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Archivos Argentinos de Pediatria Oct 2020Cerebral edema (CE) is the most severe complication of diabetic ketoacidosis (DKA) in children. There is no accurate knowledge of CE pathogenesis and its onset has been...
INTRODUCTION
Cerebral edema (CE) is the most severe complication of diabetic ketoacidosis (DKA) in children. There is no accurate knowledge of CE pathogenesis and its onset has been related to intravenous rehydration therapy during the initial treatment.
OBJECTIVES
To estimate the prevalence of CE among DKA patients treated at Hospital General de Niños Pedro de Elizalde with intravenous rehydration and analyze potential risk factors for the development of CE.
MATERIALS AND METHODS
Cross-sectional prevalence study and exploratory analysis to compare clinical and laboratory characteristics between patients with and without CE. Patients aged 1-18 years hospitalized with the diagnosis of DKA between January 1st, 2005 and December 31st, 2014 were included.
RESULTS
A total of 693 DKA events from 561 medical records were analyzed. Ten patients had evidence of CE (1.44 %; 95 % confidence interval: 0.8-2.6). Patients with CE had higher serum urea levels (p < 0.001), lower carbon dioxide pressure (p < 0.001), and lower serum sodium levels (p < 0.001) than those without CE.
CONCLUSION
The prevalence of CE among DKA patients was 1.44 %, smaller than that reported in our country (1.8 %). The risk factors at admission associated with CE development were high serum urea levels, hyponatremia, and hypocapnia.
Topics: Adolescent; Argentina; Brain Edema; Child; Child, Preschool; Cross-Sectional Studies; Diabetic Ketoacidosis; Female; Fluid Therapy; Humans; Hypocapnia; Hyponatremia; Infant; Male; Prevalence; Risk Factors; Urea
PubMed: 32924396
DOI: 10.5546/aap.2020.eng.332 -
Advances in Experimental Medicine and... 2021Emergency admissions due to acute metabolic crisis in patients with diabetes remain some of the most common and challenging conditions. DKA (Diabetic Ketoacidosis), HHS...
Emergency admissions due to acute metabolic crisis in patients with diabetes remain some of the most common and challenging conditions. DKA (Diabetic Ketoacidosis), HHS (Hyperglycaemic Hyperosmolar State) and recently focused EDKA (Euglycaemic Diabetic Ketoacidosis) are life-threatening different entities. DKA and HHS have distinctly different pathophysiology but basic management protocols are the same. EDKA is just like DKA but without hyperglycaemia. T1D, particularly children are vulnerable to DKA and T2D, particularly elderly with comorbidities are vulnerable to HHS. But these are not always the rule, these acute conditions are often occur in different age groups with diabetes. It is essential to have a coordinated care from the multidisciplinary team to ensure the timely delivery of right treatment. DKA and HHS, in many instances can present as a mixed entity as well. Mortality rate is higher for HHS than DKA but incidences of DKA are much higher than HHS. The prevalence of HHS in children and young adults are increasing due to exponential growth of obesity and increasing T2D cases in this age group. Following introduction of SGLT2i (Sodium-GLucose co-Transporter-2 inhibitor) for T2D and off-label use in T1D, some incidences of EDKA has been reported. Healthcare professionals should be more vigilant during acute illness in diabetes patients on SGLT2i without hyperglycaemia to rule out EDKA. Middle aged, mildly obese and antibody negative patients who apparently resemble as T2D without any precipitating causes sometime end up with DKA which is classified as KPD (Ketosis-prone diabetes). Many cases can be prevented by following 'Sick day rules'. Better access to medical care, structured diabetes education to patients and caregivers are key measures to prevent acute metabolic crisis.
Topics: Aged; Child; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Emergencies; Humans; Hyperglycemia; Middle Aged; Obesity; Sodium-Glucose Transporter 2 Inhibitors; Young Adult
PubMed: 32488607
DOI: 10.1007/5584_2020_545 -
Current Diabetes Reports May 2020Diabetic ketoacidosis is a life-threatening complication of diabetes characterized by hyperglycemia, acidosis, and ketosis. Ketoacidosis may occur with blood glucose... (Review)
Review
PURPOSE OF REVIEW
Diabetic ketoacidosis is a life-threatening complication of diabetes characterized by hyperglycemia, acidosis, and ketosis. Ketoacidosis may occur with blood glucose level < 200 mg/dl (improperly defined as euglycemic ketoacidosis, euKA) and also in people without diabetes. The absence of marked hyperglycemia can delay diagnosis and treatment, resulting in potential serious adverse outcomes.
RECENT FINDINGS
Recently, with the wide clinical use of sodium glucose co-transporter 2 inhibitors (SGLT2i), euKA has come back into the spotlight. Use of SGLT2i use can predispose to the development of ketoacidosis with relatively low or normal levels of blood glucose. This condition, however, can occur, in the absence of diabetes, in settings such as pregnancy, restriction on caloric intake, glycogen storage diseases or defective gluconeogenesis (alcohol abuse or chronic liver disease), and cocaine abuse. euKA is a challenging diagnosis for most physicians who may be misled by the presence of normal glycemia or mild hyperglycemia. In this article, we review pathophysiology, etiologies, clinical presentation and the management of euKA.
Topics: Blood Glucose; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Female; Humans; Hyperglycemia; Pregnancy; Sodium-Glucose Transporter 2 Inhibitors
PubMed: 32424730
DOI: 10.1007/s11892-020-01307-x -
Nature Reviews. Disease Primers May 2020
Topics: Acidosis; Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Disease Management; Fluid Therapy; Humans; Hypoglycemic Agents; Insulin; Risk Factors
PubMed: 32409653
DOI: 10.1038/s41572-020-0180-2 -
Archives of Endocrinology and Metabolism 2019The purpose of this study is to examine risk factors for recurrence of diabetic ketoacidosis and determine interventions to prevent future admissions. (Review)
Review
OBJECTIVE
The purpose of this study is to examine risk factors for recurrence of diabetic ketoacidosis and determine interventions to prevent future admissions.
MATERIALS AND METHODS
Review article.
RESULTS
Recurrent diabetic ketoacidosis is a serious and not uncommon health problem. Diabetic ketoacidosis is associated with severe morbidity and mortality and hospital admissions due to this problem constitute a serious economic burden on the healthcare system. Younger age at diabetic ketoacidosis onset, poor baseline glycemic control and elevated HbA1C, patient comorbidities, depression, alcohol or substance abuse, particularly active cocaine use, have been associated with recurrent diabetic ketoacidosis. In addition, socioeconomic factors (such as ethnic minority status, use of public health insurance and underinsurance), psychosocial, economic, and behavioral factors (including financial constraint, stretching a limited insulin supply, and homelessness) have been all reported to be associated with readmission among diabetic ketoacidosis patients.
CONCLUSIONS
Identifying high-risk patients during the first diabetic ketoacidosis admission and performing relevant interventions (repeated instructions of insulin use, social help and involvement of family members in medical treatment, collaboration with the patient's primary care physician in order to establish a close and frequent follow up program) may help prevent future admissions. Further studies need to take place to determine whether early interventions with those factors prevent future admissions.
Topics: Diabetic Ketoacidosis; Hospitalization; Humans; Recurrence; Risk Factors
PubMed: 31365631
DOI: 10.20945/2359-3997000000158 -
Diabetes Care Feb 2020Many patients with hyperglycemic crises present with combined features of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). The implications of... (Observational Study)
Observational Study
OBJECTIVE
Many patients with hyperglycemic crises present with combined features of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). The implications of concomitant acidosis and hyperosmolality are not well known. We investigated hospital outcomes in patients with isolated or combined hyperglycemic crises.
RESEARCH DESIGN AND METHODS
We analyzed admissions data listing DKA or HHS at two academic hospitals. We determined ) the frequency distributions of HHS, DKA, and combined DKA-HHS (DKA criteria plus elevated effective osmolality); ) the relationship of markers of severity of illness and clinical comorbidities with 30-day all-cause mortality; and ) the relationship of hospital complications associated with insulin therapy (hypoglycemia and hypokalemia) with mortality.
RESULTS
There were 1,211 patients who had a first admission with confirmed hyperglycemic crises criteria, 465 (38%) who had isolated DKA, 421 (35%) who had isolated HHS, and 325 (27%) who had combined features of DKA-HHS. After adjustment for age, sex, BMI, race, and Charlson Comorbidity Index score, subjects with combined DKA-HHS had higher in-hospital mortality compared with subjects with isolated hyperglycemic crises (adjusted odds ratio [aOR] 2.7; 95% CI 1.4, 4.9; = 0.0019). In all groups, hypoglycemia (<40 mg/dL) during treatment was associated with a 4.8-fold increase in mortality (aOR 4.8; 95% CI 1.4, 16.8). Hypokalemia ≤3.5 mEq/L was frequent (55%). Severe hypokalemia (≤2.5 mEq/L) was associated with increased inpatient mortality (aOR 4.9; 95% CI 1.3, 18.8; = 0.02).
CONCLUSIONS
Combined DKA-HHS is associated with higher mortality compared with isolated DKA or HHS. Severe hypokalemia and severe hypoglycemia are associated with higher hospital mortality in patients with hyperglycemic crises.
Topics: Adult; Aged; Cohort Studies; Comorbidity; Diabetic Ketoacidosis; Female; Hospital Mortality; Hospitalization; Hospitals; Humans; Hyperglycemic Hyperosmolar Nonketotic Coma; Insulin; Insulin, Regular, Human; Male; Middle Aged; Prognosis; Retrospective Studies; United States; Young Adult
PubMed: 31704689
DOI: 10.2337/dc19-1168 -
Endocrinology and Metabolism Clinics of... Mar 2023Heterogeneous forms of Ketosis-prone diabetes (KPD) are characterized by patients who present with diabetic ketoacidosis (DKA) but lack the typical features and... (Review)
Review
Heterogeneous forms of Ketosis-prone diabetes (KPD) are characterized by patients who present with diabetic ketoacidosis (DKA) but lack the typical features and biomarkers of autoimmune T1D. The A-β+ subgroup of KPD provides unique insight into the concept of "remission" since these patients have substantial preservation of beta-cell function permitting the discontinuation of insulin therapy, despite initial presentation with DKA. Measurements of C-peptide levels are essential to predict remission and guide potential insulin withdrawal. Further studies into predictors of remission and relapse can help us guide patients with A-β+ KPD toward remission and develop targeted treatments for this form of atypical diabetes.
Topics: Humans; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Insulin; Biomarkers
PubMed: 36754492
DOI: 10.1016/j.ecl.2022.06.005 -
Diabetic Medicine : a Journal of the... Apr 2022The study examined the prevalence and degree of lactate elevation in diabetic ketoacidosis, and explored which biochemical abnormalities predicted L-lactate levels.
AIMS
The study examined the prevalence and degree of lactate elevation in diabetic ketoacidosis, and explored which biochemical abnormalities predicted L-lactate levels.
METHODS
We reviewed episodes of diabetic ketoacidosis from 79 diabetes patients (one episode per patient). Separate univariate linear regression models were specified to predict lactate level from each of nine biochemical variables. Significant predictors from the univariate models were included in a final multivariate linear regression model to predict lactate levels.
RESULTS
Mean (SD) lactate level was 3.05 (1.66) mmol/L; about 65% of patients had lactate levels >2 mmol/L. In the final multivariate linear regression model (R = 0.45), higher lactate levels were associated with greater hydrogen ion concentration (standardised β = .60, t = 4.16, p < 0.0001), higher blood glucose (standardised β = .28, t = 2.67, p = 0.009) and lower glomerular filtration rate estimated from creatinine (standardised β = -.23, t = 2.29, p = 0.025). Bicarbonate, beta-hydroxybutyrate, body mass index, mean arterial pressure and calculated osmolality were not significant predictors of lactate level. There were three distinct patterns of lactate levels with treatment of diabetic ketoacidosis: group 1 = gradual decline, group 2 = initial increase and then decline and group 3 = initial decline followed by a transient peak and subsequent decline.
CONCLUSIONS
Elevated lactate level is the norm in patients with diabetic ketoacidosis. Higher blood glucose levels and higher hydrogen ion concentrations are related to greater lactate. With treatment, there are different patterns of decline in lactate levels.
Topics: 3-Hydroxybutyric Acid; Blood Glucose; Diabetes Mellitus; Diabetic Ketoacidosis; Humans; Hyperglycemia; Hyperlactatemia; Lactic Acid
PubMed: 34655270
DOI: 10.1111/dme.14723 -
Diabetes Care Sep 2021Fluid replacement to correct dehydration, acidosis, and electrolyte abnormalities is the cornerstone of treatment for diabetic ketoacidosis (DKA), but little is known... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
Fluid replacement to correct dehydration, acidosis, and electrolyte abnormalities is the cornerstone of treatment for diabetic ketoacidosis (DKA), but little is known about optimal fluid infusion rates and electrolyte content. The objective of this study was to evaluate whether different fluid protocols affect the rate of normalization of biochemical derangements during DKA treatment.
RESEARCH DESIGN AND METHODS
The current analysis involved moderate or severe DKA episodes ( = 714) in children age <18 years enrolled in the Fluid Therapies Under Investigation in DKA (FLUID) Trial. Children were assigned to one of four treatment groups using a 2 × 2 factorial design (0.90% or 0.45% saline and fast or slow rate of administration).
RESULTS
The rate of change of pH did not differ by treatment arm, but Pco increased more rapidly in the fast versus slow fluid infusion arms during the initial 4 h of treatment. The anion gap also decreased more rapidly in the fast versus slow infusion arms during the initial 4 and 8 h. Glucose-corrected sodium levels remained stable in patients assigned to 0.90% saline but decreased in those assigned to 0.45% saline at 4 and 8 h. Potassium levels decreased, while chloride levels increased more rapidly with 0.90% versus 0.45% saline. Hyperchloremic acidosis occurred more frequently in patients in the fast arms (46.1%) versus the slow arms (35.2%).
CONCLUSIONS
In children treated for DKA, faster fluid administration rates led to a more rapid normalization of anion gap and Pco than slower fluid infusion rates but were associated with an increased frequency of hyperchloremic acidosis.
Topics: Acidosis; Adolescent; Child; Diabetic Ketoacidosis; Electrolytes; Fluid Therapy; Humans; Sodium
PubMed: 34187840
DOI: 10.2337/dc20-3113 -
Current Opinion in Clinical Nutrition... Mar 2024To evaluate recent evidence (2021-2023) on fluid therapy in diabetic ketoacidosis. Key evidence gaps which require generation of new evidence are discussed. (Review)
Review
PURPOSE OF REVIEW
To evaluate recent evidence (2021-2023) on fluid therapy in diabetic ketoacidosis. Key evidence gaps which require generation of new evidence are discussed.
RECENT FINDINGS
Balanced crystalloid solutions, compared to the commonly recommended and used 0.9% sodium chloride solution (saline), may result in better outcomes for patients with diabetic ketoacidosis, including faster resolution of acidosis, less hyperchloremia and shorter hospital length of stay. Upcoming results from randomized trials may provide definitive evidence on the use of balanced crystalloid solutions in diabetic ketoacidosis. Evidence remains scarce or conflicting for the use of "two-bag" compared to conventional "one-bag" fluid, and rates of fluid administration, especially for adult patients. In children, concerns about cerebral oedema from faster fluid administration rates have not been demonstrated in cohort studies nor randomized trials.
SUMMARY
Fluid therapy is a key aspect of diabetic ketoacidosis management, with important evidence gaps persisting for several aspects of management despite recent evidence.
Topics: Child; Humans; Diabetic Ketoacidosis; Fluid Therapy; Saline Solution; Diabetes Mellitus
PubMed: 38126191
DOI: 10.1097/MCO.0000000000001005