISPAD Clinical Practice Consensus Guidelines Compendium. The complete set of guidelines can be found for free download at www.ispad.org. The evidence grad Continue reading >>

Consensus Statements And Guidelines

Consensus Statements And Guidelines

ESPE - European Society of Paediatric Endocrinology ESPE Clinical Practice Committee Statements Consensus Statement on the Use of Gonadotropin-Releasing Hormone Analogs in Children Consensus Statement on the Diagnosis and Treatment of Children with Idiopathic Short Stature: A Summary of the Growth Hormone Research Society, the Lawson Wilkins Pediatric Endocrine Society, and the European Society for Paediatric Endocrinology Workshop Growth Hormone Treatment and Risk of Solid Tumour Endorsed Consensus Statements and Guidelines Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer Treatment of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline JCEM Aug 2015 100 (8) 2807 - 2831 Pharmacological Management of Obesity: An endocrine society clinical practice guideline JCEm feb 2015 100(2) 342 -362 Pediatric Obesity - Assessment, Treatment and prevention: An Endocrine Society Clinical Practice guideline JCEM 2017 102(3)709-757 Diagnosis and treatment of Primary Adrenal insufficiency: An endocrine Society Clinical guideline JCEM Feb 2016 101 (2) 364-389 Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer Thyroid 2015 25(7) 716 - 759 Recommendations from the Pediatric Endocrine Society for Evaluation and Management of Persistent Hypoglycemia in Neonates, Infants, and Children J Paeds 2015 167 (2) 238 - 245 Continue reading >>

M A N A G E M E N T A N D T R E A T M E N T O F

M A N A G E M E N T A N D T R E A T M E N T O F

This care process model (CPM) was developed by Intermountain Healthcare’s Pediatric Clinical Specialties Program. It provides guidance for identifying and managing type 1 diabetes in children, educating and supporting patients and their families in every phase of development and treatment, and preparing our pediatric patients to transition successfully to adulthood and adult diabetes self-management. This CPM is based on guidelines from the American Diabetes Association (ADA), particularly the 2014 position statement Type 1 Diabetes Through the Life Span, as well as the opinion of local clinical experts in pediatric diabetes.ADA1,CHI Pediatric Type 1 Diabetes C a r e P r o c e s s M o d e l F E B R U A R Y 2 0 1 7 2 0 17 U p d a t e Why Focus on PEDIATRIC TYPE 1 DIABETES? Diabetes in childhood carries an enormous burden for patients and their families and represents significant cost to our healthcare system. In 2008, Intermountain Healthcare published the first CPM on the management of pediatric diabetes with the overall goal of helping providers deliver the best clinical care in a consistent and integrated way. What’s new: • Separate CPMs for type 1 and type 2 pediatric diabetes to promote more- accurate diagnosis and more-focused education and treatment. • Updated recommendations for diagnostic testing, blood glucose control, and follow-up care specifically related to pediatric type 1 diabetes. • A more comprehensive view of treatment for pediatric type 1 diabetes — one that emphasizes psychosocial wellness for patient and family and lays a foundation for better health over the lifespan. • Information and tools to support pediatric type 1 diabetes care by nonspecialist providers — important for coping with the ongoin Continue reading >>

Review Of Evidence For Adult Diabetic Ketoacidosis Management Protocols

Review Of Evidence For Adult Diabetic Ketoacidosis Management Protocols

1Department of Endocrinology, Austin Health, Melbourne, VIC, Australia 2Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia 3Department of Intensive Care, Austin Health, Melbourne, VIC, Australia 4Menzies School of Health Research, Darwin, NT, Australia Background: Diabetic ketoacidosis (DKA) is an endocrine emergency with associated risk of morbidity and mortality. Despite this, DKA management lacks strong evidence due to the absence of large randomised controlled trials (RCTs). Objective: To review existing studies investigating inpatient DKA management in adults, focusing on intravenous (IV) fluids; insulin administration; potassium, bicarbonate, and phosphate replacement; and DKA management protocols and impact of DKA resolution rates on outcomes. Methods: Ovid Medline searches were conducted with limits “all adult” and published between “1973 to current” applied. National consensus statements were also reviewed. Eligibility was determined by two reviewers’ assessment of title, abstract, and availability. Results: A total of 85 eligible articles published between 1973 and 2016 were reviewed. The salient findings were (i) Crystalloids are favoured over colloids though evidence is lacking. The preferred crystalloid and hydration rates remain contentious. (ii) IV infusion of regular human insulin is preferred over the subcutaneous route or rapid acting insulin analogues. Administering an initial IV insulin bolus before low-dose insulin infusions obviates the need for supplemental insulin. Consensus-statements recommend fixed weight-based over “sliding scale” insulin infusions although evidence is weak. (iii) Potassium replacement is imperative although no trials compare replacement rates. (iv) Bicarbonate replacement Continue reading >>

Adherence To Pediatric Diabetic Ketoacidosis Guidelines By Community Emergency Departments Providers

Adherence To Pediatric Diabetic Ketoacidosis Guidelines By Community Emergency Departments Providers

Adherence to pediatric diabetic ketoacidosis guidelines by community emergency departments providers 2Department of Pediatrics, Section of Pediatric Hospital Medicine, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, ROC 4905, Indianapolis, IN 46202-5225 USA 1Section of Pediatric Critical Care Medicine, Indianapolis, IN USA 2Department of Pediatrics, Section of Pediatric Hospital Medicine, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, ROC 4905, Indianapolis, IN 46202-5225 USA Samer Abu-Sultaneh, Phone: 317-948-7185, Email: [email protected] . Received 2017 Jan 4; Accepted 2017 Mar 14. Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Diabetic ketoacidosis (DKA) is a common presentation of type I diabetes mellitus to the emergency departments. Most children with DKA are initially managed in community emergency departments where providers may not have easy access to educational resources or pediatric-specific guidelines and protocols that are readily available at pediatric academic medical centers. The aim of this study is to evaluate adherence of community emergency departments in the state of Indiana to the pediatric DKA guidelines. We performed a retrospective chart review of patients, age 18 years of age or under, admitted to the pediatric intensive care unit with a diagnosis of DKA. A total of 100 patients w Continue reading >>

Diabetes In Childhood And Adolescence

Diabetes In Childhood And Adolescence

POCKETBOOK FOR MANAGEMENT OF IN UNDER-RESOURCED COUNTRIES 2 nd Edition 2017 The Pocket Book was prepared and edited by: • Dr. Graham Ogle, MBBS FRACP, General Manager, IDF Life for a Child Programme, Sydney Australia • Mrs. Angela Middlehurst, RN RSCN CDE, Education Manager, IDF Life for a Child Programme, Sydney Australia • Prof. Martin Silink, MBBS, MD, FRACP, Professor of Paediatric Endocrinology, University of Sydney and Chairman, IDF Life for a Child Programme and Sydney Australia • Assoc. Prof. Ragnar Hanas, MD, PhD, Uddevalla Hospital, NU Hospital Group, Uddevalla, Sweden (for ISPAD) For information on the IDF Life for a Child Programme see Chapter 16 and also www.idf.org/lifeforachild This Pocket book has been prepared and printed with financial support from the Leona M. and Harry B. Helmsley Charitable Trust and the Fondation de l’Orangerie. 2nd Edition, International Diabetes Federation, Brussels, 2017 Pocketbook for Management of Diabetes in Childhood and Adolescence in Under-Resourced Countries 2nd Edition 3 These guidelines have been developed taking into account resource- and cost-related issues affecting care for children and youth with diabetes in developing countries. Healthcare funding and available expertise vary from country to country and often also within a particular country, and therefore it is challenging to write a broad document to meet all needs. The information in these guidelines is aimed to assist health care professionals in developing countries to optimise the clinical practice they are able to give in their particular centre. In many cases, subsequent referral to a centre with greater expertise is appropriate. It is estimated that there are approximately 542,000 children under the age of 15 years with type Continue reading >>

Pem Pearls: Treatment Of Pediatric Diabetic Ketoacidosis And The Two-bag Method

Pem Pearls: Treatment Of Pediatric Diabetic Ketoacidosis And The Two-bag Method

When insulin homeostasis is disrupted and decompensates, patients are at risk for developing diabetic ketoacidosis (DKA). All of the following criteria are required for a diagnosis of DKA: Treatment is based on a simple principle: return the bodys glucose regulation to its normal state and replace all of the things the body consumed while insulin-deficient. While bolus insulin is common in the treatment of DKA in adults, it is relatively contraindicated in the pediatric patient. Dehydration and secondary sympathetic activation can interfere with local tissue perfusion and may cause irregular and unpredictable absorption. If the patient has hypovolemic shock, crystalloid fluid boluses are indicated. However, many experts recommend expanding volume gradually to reduce the risk of cerebral edema. Step 2: Fluids, glucose, and insulin using the 2-Bag Method FLUIDS: Set total fluid rate at 1.5 X maintenance intravenous fluid rate (MIVF). The fluids come from 2 separate bags (saline bag, glucose bag). Institutions vary in the use of crystalloid formulations (NS, NS, or NS). Because the whole body is expected to be potassium depleted, 40 mEq/L of potassium should be added to the fluids*. A common combination is to use 20 mEq of K-Phosphate and 20 mEq of K-Acetate. Because KCl is an additional chloride load that can cause metabolic acidosis, it should be avoided or limited when possible. Other than glucose, it should have the same electrolyte composition as Bag #1. *NOTE on potassium: In severe DKA, the potassium can be profoundly low, and starting insulin before repleting potassium may precipitate symptomatic hypokalemia. Some experts recommend not starting insulin until the potassium has been corrected to above 3.0 mmol/L. If the initial measured potassium is elevated, or the Continue reading >>

Pediatric Diabetic Ketoacidosistreatment & Management

Pediatric Diabetic Ketoacidosistreatment & Management

Pediatric Diabetic KetoacidosisTreatment & Management Author: William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Timothy E Corden, MD more... In patients with diabetic ketoacidosis, the first principals of resuscitation apply (ie, the ABCs [airway, breathing, circulation]). [ 3 ] Outcomes are best when children are closely monitored and a changing status is promptly addressed. [ 39 , 2 ] Give oxygen, although this has no effect on the respiratory drive of acidosis. Diagnose by clinical history, physical signs, and elevated blood glucose. Fluid, insulin, and electrolyte (potassium and, in select cases, bicarbonate) replacement is essential in the treatment of diabetic ketoacidosis. Early in the treatment of diabetic ketoacidosis, when blood glucose levels are very elevated, the child can continue to experience massive fluid losses and deteriorate. Strict measurement of fluid balance is essential for optimal treatment. Continuous subcutaneous insulin infusion therapy using an insulin pump should be stopped during the treatment of diabetic ketoacidosis. Children with severe acidosis (ie, pH < 7.1) or with altered consciousness should be admitted to a pediatric intensive care unit. In cases in which the occurrence of diabetic ketoacidosis signals a new diagnosis of diabetes, the process of education and support by the diabetes team should begin when the patient recovers. In cases in which diabetic ketoacidosis occurs in a child with established diabetes, explore the cause of the episode and take steps to prevent a recurrence. Following recovery from diabetic ketoacidosis, patients require subcutaneous insulin therapy. Edge JA, Roy Y, Bergomi A, et al. Conscious level in children with diabetic ketoacidosis is related to severity of acidosis and not to blood g Continue reading >>

(pdf) Diabetic Ketoacidosis (dka): Treatment Guidelines

(pdf) Diabetic Ketoacidosis (dka): Treatment Guidelines

The object of this review is to provide the definitions, frequency, risk factors, pathophysiology, diagnostic considerations, and management recommendations for diabetic ketoacidosis (DKA) in children and adolescents, and to convey current knowledge of the causes of permanent disability or mortality from complications of DKA or its management, particularly the most common complication, cerebral ... [Show full abstract] edema (CE). DKA frequency at the time of diagnosis of pediatric diabetes is 10%-70%, varying with the availability of healthcare and the incidence of type 1 diabetes (T1D) in the community. Recurrent DKA rates are also dependent on medical services and socioeconomic circumstances. Management should be in centers with experience and where vital signs, neurologic status, and biochemistry can be monitored with sufficient frequency to prevent complications or, in the case of CE, to intervene rapidly with mannitol or hypertonic saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours; an initial bolus of 10-20 mL/kg 0.9% saline is followed by 0.45% saline calculated to supply maintenance and replace 5%-10% dehydration. Potassium (K) must be replaced early and sufficiently. Bicarbonate administration is contraindicated. The prevention of DKA at onset of diabetes requires an informed community and high index of suspicion; prevention of recurrent DKA, which is almost always due to insulin omission, necessitates a committed team effort. This review deals with the two most serious side effects encountered with insulin pump therapy, severe hypoglycemia and diabetic ketoacidosis (DKA). Although clinical follow-up studies reported decreased rates of severe hypoglycemia, randomized studies have not confirmed this, showing no diff Continue reading >>

Treatment And Complications Of Diabetic Ketoacidosis In Children And Adolescents

Treatment And Complications Of Diabetic Ketoacidosis In Children And Adolescents

INTRODUCTION Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (T1DM), with a case fatality rate ranging from 0.15 percent to 0.31 percent [1-3]. DKA also can occur in children with type 2 DM (T2DM); this presentation is most common among youth of African-American descent [4-8]. (See "Classification of diabetes mellitus and genetic diabetic syndromes".) The management of DKA in children will be reviewed here (table 1). There is limited experience in the management and outcomes of DKA in children with T2DM, although the same principles should apply. The clinical manifestations and diagnosis of DKA in children and the pathogenesis of DKA are discussed elsewhere. (See "Clinical features and diagnosis of diabetic ketoacidosis in children and adolescents" and "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Epidemiology and pathogenesis".) DEFINITION Diabetic ketoacidosis – A consensus statement from the International Society for Pediatric and Adolescent Diabetes (ISPAD) in 2014 defined the following biochemical criteria for the diagnosis of diabetic ketoacidosis (DKA) [9]: Hyperglycemia – Blood glucose of >200 mg/dL (11 mmol/L) AND Metabolic acidosis – Venous pH <7.3 or a plasma bicarbonate <15 mEq/L (15 mmol/L) AND Continue reading >>

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