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 >>
National Study Of U.s. Emergency Department Visits With Diabetic Ketoacidosis, 1993–2003
Patients with diabetic ketoacidosis (DKA) are often managed in the emergency department before hospital admission. DKA hospitalizations comprise a significant portion of health care costs for diabetes (1). Although mortality for DKA has fallen, it remains an important cause of diabetes-associated death, especially among younger patients with diabetes (2). Prior analyses of DKA have been single-center intensive care unit (ICU) studies or based on hospital discharges (3–5). Patients may, however, be treated in the emergency department and then admitted to a non-ICU setting or discharged; the frequency of these practices is not known. We sought to describe the epidemiology of emergency department visits with DKA. RESEARCH DESIGN AND METHODS— We analyzed the emergency department component of the 1993–2003 U.S. National Hospital Ambulatory Medical Care Survey (NHAMCS). Our institutional review board waived review of this analysis. Methodological details are described elsewhere (6–8). Briefly, NHAMCS uses a four-stage sampling strategy covering geographic primary sampling units, hospitals within primary sampling units, emergency departments within hospitals, and patients within emergency departments. Hospitals were stratified by region, presence of emergency department, ownership type, and size. Within each stratum, hospitals were selected with a probability proportional to the number of emergency department visits. Data were collected during randomly assigned 4-week periods. Data forms include demographic information, emergency department disposition (i.e., admission, transfer, and discharge), and up to three ICD-9 discharge diagnoses. For the present analysis, we identified DKA visits based on ICD-9 code 250.1x, the unique code for DKA, in any of the diagnosis field Continue reading >>
Management Of Diabetic Ketoacidosis
Donahey, Elisabeth PharmD, BCPS; Folse, Stacey PharmD, MPH, BCPS Section Editor(s): Weant, Kyle A. PharmD, BCPS; Column Editor Diabetes, a chronic medical condition, continues to increase in prevalence. One of the most severe complications of diabetes, diabetic ketoacidosis (DKA), results from insulin deficiency and is a medical emergency that is frequently encountered in the emergency department. Prompt diagnosis, assessment of key laboratory values, appropriate treatment, and close monitoring are important to the successful treatment of this complex metabolic disorder. Fluid repletion and insulin administration are mainstays of DKA treatment and serve to restore normal hemodynamic status while decreasing the metabolic acidosis. Careful monitoring of glucose concentrations, vital signs, and electrolytes is essential to prevent complications arising from the treatment of DKA. This article provides an overview of the pathophysiology, presentation, diagnosis, treatment, monitoring, and complications of DKA. © 2012 Lippincott Williams & Wilkins, Inc. Continue reading >>
As fat is broken down, acids called ketones build up in the blood and urine. In high levels, ketones are poisonous. This condition is known as ketoacidosis. Diabetic ketoacidosis (DKA) is sometimes the first sign of type 1 diabetes in people who have not yet been diagnosed. It can also occur in someone who has already been diagnosed with type 1 diabetes. Infection, injury, a serious illness, missing doses of insulin shots, or surgery can lead to DKA in people with type 1 diabetes. People with type 2 diabetes can also develop DKA, but it is less common. It is usually triggered by uncontrolled blood sugar, missing doses of medicines, or a severe illness. Continue reading >>
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 >>
Children's Hospital Of Philadelphia
Diabetic Ketoacidosis (dka), A Medical Emergency.
Diabetic ketoacidosis (DKA) is a potentially life threatening complication of diabetes mellitis. DKA occurs predominantly in patients with type 1 diabetes and may be the presenting manifestation. It can also occur in patients with type 2 diabetes under certain circumstances. It results from a shortage of insulin; in response the body switches to burning fatty acids which produces acidic ketone bodies that cause most of the signs and symptoms. ETIOLOGY: DKA results from insulin insufficiency with a relative or absolute increase in glucagon and may be caused by insufficient or interrupted insulin therapy, infections (pneumonia, urinary tract infection, gastroenteritis, sepsis), infarction (cerebral, coronary, mesenteric, peripheral), emotional stress, excessive alcohol intake, surgery, pregnancy and trauma, and certain drugs such as steroids, cocaine etc. CLINICAL PRESENTATION: DKA clinically presents as polydypsia (excessive intake of fluid due to pronounced thirst), polyuria (excessive urination) anorexia (loss of appetite), nausea or vomiting, abdominal pain, rapid breathing (kussmaul respiration), fruity breath odor of acetone, fever, tachycardia, hypotension, signs of dehydration (dry skin and mucous membranes and poor skin turgor) and altered consciousness to coma. LABORATARY FINDINGS AND DIAGNOSIS: DKA is characterised by hyperglycemia, ketosis and metabolic acidosis (increased anion gap) along with a number of secondary metabolic derangement. The serum blood glucose is usually elevated (RBS > 250 mg/dL), ketones in the blood (serum ketones) and on urinalysis are positive, serum bicarbonate is less than 10 mmol/L, and arterial PH ranges between 6.8 to 7.3, depending upon the severity of acidosis. MANAGEMENT: Confirm the diagnosis of DKA (elevated blood sugar, posit Continue reading >>
Diabetic Ketoacidosis (dka)
Definition of diabetic ketoacidosis (DKA) A complication of diabetes mellitus (DM) caused by absolute or relative insulin deficiency It is diagnosed based on: Hyperglycaemia >11 mM or known diabetes Ketonaemia >3 mM or ketonuria >2+ Acidosis pH <7.3 and/or bicarbonate <15 mM Mostly occurs in patients with type 1 DM. However, it occur in patients with type 2 DM, although they are much more likely to suffer with the related condition hyperglycaemic hyperosmolar state (HHS) Epidemiology of DKA Annual incidence of 1-5% amongst patients with type 1 DM More common in women than men Causes of DKA Lack of compliance with insulin therapy Acute illness (e.g. infection, MI, trauma) Pathophysiology of DKA Insulin deficiency renders cells unable to take up and metabolise glucose Glucose remains trapped in the blood from where it is filtered by the kidneys in concentrations that exceed renal reabsorption capacity Glycosuria causes a profound osmotic diuresis leading to severe dehydration Unable to rely on carbohydrate metabolism, cells switch to fat metabolism and oxidise fatty acids to release acetyl coenzyme A (CoA) in concentrations that saturate the Kreb’s cycle Excess acetyl CoA is converted to the ketone bodies acetone, acetoacetate and beta-hydroxybutyrate, which are released into the blood causing a raised anion gap metabolic acidosis DKA mostly occurs in type 1 DM and is rare in type 2 DM because there is usually adequate levels of insulin to prevent ketogenesis History in DKA Polyuria Polydipsia Light-headedness Nausea and vomiting Abdominal pain Dyspnoea Drowsiness Loss of consciousness Lack of compliance with insulin therapy Symptoms of the precipitant Examination in DKA Airway May be compromised by reduced conscious level Breathing Kussmaul’s breathing Hyperventilati Continue reading >>
Episode 63 – Pediatric Dka
Pediatric DKA was identified as one of key diagnoses that we need to get better at managing in a massive national needs assessment conducted by the fine folks at TREKK – Translating Emergency Knowledge for Kids – one of EM Cases’ partners who’s mission is to improve the care of children in non-pediatric emergency departments across the country. You might be wondering – why was DKA singled out in this needs assessment? It turns out that kids who present to the ED in DKA without a known history of diabetes, can sometimes be tricky to diagnose, as they often present with vague symptoms. When a child does have a known history of diabetes, and the diagnosis of DKA is obvious, the challenge turns to managing severe, life-threatening DKA, so that we avoid the many potential complications of the DKA itself as well as the complications of treatment – cerebral edema being the big bad one. The approach to these patients has evolved over the years, even since I started practicing, from bolusing insulin and super aggressive fluid resuscitation to more gentle fluid management and delayed insulin drips, as examples. There are subtleties and controversies in the management of DKA when it comes to fluid management, correcting serum potassium and acidosis, preventing cerebral edema, as well as airway management for the really sick kids. In this episode we‘ll be asking our guest pediatric emergency medicine experts Dr. Sarah Reid, who you may remember from her powerhouse performance on our recent episodes on pediatric fever and sepsis, and Dr. Sarah Curtis, not only a pediatric emergency physician, but a prominent pediatric emergency researcher in Canada, about the key historical and examination pearls to help pick up this sometimes elusive diagnosis, what the value of serum Continue reading >>
How Do You Determine When Is Diabetic Ketoacidosis Serious Enough To Seek Professional Medical Assistance?
If you have DKA, you should seek medical assistance. There is no “safe level.” It is potentially dangerous, and even if you don’t have any immediate perception of damage, over time the acidity of the acidosis can, over time, do a lot of damage to your body. How do you know if you have it? If you have high blood sugar readings and ketones are present in your urine, you should see a doctor as soon as possible. If the amount of ketones is “large”, it is a medical emergency, regardless of how you feel or what other symptoms you have. You test for ketones by using Ketostix. Dip the tip in fresh urine caught for the purpose, The tip will turn colors, indicating the presence of urine. The color will indicate the amount of ketones, with the most intense colors meaning the highest levels. Check the expiration date on the Ketostix. If you do not test for ketones frequently, they may expire before they are used up and you should not rely on them. They may be better than nothing if that is all you have. As a diabetic or the caregiver of a diabetic, you should have Ketostix on hand. The doctor can tell you at what blood sugar reading you should check for ketones. It might be something like above 300, which means that whenever you get a reading of 300 or above, you should check for ketones. Ketones cause the urine to have an identifiable smell often described as fruity or acetone-like. If you can smell that, your level of ketones is high enough that you should see a doctor, regardless of whether you have any Ketostix. Wikipedia has an article about diabetic ketoacidosis. 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 >>
Management Of A Patient With Diabetic Ketoacidosis In The Emergency Department.
Abstract Diabetic ketoacidosis is a common problem among known and newly diagnosed diabetic children and adolescents for which they will often seek care in the emergency department (ED). Technological advances are leading to changes in outpatient management of diabetes. The ED physician needs to be aware of the new technologies in the care of diabetic children and comfortable managing patients using continuous subcutaneous insulin infusions. This article reviews the ED management of diabetic ketoacidosis and its associated complications, as well as the specific recommendations in caring for patients using the continuous subcutaneous insulin infusion, serum ketone monitoring, and continuous glucose monitoring. 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 >>
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 >>
How The Treatment Of Diabetic Ketoacidosis Has Improved
For patients with type 1 diabetes, one of the most serious medical emergencies is diabetic ketoacidosis (DKA). It can be life-threatening and, in most cases, is caused by a shortage of insulin. Glucose is the “fuel” which feeds human cells. Without it, these cells are forced to “burn” fatty acids in order to survive. This process leads to the production of acidic ketone bodies which can cause serious symptoms and complications such as passing out, confusion, vomiting, dehydration, coma, and, if not corrected in a timely manner, even death. High levels of ketones poison the body. DKA can be diagnosed with blood and urine tests and is distinguished from other ketoacidosis by the presence of high blood sugar levels. Typical treatment for DKA consists of using intravenous fluids to correct the dehydration, insulin dosing to suppress the production of ketones, and treatment for any underlying causes such as infections. Medical history notes that DKA was first diagnosed and described in 1886 and until insulin therapy was introduced in the 1920’s, this condition was almost universally fatal. However, with availability and advances in insulin therapy, the mortality rate is less than one percent when timely treatment is applied. A Clinical Pharmacist Examines DKA Ron Fila (RPh) is a clinical pharmacist at McLaren Northern Michigan in Petoskey, MI. He has first-hand experience in treating patients with DKA and, as one of the early adaptors of EndoTool he has seen how this algorithmically-based glucose management software can help physicians save lives and improve patient outcomes. “We started using EndoTool in 2013, for treating patients in the ICU,” he noted in a recent interview. “Later, we expanded our use of this software for DKA and pediatrics. “Since DKA i Continue reading >>