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What Is Ketoacidosis In Pregnancy

Diabetes: What Is Ketoacidosis And How Can Be Avoided & Treated?

Diabetes: What Is Ketoacidosis And How Can Be Avoided & Treated?

Good question! According to Wikipedia: Diabetic ketoacidosis is a potentially life-threatening complication in patients with diabetes mellitus. In order to define ketoacidosis a little better, let's go back to the source: diabetes. Someone who is diabetic is unable to produce insulin, a hormone necessary for the transfer of sugar from the bloodstream to the cells, which in turn produce energy. If this progression is disrupted, through lack of insulin for example, the body has to try to compensate by creating energy elsewhere. And so the body starts to burn fat and muscle to meet its energy needs. Unfortunately, this chemical reaction produces molecules known as ketone bodies. In small quantities, these are fine, and it is in fact normal to have traces of them in your blood (approximately 1mg/dl). However, if the quantity of ketones surpasses this threshold by too much, it starts to affect the pH of your blood (which becomes progressively more acidic). Even the slightest drop in pH can have dangerous effects: as the quantity of the ketones in your blood increases, and the blood pH diminishes, your kidneys start having problems. Eventually, if the ketoacidosis is left untreated, your kidneys can fail and you can die from dehydration, tachycardia and hypotension. A number of other symptoms can appear in extreme cases. Fortunately for us, the quantity of ketones has to be consequential, and it usually takes a while before individuals start manifesting symptoms. In my case, my diabetes went undiagnosed for a month and a half before it was discovered, and even then my ketone levels were relatively normal. If you're a diabetic, ketoacidosis can be easily avoided by controlling your blood sugar levels and maintaining a healthy lifestyle. Some doctors, preferring to stay on the Continue reading >>

What Is The Nursing Intervention For Diabetic Ketoacidosis?

What Is The Nursing Intervention For Diabetic Ketoacidosis?

My response will be geared towards the emergent presentation amd treatment. 90+ % of the time the blood sugar will be above 500 on your glucometer. Do not let this fool You! Even if it's over 2000 (my highest treated fingerstick glucose was 2042 which wasn't even this patients personal highest) you don't need to worry about administering insulin for about 1–2 hour. You first need great IV access. Being a soon to be ICU admit, I tried my best to give them at least an 18 g and a 20 g preferably not in the AC but access is better than an inconvenient location. These patients are dehydrated so get ready to administer 2 up to 4 liters of fluid. Truthfully Lactated ringers is coming en vogue as NS can worsen the acidosis by raising the chloride levels. With labs pending (electrolytes are the important labs and either an ABG or a VBG… yes a venous gas gives equally treatable results and causes much less pain). If the potassium is above the recommended value you will be able to start an insulin drip and in case you are too in the moment to remember — giving IV insulin will tank a potassium within 30 min or less so replace potassium before administering insulin in this situation!! There are a few options for insulin replacement, some use a computerized algorithm while other base insulin dosage on patient weight ( kg x .01 units/kg/hr is one example) with hourly glucose checks. While administering insulin, if they begin having seizures you will need to give IV glucose, yes it's counter intuitive but it's necessary. Regardless, go with your facilities recommendations. Ensure quality oxygenation/ventilation because the body will do its best to correct the condition itself but sometimes the patient must be intubated. All this to say this- the goal of treatment is to: hydrate, Continue reading >>

Pregnancy Ketoacidosis

Pregnancy Ketoacidosis

Ads by Google Diabetic ketoacidosis is considering as a major cause of fetal loss in diabetes pregnancy. Learn ketoacidosis symptoms, treatment and prevention. Diabetes pregnant ketoacidosis Ketones in the blood and urine are due to starvation, during starvation your body starts to break down fat for energy and ketones released as a byproduct into the urine. You should test ketones if any of the following exists, It is normal during pregnancy, insulin-sensitivity drops by as much as 56% through 36 weeks of gestation. Hormonal changes during pregnancy contribute to this. This increase in insulin requirement progressively raises the incidence of diabetic ketoacidosis, especially during second and third trimesters. The blood-glucose level is uncontrolled because of a lack of insulin, mostly due to infection. Due to lack of insulin, your body does not able to utilize glucose in the blood stream, and your body is in starvation. Your body starts to break down fat, releasing ketones as a byproduct called diabetic ketoacidosis (DKA); a serious condition for both mother and baby. If your blood-glucose level rises exponentially, you should check your urine ketones. If ketones present, you should take extra insulin and increase fluid intake. If it persists for more than three hours, you should get emergency treatment. Generally, during pregnancy, you need extra calories to fulfill both, yours and your fetus requirement. If you are not gaining weight as required, then you have to check your urine ketones first in the morning. A positive ketone result shows you are in need of more calories, particularly at the bedtime. Other than the above, you should need to test ketones once a week. What are the common signs of diabetes ketoacidosis in pregnancy? Symptoms of DKA are polyuria, poly Continue reading >>

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Tweet Diabetic ketoacidosis (DKA) is a dangerous complication faced by people with diabetes which happens when the body starts running out of insulin. DKA is most commonly associated with type 1 diabetes, however, people with type 2 diabetes that produce very little of their own insulin may also be affected. Ketoacidosis is a serious short term complication which can result in coma or even death if it is not treated quickly. Read about Diabetes and Ketones What is diabetic ketoacidosis? DKA occurs when the body has insufficient insulin to allow enough glucose to enter cells, and so the body switches to burning fatty acids and producing acidic ketone bodies. A high level of ketone bodies in the blood can cause particularly severe illness. Symptoms of DKA Diabetic ketoacidosis may itself be the symptom of undiagnosed type 1 diabetes. Typical symptoms of diabetic ketoacidosis include: Vomiting Dehydration An unusual smell on the breath –sometimes compared to the smell of pear drops Deep laboured breathing (called kussmaul breathing) or hyperventilation Rapid heartbeat Confusion and disorientation Symptoms of diabetic ketoacidosis usually evolve over a 24 hour period if blood glucose levels become and remain too high (hyperglycemia). Causes and risk factors for diabetic ketoacidosis As noted above, DKA is caused by the body having too little insulin to allow cells to take in glucose for energy. This may happen for a number of reasons including: Having blood glucose levels consistently over 15 mmol/l Missing insulin injections If a fault has developed in your insulin pen or insulin pump As a result of illness or infections High or prolonged levels of stress Excessive alcohol consumption DKA may also occur prior to a diagnosis of type 1 diabetes. Ketoacidosis can occasional Continue reading >>

Chapter 11: Diabetic Ketoacidosis In Pregnancy

Chapter 11: Diabetic Ketoacidosis In Pregnancy

Despite recent advances in the evaluation and medical treatment of diabetes in pregnancy, diabetic ketoacidosis (DKA) remains a matter of significant concern. The fetal loss rate in most contemporary series has been estimated to range from 10% to 25%. Fortunately, since the advent and implementation of insulin therapy, the maternal mortality rate has declined to 1% or less. In order to favorably influence the outcome in these high-risk patients, it is imperative that the obstetrician/provider be familiar with the basics of the pathophysiology, diagnosis, and treatment of DKA in pregnancy. DKA is characterized by hyperglycemia and accelerated ketogenesis. Both a lack of insulin and an excess of glucagon and other counter-regulatory hormones significantly contribute to these problems and their resultant clinical manifestations. Glucose normally enters the cell secondary to the effects of insulin. The cell then may use glucose for nutrition and energy production. When insulin is lacking, glucose fails to enter the cell. The cell responds to this starvation by facilitating the release of counter-regulatory hormones, including glucagon, catecholamines, and cortisol. These counter-regulatory hormones are responsible for providing the cell with an alternative substrate for nutrition and energy production. By the process of gluconeogenesis, fatty acids from adipose tissue are broken down by hepatocytes to ketones (acetone, acetoacetate, and β-hydroxybutyrate [BHB] = ketone bodies), which are then used by the body cells for nutrition and energy production (Fig. 11-1). The lack of insulin also contributes to increased lipolysis and decreased reutilization of free fatty acids, thereby providing more substrate for hepatic ketogenesis. A basic review of the biochemistry involving D Continue reading >>

Diabetes Ketoacidosis In Pregnancy

Diabetes Ketoacidosis In Pregnancy

Abstract Diabetic ketoacidosis (DKA) is a serious medical and obstetrical emergency usually occurring in patients with type 1 (insulin-dependent) diabetes mellitus. Although modern management of the patient with diabetes should prevent the occurrence of DKA during pregnancy, this complication still occurs and can result in significant morbidity and mortality for mother and/or fetus. Metabolic changes occurring during pregnancy can predispose a pregnant diabetic to DKA. The diagnosis of DKA can be more challenging during pregnancy as it does not always manifest with the classic presenting symptoms or laboratory findings. In fact, although uncommon, during pregnancy, DKA may develop even in the setting of relative normoglycemia. Prompt diagnosis and management is essential in order to optimize maternal and fetal outcomes. This article will provide the reader with information regarding the pathophysiology underlying DKA complicating pregnancy and will provide practical management guidelines for the diagnosis and management of this condition. Continue reading >>

Why Is There Hyperkalemia In Diabetic Ketoacidosis?

Why Is There Hyperkalemia In Diabetic Ketoacidosis?

Lack of insulin, thus no proper metabolism of glucose, ketones form, pH goes down, H+ concentration rises, our body tries to compensate by exchanging K+ from inside the cells for H+ outside the cells, hoping to lower H+ concentration, but at the same time elevating serum potassium. Most people are seriously dehydrated, so are in acute kidney failure, thus the kidneys aren’t able to excrete the excess of potassium from the blood, compounding the problem. On the other hand, many in reality are severely potassium depleted, so once lots of fluid so rehydration and a little insulin is administered serum potassium will plummet, so needs to be monitored 2 hourly - along with glucose, sodium and kidney function - to prevent severe hypokalemia causing fatal arrhythmias, like we experienced decades ago when this wasn’t so well understood yet. In practice, once the patient started peeing again, we started adding potassium chloride to our infusion fluids, the surplus potassium would be peed out by our kidneys so no risk for hyperkalemia. Continue reading >>

Diabetes In Pregnancy: Management From Preconception To The Postnatal Period

Diabetes In Pregnancy: Management From Preconception To The Postnatal Period

If you have type 1 diabetes, you should be given ketone testing strips and a monitor. Your care team should advise you to test the ketone levels in your blood if your blood glucose is too high (known as hyperglycaemia) or if you are unwell. This is because you are at risk of a serious condition called diabetic ketoacidosis (DKA). People with type 1 diabetes are at higher risk of DKA (although anyone with diabetes can get it). If you have any form of diabetes, your care team should advise you to get urgent medical advice if you have hyperglycaemia or you are feeling unwell, to make sure you don't have DKA. Your ketone levels should be checked as soon as possible. If you are thought to have DKA you should be admitted straight away to a unit where you can get specialist care. Continue reading >>

A Case Of Ketoacidosis In Pregnancy

A Case Of Ketoacidosis In Pregnancy

Abstract: Background: Pregnant women are predisposed to accelerated starvation due to continuous nutrient demands by the fetus, and they have increased susceptibility to ketogenesis during periods of caloric deprivation [1, 2]. We report a case of starvation ketoacidosis in a patient with gestational diabetes on a carbohydrate-restricted diet. Clinical case: A 30 year-old woman, gravida 5, para 2, with a history of spina bifida and hydrocephalus status post ventriculoperitoneal shunt, presented at 37 weeks of gestation with dyspnea. Her pregnancy had been complicated by gestational diabetes mellitus treated with a carbohydrate-restricted diet of 30 g a day. Due to a previous pregnancy complicated by late intrauterine fetal demise, a caesarean section was planned at 37 weeks of gestation after administration of steroids to induce fetal lung maturity. On admission, the patient’s blood pressure was 116/69 mm Hg, heart rate 106 beats per minute, oral temperature 36 °C, pulse ox 97%, and respiratory rate 20 breaths per minute. Laboratory tests showed a mixed metabolic acidosis and respiratory alkalosis with pH 7.3 (7.33 - 7.43), HCO3 7.3 meq/l (20 - 27 meq/l), positive urinary ketones, and glucose of 75 mg/dl (65 – 139 mg/dl). Her glycosylated hemoglobin was 5.8% (4.0 - 6.0 %), C-peptide level 14.3 ng/ml (0.6 - 12.0 ng/ml), total insulin level 4.1 uU/ml (5 to 25 uU/ml), and lactate 1.8 mmol/l (0.5 - 2.2 mmol/l). Her dyspnea progressed, requiring intubation followed by emergent caesarean section. Afterwards, she was transferred to the surgical intensive care unit. She was treated with intravenous fluids containing dextrose and bicarbonate; she never received insulin and her blood glucose ranged from 65 to 139 mg/dl. By hospital day 3, the metabolic acidosis resolved, and Continue reading >>

What You Should Know About Diabetic Ketoacidosis

What You Should Know About Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a buildup of acids in your blood. It can happen when your blood sugar is too high for too long. It could be life-threatening, but it usually takes many hours to become that serious. You can treat it and prevent it, too. It usually happens because your body doesn't have enough insulin. Your cells can't use the sugar in your blood for energy, so they use fat for fuel instead. Burning fat makes acids called ketones and, if the process goes on for a while, they could build up in your blood. That excess can change the chemical balance of your blood and throw off your entire system. People with type 1 diabetes are at risk for ketoacidosis, since their bodies don't make any insulin. Your ketones can also go up when you miss a meal, you're sick or stressed, or you have an insulin reaction. DKA can happen to people with type 2 diabetes, but it's rare. If you have type 2, especially when you're older, you're more likely to have a condition with some similar symptoms called HHNS (hyperosmolar hyperglycemic nonketotic syndrome). It can lead to severe dehydration. Test your ketones when your blood sugar is over 240 mg/dL or you have symptoms of high blood sugar, such as dry mouth, feeling really thirsty, or peeing a lot. You can check your levels with a urine test strip. Some glucose meters measure ketones, too. Try to bring your blood sugar down, and check your ketones again in 30 minutes. Call your doctor or go to the emergency room right away if that doesn't work, if you have any of the symptoms below and your ketones aren't normal, or if you have more than one symptom. You've been throwing up for more than 2 hours. You feel queasy or your belly hurts. Your breath smells fruity. You're tired, confused, or woozy. You're having a hard time breathing. Continue reading >>

A Case Of A Woman With Late-pregnancy-onset Dka Who Had Normal Glucose Tolerance In The First Trimester

A Case Of A Woman With Late-pregnancy-onset Dka Who Had Normal Glucose Tolerance In The First Trimester

Hiromi Himuro, Takashi Sugiyama, Hidekazu Nishigori, Masatoshi Saito, Satoru Nagase, Junichi Sugawara and Nobuo Yaegashi Department of Obstetrics and Gynecology Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan Summary Diabetic ketoacidosis (DKA) during pregnancy is a serious complication in both mother and fetus. Most incidences occur during late pregnancy in women with type 1 diabetes mellitus. We report the rare case of a woman with type 1 diabetes mellitus who had normal glucose tolerance during the first trimester but developed DKA during late pregnancy. Although she had initially tested positive for screening of gestational diabetes mellitus during the first trimester, subsequent diagnostic 75-g oral glucose tolerance tests showed normal glucose tolerance. She developed DKA with severe general fatigue in late pregnancy. The patient's general condition improved after treatment for ketoacidosis, and she vaginally delivered a healthy infant at term. The presence of DKA caused by the onset of diabetes should be considered, even if the patient shows normal glucose tolerance during the first trimester. The presence of DKA caused by the onset of diabetes should be considered, even if the patient shows normal glucose tolerance during the first trimester. Symptoms including severe general fatigue, nausea, and weight loss are important signs to suspect DKA. Findings such as Kussmaul breathing with ketotic odor are also typical. Urinary test, atrial gas analysis, and anion gap are important. If pH shows normal value, calculation of anion gap is important. If the value of anion gap is more than 12, a practitioner should consider the presence of metabolic acidosis. Background Diabetic ketoacidosis (DKA) is an acute metabol Continue reading >>

Diabetic Ketoacidosis In Pregnancy

Diabetic Ketoacidosis In Pregnancy

Sibai, Baha M. MD; Viteri, Oscar A. MD Pregnancies complicated by diabetic ketoacidosis are associated with increased rates of perinatal morbidity and mortality. A high index of suspicion is required, because diabetic ketoacidosis onset in pregnancy can be insidious, usually at lower glucose levels, and often progresses more rapidly as compared with nonpregnancy. Morbidity and mortality can be reduced with early detection of precipitating factors (ie, infection, intractable vomiting, inadequate insulin management or inappropriate insulin cessation, β-sympathomimetic use, steroid administration for fetal lung maturation), prompt hospitalization, and targeted therapy with intensive monitoring. A multidisciplinary approach including a maternal-fetal medicine physician, medical endocrinology specialists familiar with the physiologic changes in pregnancy, an obstetric anesthesiologist, and skilled nursing is paramount. Management principles include aggressive volume replacement, initiation of intravenous insulin therapy, correction of acidosis, correction of electrolyte abnormalities and management of precipitating factors, as well as monitoring of maternal-fetal response to treatment. When diabetic ketoacidosis occurs after 24 weeks of gestation, fetal status should be continuously monitored given associated fetal hypoxemia and acidosis. The decision for delivery can be challenging and must be based on gestational age as well as maternal-fetal responses to therapy. The natural inclination is to proceed with emergent delivery for nonreassuring fetal status that is frequently present during the acute episode, but it is imperative to correct the maternal metabolic abnormalities first, because both maternal and fetal conditions will likewise improve. Prevention strategies shou Continue reading >>

Four Case Studies Of Severe Metabolic Acidosis In Pregnancy

Four Case Studies Of Severe Metabolic Acidosis In Pregnancy

Summarized from Frise C, Mackillop L, Joash K et al. Starvation ketoacidosis in pregnancy. Eur J Obstet Gynecol 2012. Available online ahead of publication at: Arterial blood gas analysis in cases of metabolic acidosis reveals primary decrease in pH and bicarbonate, and secondary (compensatory) reduction in pCO2. The most common cause of metabolic acidosis is increased production of endogenous metabolic acids, either lactic acid, in which case the condition is called lactic acidosis, or keto-acids, in which case the condition is called ketoacidosis. Ketoacidosis most commonly occurs as an acute and life-threatening complication of type I diabetes, due to severe insulin deficiency and resulting reduced glucose availability for energy production within cells (insulin is required for glucose to enter cells). Keto-acids accumulate in blood as a result of metabolism of fats mobilized to fill the energy gap created by reduced availability of glucose within cells. Starvation is also associated with reduced availability of (dietary) glucose and potential for ketoacidosis, although compared with diabetic ketoacidosis, starvation ketoacidosis is rare, usually mild and not life-threatening. Except, that is, when it occurs during pregnancy. In a recently published paper the authors outline four cases of severe starvation ketoacidosis, all occurring in the third trimester of pregnancy, following prolonged vomiting over a period of days. All four women presented for emergency admission in a very poorly state and still vomiting with severe partially compensated metabolic acidosis (bicarbonate in the range of 8-13 mmol/L and base deficit in the range of 14-22 mmol/L). All four required transfer to intensive care and premature delivery of their babies by emergency Cesarean section. Fort Continue reading >>

Diabetic Ketoacidosis In Pregnancy

Diabetic Ketoacidosis In Pregnancy

Diabetic ketoacidosis is a serious metabolic complication of diabetes with high mortality if undetected. Its occurrence in pregnancy compromises both the fetus and the mother profoundly. Although predictably more common in patients with type 1 diabetes, it has been recognised in those with type 2 diabetes as well as gestational diabetes, especially with the use of corticosteroids for fetal lung maturity and β2-agonists for tocolysis.1–3 Diabetic ketoacidosis usually occurs in the second and third trimesters because of increased insulin resistance, and is also seen in newly presenting type 1 diabetes patients. With increasing practice of antepartum diabetes screening and the availability of early and frequent prenatal care/surveillance, the incidence and outcomes of diabetic ketoacidosis in pregnancy have vastly improved. However, it still remains a major clinical problem in pregnancy since it tends to occur at lower blood glucose levels and more rapidly than in non-pregnant patients often causing delay in the diagnosis. The purpose of this article is to illustrate a typical patient who may present with diabetic ketoacidosis in pregnancy and review the literature on this relatively uncommon condition and provide an insight into the pathophysiology and management. MAGNITUDE OF THE PROBLEM In non-pregnant patients with type 1 diabetes, the incidence of diabetic ketoacidosis is about 1–5 episodes per 100 per year with mortality averaging 5%–10%.4 The incidence rates of diabetic ketoacidosis in pregnancy and the corresponding fetal mortality rates from different retrospective studies5–8 are summarised in the table 1. As is evident from the table, both the incidence and rates of fetal loss in pregnancies have fallen in recent times compared with those before. In 1963 Continue reading >>

Fetal Effects Of Diabetic Ketoacidosis

Fetal Effects Of Diabetic Ketoacidosis

The greatest hazard facing the pregnant diabetic patient with DKA is fetal loss. The exact fetal loss rate is difficult to assess because of the small reported series in the literature. Historically, the reported fetal mortality ranged between 30 and 90%7 but remarkable progress has been made both in fetal assessment techniques and in the treatment of DKA, and mortality rates in more recent reviews are 10%.20 Needless to say, fetal loss is primarily related to the severity of the maternal illness and the degree of metabolic decompensation. Most fetal losses occur prior to diagnosis and therefore to the onset of efficient treatment. As ketone bodies freely cross the placenta, maternal acidosis is assumed to cause fetal acidosis; however, the exact mechanism by which maternal DKA affects the fetus remains unclear. Suggestions include a decrease in uterine blood flow and fetal hypoxemia, maternal hyperke-tonemia inducing fetal hypoxemia, and fetal hyperglycemia causing an increased fetal oxidative mechanism and a decreased fetal myocardial contractility. Indeed, fetal potassium deficit has been found to lead to fetal cardiac arrest.7 Fetal hypoxia may also be attributed to a DKA-associated phosphate deficit which leads to depletion of red cell 2,3-diphosphoglycerate and consequent impairment of oxygen delivery. The risk of fetal distress, and even death, during the maternal DKA state makes it mandatory to continuously monitor the fetal heart and to assess the biophysical score, and to evaluate the fetal acid-base balance by cordocentesis if necessary. In the few case reports of fetal monitoring during maternal DKA, a nonreassuring pattern with tachycardia, reduced variability and late decelerations was reported.21,22 LoBue and Goodlin23 found that the administration of jus Continue reading >>

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