Diabetic Ketoacidosis And Hyperglycaemic Hyperosmolar State
The hallmark of diabetes is a raised plasma glucose resulting from an absolute or relative lack of insulin action. Untreated, this can lead to two distinct yet overlapping life-threatening emergencies. Near-complete lack of insulin will result in diabetic ketoacidosis, which is therefore more characteristic of type 1 diabetes, whereas partial insulin deficiency will suppress hepatic ketogenesis but not hepatic glucose output, resulting in hyperglycaemia and dehydration, and culminating in the hyperglycaemic hyperosmolar state. Hyperglycaemia is characteristic of diabetic ketoacidosis, particularly in the previously undiagnosed, but it is the acidosis and the associated electrolyte disorders that make this a life-threatening condition. Hyperglycaemia is the dominant feature of the hyperglycaemic hyperosmolar state, causing severe polyuria and fluid loss and leading to cellular dehydration. Progression from uncontrolled diabetes to a metabolic emergency may result from unrecognised diabetes, sometimes aggravated by glucose containing drinks, or metabolic stress due to infection or intercurrent illness and associated with increased levels of counter-regulatory hormones. Since diabetic ketoacidosis and the hyperglycaemic hyperosmolar state have a similar underlying pathophysiology the principles of treatment are similar (but not identical), and the conditions may be considered two extremes of a spectrum of disease, with individual patients often showing aspects of both. Pathogenesis of DKA and HHS Insulin is a powerful anabolic hormone which helps nutrients to enter the cells, where these nutrients can be used either as fuel or as building blocks for cell growth and expansion. The complementary action of insulin is to antagonise the breakdown of fuel stores. Thus, the relea Continue reading >>
Symptoms Of Kussmaul Respirations: Its Causes And Treatment
Kussmaul respiration is an abnormal pattern of respiration characterized by deep and hurried breathing. It is one of the most distinctive feature of diabetic ketoacidosis, a serious metabolic complication of diabetes with associated dysfunction of kidneys. Kussmaul breathing causes low level of carbon dioxide in the blood. When the acid content in the blood increases as in metabolic acidosis, diabetic acidosis, or kidney failure, there is increased desire by the patient to breathe deep and rapidly. As a result carbon dioxide saturation in blood decreases. In the beginning, it is shallow and rapid respiration, however, as the condition worsens, it leads to rapid and fast breathing. The patient seems to be gasping for air. This type of abnormal breathing is called Kussmaul respiration. What Causes Kussmaul Respirations? Kussmaul breathing is a condition which results from low level of carbon dioxide in blood. This abnormal form of respiration is commonly seen in people having diabetic ketoacidosis. Kussmaul respiration is deep and fast breathing. Deep breathing and rapid exhalation causes low level of carbon dioxide in the blood leading to hyperventilation. Following conditions can cause kussmaul respiration. Diabetic ketoacidosis: This condition occurs in people suffering from type 1 and type 2 diabetes. It occurs when there is absolute insulin deficiency as in type 1 diabetes or among people with uncontrolled diabetes as in type 2 diabetes. Deficiency of insulin hormone hampers utilization of glucose as an energy source for cellular activity of the muscles and tissues. Body has to rely on fat and protein for energy source instead of glucose, although there is increased circulating glucose in the blood. Breakdown of fat and protein causes release of waste products in the Continue reading >>
What Is Kussmaul Breathing?
People with diabetes mellitus, especially type 1 diabetes and rarely in type 2 diabetes, tend to burn fatty acids which brings changes in the breathing patterns. Apart from diabetes, other forms of metabolic acidosis also result in Kussmaul breathing . The breathing is usually involuntary, in an effort by the body to get rid of unnecessary acids. Read on to find out more about Kussmaul breathing . In type 1 diabetics, when the body runs out of insulin or is not provided with enough insulin (especially during the times of excessive physical activity), it starts to burn fatty acids to produce energy. Burning fatty acids produces ketones as waste products which are released into the blood stream increasing the acidity of the blood (diabetic ketoacidosis). If the kidneys fail to discharge this excess acids through urine or if there is too many of acid units than the kidneys can process, the only way the body can reduce acidity is through respiration. In the beginning the breathing pattern is usually rapid, short, and shallow, and as the acidosis progresses it becomes slow, deep, and long to exhale the acids. This is similar to hyperventilation with characteristics of air hunger and results in a decrease in partial pressure of carbon dioxide and bicarbonate levels in the blood. The reason behind this abnormal breathing pattern is differentiated by the presence of high blood sugar levels from other forms of ketoacidosis. The presence of high blood sugar levels indicates diabetic ketoacidosis. In less severe cases of metabolic acidosis or diabetic ketoacidosis, the breathing usually comes back to normal when the blood’s composition becomes normal. Severe cases of acidosis along with this type of breathing can lead to coma. If you find yourself or someone you know suffering f Continue reading >>
Pediatric Diabetic Ketoacidosis
Author: William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Timothy E Corden, MD more... Diabetic ketoacidosis, in pediatric and adult cases, is a metabolic derangement caused by the absolute or relative deficiency of the anabolic hormone insulin. Together with the major complication of cerebral edema, it is the most important cause of mortality and severe morbidity in children with diabetes. Symptoms of acidosis and dehydration include the following: Abdominal pain - May be severe enough to present as a surgical emergency Shortness of breath - May be mistaken for primary respiratory distress Confusion and coma in the absence of recognized head injury [ 1 ] Symptoms of hyperglycemia, a consequence of insulin deficiency, include the following: Polyuria - Increased volume and frequency of urination Nocturia and secondary enuresis in a previously continent child Weight loss - May be dramatic due to breakdown of protein and fat stores Patients with diabetic ketoacidosis may also have the following signs and symptoms: Signs of intercurrent infection (eg, urinary or respiratory tract infection) Weakness and nonspecific malaise that may precede other symptoms of hyperglycemia Kussmaul breathing or deep sighing respiration - A mark of acidosis Ketone odor - Patient may have a smell of ketones on his/her breath Impaired consciousness - Occurs in approximately 20% of patients Abdominal tenderness - Usually nonspecific or epigastric in location Most cases of cerebral edema occur 4-12 hours after initiation of treatment. Diagnostic criteria of cerebral edema include the following: Abnormal motor or verbal response to pain Cranial nerve palsy - Especially III, IV, and VI Abnormal neurogenic breathing pattern (eg, Cheyne-Stokes), apneusis Altered mentation, fluctuating Continue reading >>
[ketoacidotic Diabetic Metabolic Dysregulation: Pathophysiology, Clinical Aspects, Diagnosis And Therapy].
Abstract When glucose utilisation is impaired due to decreased insulin effect, ketones are produced by the liver from free fatty acids to supply an alternate source of energy. This adaptation may be associated with severe metabolic acidosis and tends to occur in patients with type I (insulin-dependent) diabetes mellitus. In addition, hypovolemia is an almost invariable finding with marked hypoglycemia and is primarily induced by the associated glucosuria. Ketoacidosis stimulates both the central and peripheral chemoreceptors controlling respiration, resulting in alveolar hyperventilation (Kussmaul's respiration). With the ensuing fall in pCO2 the patient tries to raise the extracellular pH. A fruity odor of acetone on the patient's breath sometimes suggests that ketoacidosis is present. The classical triad of symptoms associated with hyperglycemia are polyuria, polydipsia, and weight loss. Circulatory insufficiency with hypotension is not uncommon due to the marked fluid loss and acidemia. In more severely affected patients, neurologic abnormalities may be seen, including lethargy, seizures or coma. Some patients also have marked vomiting and abdominal pain. The history and physical examination may provide important clues to the presence of uncontrolled diabetes mellitus. Once suspected, the diagnosis can be easily confirmed by measuring the plasma glucose concentration. Glucosuria and ketonuria can be semiquantitatively detected with reagent sticks. Blood gas analysis and anion gap give objective information as to the severity of the metabolic acidosis. Therapy must be directed toward each of the metabolic disturbances: hyperosmolality, ketoacidosis, hypovolemia and potassium, and phosphate depletion. The mainstays of therapy are the administration of low-dose insulin 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 >>
What Is Kussmaul Breathing?
Kussmaul breathing is a deep, labored breathing pattern that indicates that the body or organs have become too acidic. The body is constantly doing work to maintain an average temperature and neutral blood acidity. To make sure this balance happens; the kidneys and cells rely on bases or buffers, chemical compounds that bind with hydrogen ions. Disruptions to these compounds cause Kussmaul breathing, which is typically associated with conditions that cause metabolic disturbances, such as kidney failure and diabetes. Contents of this article: Kussmaul breathing is a type of hyperventilation that is the lung's emergency response to acidosis. Kussmaul breathing causes a labored, deeper breathing rate. It is most commonly associated with conditions that cause metabolic acidosis, particularly diabetes. Because Kussmaul breathing is a sign of severe metabolic acidosis, which is a life-threatening condition, hospitalization is usually necessary. What is Kussmaul breathing? When the body produces or ingests too much acid; or the kidneys or lungs are failing, blood acid levels increase. If the blood becomes too acidic, acidosis occurs, and the body takes action to restore the imbalance. By using deeper, longer breaths, the lungs can expel more acidic carbon dioxide (C02) than normal. The condition takes its name from Adolph Kussmaul, the German physician who first described the breathing pattern in 1874. Symptoms As a type of hyperventilation, some people describe Kussmaul breathing as panicked breathing, where someone appears to be gasping for breath. The deep, powerful breathing associated with Kussmaul breathing often causes inhalation and exhalation to become more evident and loud. Some compare the sound to exaggerated sighing. Symptoms of acidosis Before the deep and labore Continue reading >>
Not to be confused with Kussmaul's sign. Graph showing the Kussmaul breathing and other pathological breathing patterns. Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure. It is a form of hyperventilation, which is any breathing pattern that reduces carbon dioxide in the blood due to increased rate or depth of respiration. In metabolic acidosis, breathing is first rapid and shallow but as acidosis worsens, breathing gradually becomes deep, labored and gasping. It is this latter type of breathing pattern that is referred to as Kussmaul breathing. Terminology Adolph Kussmaul, who introduced the term, referred to breathing when metabolic acidosis was sufficiently severe for the respiratory rate to be abnormal or reduced. This definition is also followed by several other sources, including for instance Merriam-Webster, which defines Kussmaul breathing as "abnormally slow deep respiration characteristic of air hunger and occurring especially in acidotic states". Other sources, however, use the term Kussmaul respiration also when acidosis is less severe, in which case breathing is rapid. Note that Kussmaul breathing occurs only in advanced stages of acidosis, and is fairly rarely reached. In less severe cases of acidosis, rapid, shallow breathing is seen. Kussmaul breathing is a kind of very deep, gasping, desperate breathing. Occasionally, medical literature refers to any abnormal breathing pattern in acidosis as Kussmaul breathing; however, this is inaccurate. History Kussmaul breathing is named for Adolph Kussmaul, the 19th century German doctor who first noted it among patients with advanced diabetes mellitus. Kussm Continue reading >>
Diabetic Emergencies: Ketoacidosis
Our flight crew was dispatched to a small local hospital for a 58 year old male with an altered level of consciousness and elevated blood sugar. His son had found him unresponsive on the couch and called EMS for help. While en route to the local hospital a bedside glucose was checked reporting "high." His respiratory rate was 36 and his heart rate was in the 150s. He was slow to respond, but woke to verbal commands and was orientated to person only. At the hospital, another bedside glucose returned "high" and he received 10 units of insulin IV. A foley catheter was inserted draining 1400 ml of urine immediately. The flight crew arrived to find our patient’s LOC without change. Pupils were equal at 3 mm, and sluggish in response to light. Mucous membranes were dry. He had a respiratory rate of 36 breaths per minute and shallow. His lung sounds were clear and equal bilateral. An incision at his right shoulder from a surgery one week ago appeared well healed with no redness or signs of infection. Lab results available at the time of transport were limited to: Glucose — 799 mg/dl CO2 — 3.1 mEq/L ph — 6.77 (venous) Fluid intake — 800 ml 0.9% sodium chloride Urine output — 1400 ml The only medication given so far was regular insulin 10 units IV. Definition: Diabetes mellitus is a chronic disease comprised of a group of hyperglycemic disorders, characterized by high serum glucose, and disturbances of carbohydrate and lipid metabolism. Type 1 The patient is usually less than 40 years old at the time of onset. Peak age of onset is 10 to 14 years old. They are typically lean and ketosis prone. Plasma insulin levels are low to absent. Type 2 This patient is usually 45 to 65 years old at the time of onset. These patients are typically overweight, with normal to high ins Continue reading >>
What Can Cause Kussmaul Breathing & How Is It Treated?
Kussmaul Breathing is the name given to a condition in which the patient develops an extremely deep and labored breathing pattern. This is seen mostly in people who are diabetic and have severe forms of metabolic acidosis, especially diabetic ketoacidosis with kidney dysfunction. Kussmaul Breathing can also be explained as a form of hyperventilation which is a condition in which an individual breathes in such a deep pattern that the level of carbon dioxide decreases in the blood, which is seen mostly in metabolic acidosis where the breathing becomes extremely fast and shallow and as the condition worsens the breathing becomes shallow and deep and it looks as if the individual is virtually gasping for breath. This type of breathing in which the individual is virtually gasping for air is what is termed as Kussmaul Breathing. Kussmaul Breathing is a condition which results due to low levels of carbon dioxide in the blood. It is normally seen in people who have uncontrolled diabetes to level where they develop diabetic ketoacidosis resulting in the patient to have a very shallow and deep breathing. The carbon dioxide level decreases due to the desire of the individual to take a deep breath and exhale more amount of carbon dioxide than the norm resulting in a marked decrease in the level of carbon dioxide in the blood causing hyperventilation or Kussmaul Breathing. The conditions which can cause Kussmaul Breathing are: Diabetic Ketoacidosis: Diabetic ketoacidosis is a condition in which the glucose present in the blood is not able to be used by the body to produce energy because of severe need for insulin which is not there. This results in the inability of the body to get rid of the glucose to produce energy for the body. Metabolic Acidosis: This is a medical condition in w Continue reading >>
What Causes Kussmaul Respiration?
Kussmaul respiration, typically marked by increase in rate and depth of breathing, has been linked to ketoacidosis, a complication in diabetes. Poor kidney function that increases acidity in plasma can also cause this abnormal breathing pattern. Kussmaul respiration is christened after a 19th century German doctor, Adolph Kussmaul who first observed it among patients with uncontrolled diabetes. Kussmaul breathing refers to an unnatural breathing pattern that is typically marked by abnormally low levels of carbon dioxide in the blood. In this condition, the person breathes abnormally too deeply. This is a type of hyperventilation wherein breathing is rapid, yet abnormally deep. The person experiences an overwhelming desire to breathe deeply. This condition has often been associated with people affected with diabetes. The fast deep breathing pattern leads to exhalation of abnormally high amounts of carbon dioxide. As a result, the level of carbon dioxide in the blood decreases dramatically. Kussmaul breathing is likely to be noticed in people affected with ketoacidosis. In this condition, diabetic patients are unable to use sugar (glucose) for energy production. This happens due to acute shortage of insulin, which makes it difficult to drive away the glucose into the cells. The body stops using sugar in favor of fat to generate energy. The breakdown of fats to produce energy, causes release of waste products such as ketones in the bloodstream. Over time, blood ketone levels rise substantially, which is a cause for concern. Due to the accumulation of ketone bodies in the body tissues, diabetic patients tend to have ketone breath. Breathing pattern also changes, which is noticed in the form of deep sighing breaths. This condition is typically marked by acid overload (usual Continue reading >>
What is Kussmaul Breathing? Kussmaul Breathing is the term given to a condition in which the patient builds up an extremely deep and difficult breathing pattern. This is seen mostly in individuals who are diabetic and have severe forms of metabolic acidosis, particularly diabetic ketoacidosis with kidney dysfunction. Kussmaul Breathing can likewise be clarified as a type of hyperventilation which is a condition in which an individual breathes in such a deep pattern, to the point that the level of carbon dioxide reduces in the blood, which is seen for the most part in metabolic acidosis where the breathing turns out to be more quick and shallow and as the condition exacerbates the breathing gets to be distinctly shallow and profound and it looks as though the individual is virtually gasping for breath. This kind of breathing in which the individual is essentially gasping for air is what is named as Kussmaul Breathing. Kussmaul’s Respiration There are diverse medical conditions that can influence the basic/acidic balance in your body, which means your body can turn out to be more basic or acidic. At the point when a man is acidotic, that is to say they are experiencing a pathological process (known as acidosis) that prompts to acidemia, an abnormal low pH of the blood, they may experience Kussmaul’s respiration. Kussmaul’s respiration, as German doctor Adolph Kussmaul himself portrayed, is in fact profound, slow, and labored breathing, which we now know is because of serious acidemia coming from metabolic acidosis. Nonetheless, these days, it is now and again used to portray shallow and rapid breathing examples in instances of less severe acidemia too. Reasons for this breathing pattern happening All things considered, what do you take in? Oxygen, isn’t that so? W Continue reading >>
Kussmaul Breathing - An Overview | Sciencedirect Topics
Nicholas J. White, in Manson's Tropical Infectious Diseases (Twenty-third Edition) , 2014 Hyperventilation or Kussmaul's breathing (sometimes termed respiratory distress) is a poor prognostic sign in malaria. In the tachypnoea associated with high fever, breathing is shallow compared with the ominous laboured hyperventilation associated with metabolic acidosis, pulmonary oedema or bronchopneumonia. Acute pulmonary oedema (acute respiratory distress syndrome) may develop at any time in severe falciparum malaria. It is particularly common in pregnant women, but rare in children. In some cases malaria ARDS may be difficult to distinguish clinically from pneumonia. The heart sounds are normal. The central venous pressure and pulmonary artery occlusion pressures are usually normal, the cardiac index is high and systemic vascular resistance is low. This points to an increase in capillary permeability (unless the patient has been overhydrated). The chest radiograph shows increased interstitial shadowing and a normal heart size. Julian L. Seifter, in Goldman's Cecil Medicine (Twenty Fourth Edition) , 2012 Symptoms include nausea, vomiting, anorexia, polydipsia, and polyuria. Patients often exhibit Kussmaul respirations and volume depletion. Neurologic symptoms include fatigue and lethargy with depression of the sensorium. CSF exhibits a change in acid-base status with treatment of diabetic ketoacidosis. Even without bicarbonate administration, CSF pH falls as a result of the ventilatory response to the correction of acidosis and the sudden rise in Pco2. However, no correlation between decreased CSF pH and depression of sensorium has been established. Ketoacidosis is also seen in cases of starvation, in which it is generally mild and not associated with hyperglycemia. Ketoacids Continue reading >>
Respiratory System And Diabetes
Tweet The respiratory system is the system of organs that allow the body to take in oxygen and expel carbon dioxide, this process is known as gaseous exchange. We generally breathe between 12 and 20 times a minute. There are a number of complications of diabetes that can negatively affect our breathing. Parts of the respiratory system The following parts of the body make up the respiratory system: Mouth and nose Trachea (windpipe) Lungs Diaphragm How the respiratory system works Breathing is usually initiated by contraction of the diaphragm, a muscle which separates the chest cavity from the abdomen. Tweet Type 2 diabetes mellitus is a metabolic disorder that results in hyperglycemia (high blood glucose levels) due to the body: Being ineffective at using the insulin it has produced; also known as insulin resistance and/or Being unable to produce enough insulin Type 2 diabetes is characterised by the body being unable to metabolise glucose (a simple sugar). This leads to high levels of blood glucose which over time may damage the organs of the body. From this, it can be understood that for someone with diabetes something that is food for ordinary people can become a sort of metabolic poison. This is why people with diabetes are advised to avoid sources of dietary sugar. The good news is for very many people with type 2 diabetes this is all they have to do to stay well. If you can keep your blood sugar lower by avoiding dietary sugar, likely you will never need long-term medication. Type 2 diabetes was formerly known as non-insulin-dependent or adult-onset diabetes due to its occurrence mainly in people over 40. However, type 2 diabetes is now becoming more common in young adults, teens and children and accounts for roughly 90% of all diabetes cases worldwide. How serious Continue reading >>
Hammans Syndrome In Diabetic Ketoacidosis
Hammans syndrome in diabetic ketoacidosis Charing Cross Hospital, Imperial College Healthcare Trust, London, UK, Received 2017 Oct 6; Accepted 2017 Nov 8. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License . Hammans syndrome (spontaneous subcutaneous emphysema and pneumomediastinum) is a rare complication of diabetic ketoacidosis (DKA), with a multifactorial etiology. Awareness of this syndrome is important: it is likely underdiagnosed as the main symptom of shortness of breath is often attributed to Kussmauls breathing and the findings on chest radiograph can be subtle and easily missed. It is also important to be aware of and consider Boerhaaves syndrome as a differential diagnosis, a more serious condition with a 40% mortality rate when diagnosis is delayed. We present a case of pneumomediastinum, pneumopericardium, epidural emphysema and subcutaneous emphysema complicating DKA in an eighteen-year-old patient. We hope that increasing awareness of Hammans syndrome, and how to distinguish it from Boerhaaves syndrome, will lead to better recognition and management of these syndromes in patients with diabetic ketoacidosis. Hammans syndrome (spontaneous subcutaneous emphysema and pneumomediastinum) is a rare complication of DKA. Presentation may be with chest or neck pain and shortness of breath, and signs are subcutaneous emphysema and Hammans sign a precordial crunching or popping sound during systole. Boerhaaves syndrome should be considered as a differential diagnosis, especially in cases with severe vomiting. The diagnosis of pneumomediastinum is made on chest radiograph, but a CT thorax with water-soluble oral contrast looking for contrast leak may be required if there is high clinical suspicion of Boerrhaves synd Continue reading >>