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The Journal of Emergency Medicine Sep 2020Diabetic ketoacidosis (DKA) is a hyperglycemic emergency that presents commonly to the emergency department. Severe DKA has the potential for significant morbidity and... (Review)
Review
BACKGROUND
Diabetic ketoacidosis (DKA) is a hyperglycemic emergency that presents commonly to the emergency department. Severe DKA has the potential for significant morbidity and mortality if not recognized early and treated appropriately. It is incumbent on the emergency clinician to be vigilant in the management of these critically ill patients.
OBJECTIVE
This narrative review evaluates the emergency medicine management of the adult patient with severe DKA.
DISCUSSION
DKA is a condition found most commonly in patients with insulin-dependent diabetes, often due to nonadherence with diabetic medications or an inciting event, such as infection or ischemia. The severity of DKA is classified based on the level of acidosis present rather than absolute glucose level. The management of severe DKA involves assessing and treating the inciting event, fluid hydration, insulin, and potassium repletion. Close monitoring is necessary to prevent the complications that can occur.
CONCLUSIONS
DKA is a medical condition that has the potential for significant morbidity and mortality if not recognized and managed appropriately.
Topics: Acidosis; Adult; Critical Illness; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Humans; Insulin
PubMed: 32763063
DOI: 10.1016/j.jemermed.2020.06.059 -
Acta Diabetologica Mar 2023To investigate the main feature and the association between euglycemic diabetic ketoacidosis (euDKA) /diabetic ketoacidosis (DKA) and sodium-dependent glucose...
AIMS
To investigate the main feature and the association between euglycemic diabetic ketoacidosis (euDKA) /diabetic ketoacidosis (DKA) and sodium-dependent glucose transporters 2 inhibitors (SGLT-2i) from the FDA adverse event reporting system (FAERS).
METHODS
Cases of SGLT-2i-associated with euDKA/DKA were extracted from the FAERS database and compared with the reports for other hypoglycemia agents (ATC10 class). Disproportionality analyses used the reporting odds ratio (ROR) and information components (IC). The lower limit of the IC 95% credibility interval for IC > 0 is considered a reported signal, with at least 3 cases.
RESULTS
A total of 10,195 cases of euDKA (n = 1680) and DKA (n = 8515) associated with SGLT-2i were identified from the FAERS. The SGLT-2i was associated with higher reporting of euDKA and DKA compared to other hypoglycemia agents (ROR = 16.69 [95% CI 14.89-18.70], IC = 3.27 [95% CI 2.91-3.66] for euDKA; ROR = 16.44 [95% CI 15.72-17.20], IC = 3.19 [95% CI 3.05-3.34] for DKA). In available data, the median onset time of euDKA/DKA was 31 days, and canagliflozin had the longest onset time (96.5 days for euDKA and 75 days for DKA) compared with dapagliflozin and empagliflozin (p < 0.05). Male patients predominate in euDKA (51.9%), and female patients predominate in DKA (53.7%). Most patients discontinue the treatment (95.5% for euDKA, 93.9% for DKA), and approximately 49.0% (n = 3658) of patients had symptomatic remission after discontinuation of SGLT-2i, and 2.3% (n = 173) of patients had no remission. About 75.6% (n = 6126) of patients need hospitalization after euDKA/DKA.
CONCLUSIONS
Post-marketing data showed that SGLT-2i was significantly associated with higher reporting of euDKA/DKA. Although euDKA/DKA is rare, clinicians should be aware of SGLT-2i-associated euDKA/DKA events.
Topics: Humans; Male; Female; Sodium-Glucose Transporter 2 Inhibitors; Diabetic Ketoacidosis; Diabetes Mellitus, Type 2; Pharmacovigilance; Hypoglycemic Agents; Hypoglycemia
PubMed: 36576563
DOI: 10.1007/s00592-022-02015-6 -
European Journal of Obstetrics,... Feb 2022Diabetic ketoacidosis (DKA) during pregnancy is a life-threatening emergency for both the mother and the fetus. The pathophysiology of DKA in pregnancy has its own... (Review)
Review
OBJECTIVE
Diabetic ketoacidosis (DKA) during pregnancy is a life-threatening emergency for both the mother and the fetus. The pathophysiology of DKA in pregnancy has its own characteristics due to multiple factors, such as insulin resistance, accelerated starvation and respiratory alkalosis, thus creating ketosis-prone state, with DKA occurring at milder degrees of hyperglycemia, even in normoglycemic levels, which can result in delayed diagnosis and treatment with potential for adverse metabolic consequences.
STUDY DESIGN
In this article, we presented 8 clinical cases of DKA during pregnancy. We discuss the spectrum of the clinical picture, the entity of euglycemic DKA vs hyperglycemic DKA, the period of pregnancy in appearance of episode of DKA and triggers of DKA.
CONCLUSION
The treatment of DKA in pregnant women must be started immediately and must be accentuated on intravenous fluids, insulin and electrolyte replacement. DKA in pregnancy may be euglycemic. Prevention, early recognition, immediate hospitalization, and aggressive management remain the cornerstones in DKA management in pregnancy.
Topics: Diabetes Mellitus; Diabetic Ketoacidosis; Female; Humans; Hyperglycemia; Insulin; Pregnancy; Pregnancy Complications; Pregnancy in Diabetics
PubMed: 34968873
DOI: 10.1016/j.ejogrb.2021.12.011 -
Clinical Obstetrics and Gynecology Mar 2023Diabetic ketoacidosis (DKA) is a rare, but potentially life-threatening complication of diabetes. Certain physiological changes during pregnancy predispose pregnant...
Diabetic ketoacidosis (DKA) is a rare, but potentially life-threatening complication of diabetes. Certain physiological changes during pregnancy predispose pregnant individuals to developing DKA. Early recognition and aggressive treatment are essential to avoid maternal and fetal morbidity and mortality. Although laboratory values can help to support, pregnant patients with DKA may not meet the usual criteria and the diagnosis can be made clinically. The key components to treatment include volume replacement, insulin infusion, correction of serum potassium, and fetal monitoring. With appropriate treatment, maternal mortality is low. After recovery, steps should be taken to avoid recurrence.
Topics: Pregnancy; Female; Humans; Diabetic Ketoacidosis; Pregnancy in Diabetics; Fetus; Prenatal Care; Fetal Monitoring; Diabetes Mellitus
PubMed: 36657054
DOI: 10.1097/GRF.0000000000000758 -
Intensive Care Medicine Jan 2023
Topics: Humans; Diabetic Ketoacidosis; Hypoglycemic Agents; Insulin; Diabetes Mellitus
PubMed: 36166056
DOI: 10.1007/s00134-022-06894-9 -
The Journal of Clinical Endocrinology... Nov 2022Diabetic ketoacidosis (DKA) in pregnancy is an obstetric emergency with risk of maternofetal death.
CONTEXT
Diabetic ketoacidosis (DKA) in pregnancy is an obstetric emergency with risk of maternofetal death.
OBJECTIVE
This work aimed to evaluate DKA events in pregnant women admitted to our inpatient obstetric service, and to examine associated clinical risk factors, presentation, and pregnancy outcomes.
METHODS
A retrospective cohort study was conducted at the Mayo Clinic, Rochester, Minnesota, USA, and included women aged 17 to 45 years who were treated for DKA during pregnancy between January 1, 2004 and December 31, 2021. Main outcome measures included maternal and fetal death along with a broad spectrum of maternal and fetal pregnancy outcomes.
RESULTS
A total of 71 DKA events were identified in 58 pregnancies among 51 women, 48 (82.8%) of whom had type 1 diabetes. There were no maternal deaths, but fetal demise occurred in 10 (17.2%) pregnancies (6 miscarriages and 4 stillbirths). Maternal social stressors were frequently present (n = 30, 51.0%), and glycemic control was suboptimal (median first trimester glycated hemoglobin A1c = 9.0%). Preeclampsia was diagnosed in 17 (29.3%) pregnancies. Infants born to women with DKA were large for gestational age (n = 16, 33.3%), suffered from neonatal hypoglycemia (n = 29, 60.4%) and required intensive care unit admission (n = 25, 52.1%).
CONCLUSION
DKA is associated with a high rate of maternofetal morbidity and fetal loss. Prenatal education strategies for women with diabetes mellitus should include a strong focus on DKA prevention, and clinicians and patients should have a high index of suspicion for DKA in all pregnant women who present with symptoms that could be attributed to this condition.
Topics: Infant, Newborn; Female; Humans; Pregnancy; Diabetic Ketoacidosis; Retrospective Studies; Diabetes Mellitus, Type 1; Pregnancy Outcome; Risk Factors
PubMed: 35917830
DOI: 10.1210/clinem/dgac464 -
American Journal of Kidney Diseases :... Oct 2021The anion gap (AG) is a mathematical construct that compares the blood sodium concentration with the sum of the chloride and bicarbonate concentrations. It is a helpful... (Review)
Review
The anion gap (AG) is a mathematical construct that compares the blood sodium concentration with the sum of the chloride and bicarbonate concentrations. It is a helpful calculation that divides the metabolic acidoses into 2 categories: high AG metabolic acidosis (HAGMA) and hyperchloremic metabolic acidosis-and thereby delimits the potential etiologies of the disorder. When the [AG] is compared with changes in the bicarbonate concentration, other occult acid-base disorders can be identified. Furthermore, finding that the AG is very small or negative can suggest several occult clinical disorders or raise the possibility of electrolyte measurement artifacts. In this installment of AJKD's Core Curriculum in Nephrology, we discuss cases that represent several very common and several rare causes of HAGMA. These case scenarios highlight how the AG can provide vital clues that direct the clinician toward the correct diagnosis. We also show how to calculate and, if necessary, correct the AG for hypoalbuminemia and severe hyperglycemia. Plasma osmolality and osmolal gap calculations are described and when used together with the AG guide appropriate clinical decision making.
Topics: Acid-Base Equilibrium; Acid-Base Imbalance; Acidosis; Adult; Aged; Curriculum; Diabetic Ketoacidosis; Female; Fluid Therapy; Humans; Male; Middle Aged; Osmolar Concentration; Young Adult
PubMed: 34400023
DOI: 10.1053/j.ajkd.2021.02.341 -
The Lancet. Diabetes & Endocrinology May 2020Diabetic ketoacidosis (DKA) is a serious acute complication of type 1 diabetes, which is receiving more attention given the increased DKA risk associated with SGLT... (Review)
Review
Diabetic ketoacidosis (DKA) is a serious acute complication of type 1 diabetes, which is receiving more attention given the increased DKA risk associated with SGLT inhibitors. Sociodemographic and modifiable risk factors were identified with strong evidence for an increased risk of DKA, including socioeconomic disadvantage, adolescent age (13-25 years), female sex, high HbA, previous DKA, and psychiatric comorbidities (eg, eating disorders and depression). Possible prevention strategies, which include the identification of people at risk based on non-modifiable sociodemographic risk factors, are proposed. As a second risk mitigation strategy, structured diabetes self-management education that addresses modifiable risk factors can be used. Evidence has found that structured education leads to reduced DKA rates. Knowledge of these risk factors and potent risk mitigation strategies are important to identify subgroups of people with an elevated DKA risk. This knowledge should also be used when adjunct therapy options with an increased DKA risk are considered. Prevention of DKA in people with type 1 diabetes is an important clinical task, which should also be addressed when SGLT inhibitors are part of therapy.
Topics: Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Female; Humans; Male; Risk Factors; Sodium-Glucose Transporter 2 Inhibitors
PubMed: 32333879
DOI: 10.1016/S2213-8587(20)30042-5 -
The American Journal of the Medical... Jun 2021Diabetic ketoacidosis (DKA) is a serious complication of diabetes mellitus. Hyperglycemia, acidosis, and electrolyte imbalances can directly affect the heart by inducing... (Review)
Review
Diabetic ketoacidosis (DKA) is a serious complication of diabetes mellitus. Hyperglycemia, acidosis, and electrolyte imbalances can directly affect the heart by inducing toxicity, impairing myocardial blood flow, autonomic dysfunction, and altering activation and conduction of electrical impulses throughout the heart, increasing the risk of arrhythmias and ischemia. The electrocardiogram is useful in monitoring patients during and after an episode of DKA, as it allows the detection of arrhythmias and guides metabolic correction. Unfortunately, reports on electrocardiographic abnormalities in patients with DKA are lacking. We found two electrocardiographic patterns that are frequently reported in the literature: a pseudo-myocardial infarction and a Brugada Phenocopy. Both are associated with DKA metabolic anomalies and they resolve after treatment. Because of their clinical relevance and the challenge they represent for clinicians, we analyzed the clinical characteristics of these patients and the mechanisms involved in these electrocardiographic findings.
Topics: Acute Disease; Arrhythmias, Cardiac; Diabetic Ketoacidosis; Electrocardiography; Heart Rate; Humans
PubMed: 33941367
DOI: 10.1016/j.amjms.2020.11.030 -
Archives of Disease in Childhood Nov 2022Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, which may lead to significant morbidity and mortality. (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, which may lead to significant morbidity and mortality.
OBJECTIVES
To compare the safety and efficacy of liberalised versus conservative intravenous fluid regimens in the management of DKA in children.
DATA SOURCE AND STUDY SELECTION
Databases from inception to January 2022: MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials were included. Only randomised controlled trials (RCTs) that included children aged under 18 years were assessed. Two reviewers performed data assessment and extraction.
DATA EXTRACTION AND SYNTHESIS
Three studies out of 1536 citations were included.
MAIN OUTCOMES
The time to the recovery from the DKA; the frequency of paeditric intensive care unit (PICU) admissions; development of brain oedema; reduction in Glasgow Coma Scale (GCS); development of acute kidney injury and all-cause mortality.
RESULTS
We included three RCTs (n=1457). No evidence of difference was noted in the GCS reduction (risk ratio (RR)=0.77, 95% CI 0.44 to 1.36) or development of brain oedema (RR=0.50, 95% CI 0.15 to 1.68). The time to recovery from DKA was longer in the conservative group (mean difference=1.42, 95% CI 0.28 to 2.56). Time to hospital discharge, adverse or serious adverse events were comparable in the two studied groups.
CONCLUSION
There is no evidence from this meta-analysis that rate of fluid administration has any effect on adverse neurological and other outcomes or length of hospital stay.
Topics: Child; Humans; Adolescent; Diabetic Ketoacidosis; Brain Edema; Length of Stay; Clinical Protocols; Glasgow Coma Scale; Diabetes Mellitus
PubMed: 35738870
DOI: 10.1136/archdischild-2022-324042