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 >>
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 >>
Patient professional reference Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Pre-diabetes (Impaired Glucose Tolerance) article more useful, or one of our other health articles. See also the separate Childhood Ketoacidosis article. Diabetic ketoacidosis (DKA) is a medical emergency with a significant morbidity and mortality. It should be diagnosed promptly and managed intensively. DKA is characterised by hyperglycaemia, acidosis and ketonaemia: Ketonaemia (3 mmol/L and over), or significant ketonuria (more than 2+ on standard urine sticks). Blood glucose over 11 mmol/L or known diabetes mellitus (the degree of hyperglycaemia is not a reliable indicator of DKA and the blood glucose may rarely be normal or only slightly elevated in DKA). Bicarbonate below 15 mmol/L and/or venous pH less than 7.3. However, hyperglycaemia may not always be present and low blood ketone levels (<3 mmol/L) do not always exclude DKA. Epidemiology DKA is normally seen in people with type 1 diabetes. Data from the UK National Diabetes Audit show a crude one-year incidence of 3.6% among people with type 1 diabetes. In the UK nearly 4% of people with type 1 diabetes experience DKA each year. About 6% of cases of DKA occur in adults newly presenting with type 1 diabetes. About 8% of episodes occur in hospital patients who did not primarily present with DKA. However, DKA may also occur in people with type 2 diabetes, although people with type 2 diabetes are much more likely to have a hyperosmolar hyperglycaemic state. Ketosis-prone type 2 diabetes tends to be more common in older, overweight, non-white people with type 2 diabetes, and DKA may be their Continue reading >>
Diabetic Ketoacidosis Symptoms
What is diabetic ketoacidosis? Diabetic ketoacidosis, also referred to as simply ketoacidosis or DKA, is a serious and even life-threatening complication of type 1 diabetes. DKA is rare in people with type 2 diabetes. DKA is caused when insulin levels are low and not enough glucose can get into the body's cells. Without glucose for energy, the body starts to burn fat for energy. Ketones are products that are created when the body burns fat. The buildup of ketones causes the blood to become more acidic. The high levels of blood glucose in DKA cause the kidneys to excrete glucose and water, leading to dehydration and imbalances in body electrolyte levels. Diabetic ketoacidosis most commonly develops either due to an interruption in insulin treatment or a severe illness, including the flu. What are the symptoms and signs of diabetic ketoacidosis? The development of DKA is usually a slow process. However, if vomiting develops, the symptoms can progress more rapidly due to the more rapid loss of body fluid. Excessive urination, which occurs because the kidneys try to rid the body of excess glucose, and water is excreted along with the glucose High blood glucose (sugar) levels The presence of ketones in the urine Other signs and symptoms of ketoacidosis occur as the condition progresses: These include: Fatigue, which can be severe Flushing of the skin Fruity odor to the breath, caused by ketones Difficulty breathing Type 2 Diabetes Diagnosis, Treatment, Medication What should I do if I think I may have, or someone I know may diabetic ketoacidosis? You should test your urine for ketones if you suspect you have early symptoms or warning signs of ketoacidosis. Call your health-care professional if your urine shows high levels of ketones. High levels of ketones and high blood sug Continue reading >>
Type 1 Diabetes In Adults: Diagnosis And Management.
Go to: 12.1. Ketone monitoring  12.1.1. Introduction Ketosis and ketonuria reflect a greater degree of insulin deficiency than hyperglycaemia alone. The presence of ketones indicates that insulin concentrations are too low not only to control blood glucose concentrations but also to prevent the breakdown of fat (lipolysis). Because ketones are acid substances, high ketone concentrations in the blood may create acidosis. Diabetic ketoacidosis (DKA) is a medical emergency and in its established state carries a 0.7–5% mortality in adults.459,476,784 High ketones in the blood are associated with high levels of fatty acids and together create insulin resistance. The patient with significant ketonaemia will require more insulin than usual to control the blood glucose. Traditionally, ketonaemia has been assessed by urine testing. This has been applied in three main settings: it is recommended as part of guidance for patient self-management of acute illness at home, when patients are advised to increase their usual corrective insulin doses in the presence of significant ketonuria; in the assessment of patients presenting to emergency services with hyperglycaemia, where presence of ketonuria may influence management decisions, including need for admission and in the management of established DKA, where resolution of ketonuria is an important indication of recovery. However, not all ketone bodies are detected by urine testing. For example, beta-hydroxybutyrate (β-OHB) is not detected with current strip tests and if there is a high β-OHB:acetoacetate ratio, urine testing may give a falsely low estimate of ketosis. Furthermore, after an episode of ketoacidosis, where measurement of blood ketones may provide a more accurate assessment of re-insulinisation than blood glucos Continue reading >>
A Preventable Crisis People who have had diabetic ketoacidosis, or DKA, will tell you it’s worse than any flu they’ve ever had, describing an overwhelming feeling of lethargy, unquenchable thirst, and unrelenting vomiting. “It’s sort of like having molasses for blood,” says George. “Everything moves so slow, the mouth can feel so dry, and there is a cloud over your head. Just before diagnosis, when I was in high school, I would get out of a class and go to the bathroom to pee for about 10–12 minutes. Then I would head to the water fountain and begin drinking water for minutes at a time, usually until well after the next class had begun.” George, generally an upbeat person, said that while he has experienced varying degrees of DKA in his 40 years or so of having diabetes, “…at its worst, there is one reprieve from its ill feeling: Unfortunately, that is a coma.” But DKA can be more than a feeling of extreme discomfort, and it can result in more than a coma. “It has the potential to kill,” says Richard Hellman, MD, past president of the American Association of Clinical Endocrinologists. “DKA is a medical emergency. It’s the biggest medical emergency related to diabetes. It’s also the most likely time for a child with diabetes to die.” DKA occurs when there is not enough insulin in the body, resulting in high blood glucose; the person is dehydrated; and too many ketones are present in the bloodstream, making it acidic. The initial insulin deficit is most often caused by the onset of diabetes, by an illness or infection, or by not taking insulin when it is needed. Ketones are your brain’s “second-best fuel,” Hellman says, with glucose being number one. If you don’t have enough glucose in your cells to supply energy to your brain, yo Continue reading >>
Chapter 220. Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA) is an acute, life-threatening complication of diabetes mellitus. The incidence and prevalence of diabetes are rising; as of 2005, an estimated 7% of the U.S. population had diabetes. In patients age 60 or older, the prevalence is estimated to be 20.9%.1 DKA occurs predominately in patients with type 1 (insulin-dependent) diabetes mellitus, but unprovoked DKA can occur in newly diagnosed type 2 (non–insulin-dependent) diabetes mellitus, especially in blacks and Hispanics.2 Between 1993 and 2003, the yearly rate of ED visits for DKA per 10,000 U.S. population with diabetes was 64, with a trend toward an increased rate of visits among the black population compared with the white population.3 Europe has a comparable incidence. A better understanding of pathophysiology and an aggressive, uniform approach to diagnosis and management have reduced mortality to <5% of reported episodes in experienced centers.4 However, mortality is higher in the elderly due to underlying renal disease or coexisting infection and in the presence of coma or hypotension. DKA is a response to cellular starvation brought on by relative insulin deficiency and counterregulatory or catabolic hormone excess (Figure 220-1). Insulin is the only anabolic hormone produced by the endocrine pancreas and is responsible for the metabolism and storage of carbohydrates, fat, and protein. Counterregulatory hormones include glucagon, catecholamines, cortisol, and growth hormone. Complete or relative absence of insulin and the excess counterregulatory hormones result in hyperglycemia (due to excess production and underutilization of glucose), osmotic diuresis, prerenal azotemia, worsening hyperglycemia, ketone formation, and a wide-anion gap metabolic acidosis.4 Insulin deficiency. Patho Continue reading >>
Quick Facts If the body’s cells don’t get enough glucose it starts to burn fat for energy When the body burns fat instead of glucose it causes waste products called ketones Ketones are usually associated with high blood glucose, but also may occur when a child is ill and blood glucose levels fall below the patient’s target range At first, ketones will be cleared by the kidneys into the urine but, as their production increases, they build up in the bloodstream, increasing the acidity of the blood and causing diabetic ketoacidosis (DKA), a potential medical emergency Ketoacidosis needs to be treated quickly as it can lead to a diabetic coma Blood and urine tests can detect high levels of ketones easily Ketones and Hyperglycemia Diabetic ketoacidosis can develop over hours or days and is associated with hyperglycemia - a buildup of ketones in the blood, and dehydration. Hyperglycemia alone does not usually result in a medical emergency. The following situations may lead to a buildup of ketones along with hyperglycemia, which can lead to a medical emergency: Illness and infection Significant or prolonged insulin deficiency from failure to take any insulin or the correct amount of insulin Diabetic Ketoacidosis Symptoms Severe abdominal pain with vomiting Dry mouth and extreme thirst Fruity breath, heavy breathing and shortness of breath Chest pain Increasing sleepiness or lethargy Depressed level of consciousness Seeking Medical Treatment If you have 1+ of ketones in your urine, contact your diabetes educator urgently Drink plenty of water (6 to 10 cups of water within two hours) Take an extra dose of rapid acting insulin and re-check your blood sugar If it is still high, re-check the ketone level. If your ketone level is not lower, please go to the Emergency Departmen Continue reading >>
Diabetic ketoacidosis (DKA) is a serious problem that can occur in people with diabetes if their body starts to run out of insulin. This causes harmful substances called ketones to build up in the body, which can be life-threatening if not spotted and treated quickly. DKA mainly affects people with type 1 diabetes, but can sometimes occur in people with type 2 diabetes. If you have diabetes, it's important to be aware of the risk and know what to do if DKA occurs. Symptoms of diabetic ketoacidosis Signs of DKA include: needing to pee more than usual being sick breath that smells fruity (like pear drop sweets or nail varnish) deep or fast breathing feeling very tired or sleepy passing out DKA can also cause high blood sugar (hyperglycaemia) and a high level of ketones in your blood or urine, which you can check for using home-testing kits. Symptoms usually develop over 24 hours, but can come on faster. Check your blood sugar and ketone levels Check your blood sugar level if you have symptoms of DKA. If your blood sugar is 11mmol/L or over and you have a blood or urine ketone testing kit, check your ketone level. If you do a blood ketone test: lower than 0.6mmol/L is a normal reading 0.6 to 1.5mmol/L means you're at a slightly increased risk of DKA and should test again in a couple of hours 1.6 to 2.9mmol/L means you're at an increased risk of DKA and should contact your diabetes team or GP as soon as possible 3mmol/L or over means you have a very high risk of DKA and should get medical help immediately If you do a urine ketone test, a result of more than 2+ means there's a high chance you have DKA. When to get medical help Go to your nearest accident and emergency (A&E) department straight away if you think you have DKA, especially if you have a high level of ketones in 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 >>
Why Do People Who Suffer From Diabetes Get Sick Faster?
Everybody has a high release of stress hormones when they’re battling or about to battle an illness. Typically, stress hormones cause a rise in blood glucose level because they cause the liver to release more glucose than normal into the bloodstream. People who don’t have diabetes can compensate by releasing more insulin, but people who have diabetes may produce no insulin, or their bodies may not use insulin efficiently, so blood glucose levels stay high unless something is done (such as taking insulin) to lower them. The release of stress hormones and consequent rise in blood glucose level is why people with diabetes are advised to continue taking their diabetes medicines (insulin or oral medicines) when they are sick, even if they’re vomiting. Monitoring blood glucose levels every 2–4 hours and sipping liquids every 15 minutes to stay hydrated are also important. Not taking diabetes medicines during an illness raises the risk of developing diabetic ketoacidosis, a medical emergency characterized by high blood glucose levels, the presence of ketones in the blood and urine, and dehydration. When the body doesn’t have enough insulin available to use glucose as its primary fuel source, it breaks down stored fat for energy, which leads to the production of acidic metabolic by-products called ketones. An accumulation of ketones causes the blood — and eventually the body’s tissues — to become acidic, throwing off the delicate mechanisms that regulate bodily functioning Continue reading >>
Children's Hospital Of Philadelphia
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 >>
Fluid Replacement Give Sodium Chloride 0.9% Intravenously As Follows:
Diabetic emergencies: guidelines for the management of diabetic ketoacidosis and management of hyperosmolar non-ketotic diabetic coma The following guideline is approved only for use at University College London Hospitals NHS Foundation Trust. It is provided as supporting information for the UCLH Injectable Medicines Administration Guide. Neither UCLH nor Wiley accept liability for errors or omissions within the guideline. Wherever possible, users of the Guide should refer to locally produced practice guidelines. UCLHâ€™s guidelines represent the expert opinion of the clinicians within the hospital and may not be applicable to patients outside the Trust. Adapted from UCLH Guidelines for the management of common medical emergencies and for the use of antimicrobial drugs Reviewed by: Dr Stephanie Baldeweg, Consultant Endocrinologist, UCLH and Mrs Sejal Rabone, Pharmacist, MES Directorate, UCLH January 2006 Management of diabetic ketoacidosis and management of hyperosmolar The principal problems are dehydration and acidosis. Diabetic ketoacidosis is a medical emergency. Aim of treatment: Correct acidosis with IV fluids and insulin, and restore electrolyte balance. Criteria for diagnosis: â€¢ Blood glucose > 10 mmol/L and â€¢ Positive urine ketones test and â€¢ Acidosis (pH â‰¤ 7.3 or bicarbonate â‰¤ 15 mmol/L) Also look for thirst and polyuria, hyperventilation (Kussmaul), abdominal pain, vomiting. Immediate admission to critical care must take priority over all except lifesaving interventions. Refer the patient to the DMR immediately whilst continuing management in A&E. Contact a member of the diabetic team (registrar bleep MX109); it is better to seek advice early than late. Urgent Investigations â€¢ Blood glucose. This is accurate up to abou Continue reading >>
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) are the most serious and life-threatening complications of diabetes. Although significant overlap exists between these two entities, this article addresses issues specific to DKA. DKA is a syndrome characterized by hyperglycemia, ketosis, and acidosis. It occurs as the result of a relative or absolute insulin deficiency and an excess of insulin counter-regulatory hormones (ICRH) . To access this article, please choose from the options below Continue reading >>