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The American Journal of Emergency... Jun 2021Diabetic ketoacidosis is an endocrine emergency. A subset of diabetic patients may present with relative euglycemia with acidosis, known as euglycemic diabetic... (Review)
Review
INTRODUCTION
Diabetic ketoacidosis is an endocrine emergency. A subset of diabetic patients may present with relative euglycemia with acidosis, known as euglycemic diabetic ketoacidosis (EDKA), which is often misdiagnosed due to a serum glucose <250 mg/dL.
OBJECTIVE
This narrative review evaluates the pathogenesis, diagnosis, and management of EDKA for emergency clinicians.
DISCUSSION
EDKA is comprised of serum glucose <250 mg/dL with an anion gap metabolic acidosis and ketosis. It most commonly occurs in patients with a history of low glucose states such as starvation, chronic liver disease, pregnancy, infection, and alcohol use. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, which result in increased urinary glucose excretion, are also associated with EDKA. The underlying pathophysiology involves insulin deficiency or resistance with glucagon release, poor glucose availability, ketone body production, and urinary glucose excretion. Patients typically present with nausea, vomiting, malaise, or fatigue. The physician must determine and treat the underlying etiology of EDKA. Laboratory assessment includes venous blood gas for serum pH, bicarbonate, and ketones. Management includes resuscitation with intravenous fluids, insulin, and glucose, with treatment of the underlying etiology.
CONCLUSIONS
Clinician knowledge of this condition can improve the evaluation and management of patients with EDKA.
Topics: Diabetic Ketoacidosis; Diagnosis, Differential; Emergency Service, Hospital; Humans
PubMed: 33626481
DOI: 10.1016/j.ajem.2021.02.015 -
Disease-a-month : DM Mar 2023Diabetic ketoacidosis (DKA) is a form of a hyperglycemic emergency mainly characterized by the triad of hyperglycemia, ketosis, and anion gap metabolic acidosis. DKA may... (Review)
Review
Diabetic ketoacidosis (DKA) is a form of a hyperglycemic emergency mainly characterized by the triad of hyperglycemia, ketosis, and anion gap metabolic acidosis. DKA may be the initial presentation in approximately 25-40 % of patients with type 1 diabetes. It may also occur in at least 34% of patients with type 2 diabetes. DKA has economic as well as medical implications. This review aims to explore and discuss diabetic ketoacidosis, its pathophysiology, clinical presentation, diagnosis, and management, including nuances in special populations such as pediatrics, obstetrics, and patients with chronic kidney disease.
Topics: Pregnancy; Female; Humans; Child; Diabetic Ketoacidosis; Diabetes Mellitus, Type 2; Acidosis; Diabetes Mellitus, Type 1; Diagnosis, Differential
PubMed: 35577617
DOI: 10.1016/j.disamonth.2022.101418 -
Nature Reviews. Disease Primers May 2020Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three... (Review)
Review
Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.
Topics: Acidosis; Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Disease Management; Fluid Therapy; Humans; Hypoglycemic Agents; Insulin; Risk Factors
PubMed: 32409703
DOI: 10.1038/s41572-020-0165-1 -
Pediatric Diabetes Nov 2022
Review
Topics: Consensus; Diabetes Mellitus; Diabetic Ketoacidosis; Humans; Hyperglycemic Hyperosmolar Nonketotic Coma; Hypoglycemic Agents
PubMed: 36250645
DOI: 10.1111/pedi.13406 -
Clinical Medicine (London, England) Sep 2019Diabetic ketoacidosis (DKA) is not a rare presentation to hospital, despite being an entirely preventable condition. A concerning number of people also develop DKA while...
Diabetic ketoacidosis (DKA) is not a rare presentation to hospital, despite being an entirely preventable condition. A concerning number of people also develop DKA while already in hospital. Management of DKA has changed in the last decade, and national guidelines introduced, to help standardise care, spread best practice, and reduce mortality and morbidity.
Topics: Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Humans; Practice Guidelines as Topic
PubMed: 31530688
DOI: 10.7861/clinmed.2019-0284 -
Diabetic Medicine : a Journal of the... Jun 2022This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of ketoacidosis; available at...
This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of ketoacidosis; available at https://abcd.care/resource/management-diabetic-ketoacidosis-dka-adults. The document explicitly states that when a person aged 16-18 is under the care of the paediatric team, then the paediatric guideline should be used, and if they are cared for by an adult team, then this guideline should be used. The guideline takes into account new evidence on the use of the previous version of this document, particularly the high prevalence of hypoglycaemia and hypokalaemia, and recommends that when the glucose concentration drops below 14 mmol/L, that de-escalating the insulin infusion rate from 0.1 to 0.05 units/kg/h should be considered. Furthermore, a section has been added to address the recognition that use of sodium glucose co-transporter 2 inhibitors is associated with an increased risk of euglycaemic ketoacidosis. The management of ketoacidosis in people with end-stage renal failure or on dialysis is also mentioned. Finally, the algorithms to illustrate the guideline have been updated.
Topics: Adult; Child; Diabetes Mellitus; Diabetic Ketoacidosis; Glucose; Hospitalization; Humans; Inpatients; Insulin; Sodium-Glucose Transporter 2 Inhibitors
PubMed: 35224769
DOI: 10.1111/dme.14788 -
European Journal of Internal Medicine Nov 2023Diabetic ketoacidosis (DKA) is an acute life-threatening emergency in patients with diabetes, it can result in serious morbidity and mortality. Management of DKA... (Review)
Review
Diabetic ketoacidosis (DKA) is an acute life-threatening emergency in patients with diabetes, it can result in serious morbidity and mortality. Management of DKA requires reversing metabolic derangements, correcting volume depletion, electrolyte imbalances and acidosis while concurrently treating the precipitating illness. There are still controversies regarding certain aspects of DKA management. Different society guidelines have inconsistencies in their recommendations, while some aspects of treatment are not precise enough or have not been thoroughly studied. These controversies may include issues such as optimal fluid resuscitation, rate and type of Insulin therapy, potassium and bicarbonate replacement. Many institutions follow common society guidelines, however, other institutions either develop their own protocols for internal use or do not routinely use any protocols, resulting in inconsistencies in treatment and increased risk of complications and suboptimal outcomes. The objectives of this article are to review knowledge gaps and controversies in the treatment of DKA and provide our perspective on these issues. Moreover, we believe that special patient factors and comorbidities should receive more careful attention and consideration. Factors like pregnancy, renal disease, congestive heart failure, acute coronary syndrome, older age, use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and site of care all impact the treatment approach and require tailored management strategies. However, guidelines often lack sufficient recommendations regarding specific conditions and comorbidities, we aim to address unique circumstances and provide an approach to managing complex patients with specific conditions and co-morbidities. We also sought to examine changes and trends in the treatment of DKA, illuminate on aspects of latest research with a perspective towards future developments and modifications.
Topics: Pregnancy; Female; Humans; Diabetic Ketoacidosis; Insulin; Fluid Therapy; Potassium; Diabetes Mellitus
PubMed: 37419787
DOI: 10.1016/j.ejim.2023.07.005 -
Annals of Internal Medicine Mar 2022Type 1 diabetes mellitus (T1DM) is an endocrine disorder in which pancreatic β cells stop producing insulin, typically due to autoimmune destruction. This results in... (Review)
Review
Type 1 diabetes mellitus (T1DM) is an endocrine disorder in which pancreatic β cells stop producing insulin, typically due to autoimmune destruction. This results in hyperglycemia and ketosis; thus, insulin replacement is vital to management. Incidence peaks in puberty and early adulthood, but onset can occur at any age. However, prevalence is highest among adults because persons with T1DM live for many years. Symptoms include polyuria, polydipsia, and weight loss. Acute complications include diabetic ketoacidosis, which requires urgent management. Long-term complications include microvascular and macrovascular disease. Patients with T1DM are at higher risk for other autoimmune diseases and psychosocial issues. Management should focus on optimizing glucose control to reduce acute and long-term complications.
Topics: Adult; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Humans; Hyperglycemia; Insulin; Ketosis
PubMed: 35254878
DOI: 10.7326/AITC202203150 -
Diabetes Research and Clinical Practice Sep 2019Diabetic ketoacidosis (DKA) remains one of the most frequently encountered diabetes related emergencies, and despite updates in management and increasing standardisation... (Review)
Review
AIMS
Diabetic ketoacidosis (DKA) remains one of the most frequently encountered diabetes related emergencies, and despite updates in management and increasing standardisation of care, still has an appreciable morbidity and mortality. This review focusses on the pathophysiology and epidemiology of DKA, but also on the importance of having a standardised definition.
METHODS
Relevant data were reviewed where there was available basic science or clinical papers published in peer-reviewed international journals on DKA. These included consensus documents and national or international guidelines.
RESULTS
The prevalence of DKA varies around the world, but part of this could be down to the way the condition is defined. Examples of this difference include the recent studies on sodium glucose co-transporter inhibitors in people with type 1 and type 2 diabetes which have all been associated with increased rates of DKA, but have highlighted how differences in definitions can make comparisons between agents very difficult.
CONCLUSIONS
DKA should only be diagnosed when all three components are present - the 'D', the 'K' and the 'A'. In addition, the definitions used to diagnose DKA should be standardised - in particular for clinical trials.
Topics: Adult; Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Humans; Prevalence; United Kingdom
PubMed: 31344382
DOI: 10.1016/j.diabres.2019.107797 -
BMJ (Clinical Research Ed.) Nov 2020
Review
Topics: Diabetes Mellitus; Diabetic Ketoacidosis; Humans; Hypoglycemic Agents; Risk Factors; Sodium-Glucose Transporter 2 Inhibitors
PubMed: 33184044
DOI: 10.1136/bmj.m4147