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BMJ Case Reports May 2023Pneumomediastinum is an uncommon finding in patients with diabetic ketoacidosis (DKA) and may occur spontaneously or secondary to an effort rupture of the oesophagus....
Pneumomediastinum is an uncommon finding in patients with diabetic ketoacidosis (DKA) and may occur spontaneously or secondary to an effort rupture of the oesophagus. Excluding oesophageal rupture is important, as delaying treatment increases the risk of mortality. We discuss a case of DKA complicated by vomiting, pneumomediastinum, pneumopericardium and air in the epidural space. Instead of fluoroscopic oesophagography, chest CT was used to investigate oesophageal rupture. We present an overview of case reports and retrospective studies illustrating the utility of chest CT in the investigation of oesophageal rupture over fluoroscopic oesophagography.
Topics: Humans; Mediastinal Emphysema; Diabetic Ketoacidosis; Retrospective Studies; Thorax; Tomography, X-Ray Computed; Esophageal Diseases; Thoracic Injuries; Diabetes Mellitus
PubMed: 37137549
DOI: 10.1136/bcr-2023-255018 -
BMJ Open Diabetes Research & Care Feb 2021Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus (T1DM) characterized by hyperglycemia and metabolic acidosis. Hypophosphatemia... (Observational Study)
Observational Study
INTRODUCTION
Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus (T1DM) characterized by hyperglycemia and metabolic acidosis. Hypophosphatemia in DKA often occurs during hospital admittance for DKA. Literature on the magnitude, determinants and consequences of hypophosphatemia in DKA is scarce. Primary aim of this study was to investigate the incidence and consequences of hypophosphatemia during hospitalisation for DKA.
RESEARCH DESIGN AND METHODS
Cohort study among individuals with T1DM who were admitted for DKA between 2005 and 2020 in an academic and a non-academic hospital. Multivariate regression models were performed to investigate determinants of the lowest phosphate during the treatment of DKA.
RESULTS
A total of 127 episodes of DKA among 80 individuals were identified. Age at DKA presentation was 28 (22-46) years, 45% of the cases was female, diabetes duration was 13.2 (8.9-25.5) years with glycosylated hemoglobin levels of 91.9±26.2 mmol/mol. In 9% of all cases, DKA was the first presentation of T1DM. Lowest phosphate levelss reported during the treatment phase were 0.54 (0.32-0.83) mmol/L and hypophosphatemia was present in 74% (62/84). The time to lowest phosphate was 16 (8-23) hours. In multivariate analysis, baseline bicarbonate and hemoglobin at admission were significantly associated with the lowest phosphate level reported. No adverse effects of hypophosphatemia on hospital stay duration, morbidity or mortality were found, even if left untreated.
CONCLUSIONS
Hypophosphatemia during DKA is common and increases with severe acidosis. However, in this study it was not related to adverse outcomes. Although limitations of this retrospective study should be taken into account, the routine and repeated measurement of phosphate levels in DKA could be reconsidered, provided that possible symptoms related to hypophosphatemia are monitored.
Topics: Cohort Studies; Diabetic Ketoacidosis; Female; Humans; Hypophosphatemia; Incidence; Retrospective Studies
PubMed: 33597187
DOI: 10.1136/bmjdrc-2020-002018 -
Reviews on Recent Clinical Trials 2020Diabetic Ketoacidosis (DKA) is one of the most commonly encountered diabetic complication emergencies. It typically affects people with type 1 diabetes at the onset of... (Review)
Review
BACKGROUND
Diabetic Ketoacidosis (DKA) is one of the most commonly encountered diabetic complication emergencies. It typically affects people with type 1 diabetes at the onset of the disease. It can also affect people with type 2 diabetes, although this is uncommon.
METHODS
Research and online content related to diabetes online activity is reviewed. DKA is caused by a relative or absolute deficiency of insulin and elevated levels of counter-regulatory hormones.
RESULTS
Goals of therapy are to correct dehydration, acidosis, and to reverse ketosis, gradually restoring blood glucose concentration to near normal.
CONCLUSION
It is essential to monitor potential complications of DKA and, if necessary, to treat them and any precipitating events.
Topics: Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Emergencies; Humans; Insulin
PubMed: 32646361
DOI: 10.2174/1574887115666200709172402 -
Annals of Saudi Medicine 2022Diabetic ketoacidosis (DKA) is one of the complications of diabetes mellitus (DM), primarily type 1 DM. To our knowledge, only one study explored DKA readmission rates...
BACKGROUND
Diabetic ketoacidosis (DKA) is one of the complications of diabetes mellitus (DM), primarily type 1 DM. To our knowledge, only one study explored DKA readmission rates in Saudi Arabia.
OBJECTIVES
Identify and analyze precipitating factors for DKA admission and readmission.
DESIGN
Medical record review.
SETTING
Tertiary care center.
PATIENTS AND METHODS
We identified all patients aged 15 years and older admitted with DKA from 2018 to 2020. Descriptive factors and uni-and multivariate analyses are presented for associations with initial admission and readmission.
MAIN OUTCOME MEASURES
Relationships between precipitating factors and initial admission and readmission.
SAMPLE SIZE
176 patients.
RESULTS
Most of the patients had type 1 DM (n=157). The median (interquartile percentiles) for duration of DM was 6.0 (1.0-12.0) years. The mean (SD) HbA1C (%) was 11.8 (2.6). The factors that precipitated DKA were most commonly treatment nonadherence (55.1%), followed by infections (31.8%) and nonadherence to diet (25.6%). The most common symptoms were nausea and vomiting (87.5%), followed by abdominal pain (72.7%). During the study period, 32.4% of the sample were read-mitted with DKA. The median (interquartile range) duration between the first and second admission was 12 (4-25) weeks. In the multivariate analysis, increased odds of readmission for DKA were associated with type 1 DM and medication nonadherence (=.038, =.013, respectively). The severity of the initial DKA and the control of DM were not associated with the readmission rate.
CONCLUSION
Treatment nonadherence is the leading precipitating factor of DKA in our region. Patient education and counseling play a major role in addressing this preventable complication and its medical and financial burden. We advocate more efforts dedicated toward patient education and logistic support.
LIMITATIONS
Retrospective-single center.
CONFLICT OF INTEREST
None.
Topics: Adolescent; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Humans; Patient Readmission; Retrospective Studies; Saudi Arabia
PubMed: 35380064
DOI: 10.5144/0256-4947.2022.119 -
The Journal of Emergency Medicine Jul 2023Missed diagnosis can predispose to worse condition-specific outcomes.
BACKGROUND
Missed diagnosis can predispose to worse condition-specific outcomes.
OBJECTIVE
To determine 90-day complication rates and hospital utilization after a missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis.
METHODS
We evaluated patients under 21 years of age visiting five pediatric emergency departments (EDs) with a study condition. Case patients had a preceding ED visit within 7 days of diagnosis and underwent case review to confirm a missed diagnosis. Control patients had no preceding ED visit. We compared complication rates and utilization between case and control patients after adjusting for age, sex, and insurance.
RESULTS
We analyzed 29,398 children with appendicitis, 5366 with DKA, and 3622 with sepsis, of whom 429, 33, and 46, respectively, had a missed diagnosis. Patients with missed diagnosis of appendicitis or DKA had more hospital days and readmissions; there were no significant differences for those with sepsis. Those with missed appendicitis were more likely to have abdominal abscess drainage (adjusted odds ratio [aOR] 3.0, 95% confidence interval [CI] 2.4-3.6) or perforated appendicitis (aOR 3.1, 95% CI 2.5-3.8). Those with missed DKA were more likely to have cerebral edema (aOR 4.6, 95% CI 1.5-11.3), mechanical ventilation (aOR 13.4, 95% CI 3.8-37.1), or death (aOR 28.4, 95% CI 1.4-207.5). Those with missed sepsis were less likely to have mechanical ventilation (aOR 0.5, 95% CI 0.2-0.9). Other illness complications were not significantly different by missed diagnosis.
CONCLUSIONS
Children with delayed diagnosis of appendicitis or new-onset DKA had a higher risk of 90-day complications and hospital utilization than those with a timely diagnosis.
Topics: Child; Humans; Appendicitis; Missed Diagnosis; Diabetic Ketoacidosis; Hospitals, Pediatric; Retrospective Studies; Sepsis; Diabetes Mellitus
PubMed: 37355425
DOI: 10.1016/j.jemermed.2023.04.006 -
Pediatric Nephrology (Berlin, Germany) Jul 2023One-third of children with type 1 diabetes mellitus manifest with diabetic ketoacidosis (DKA). Most children presenting with DKA are in a volume-depleted state, leading... (Review)
Review
BACKGROUND
One-third of children with type 1 diabetes mellitus manifest with diabetic ketoacidosis (DKA). Most children presenting with DKA are in a volume-depleted state, leading to acute kidney injury (AKI). Besides volume depletion, hyperglycemia can induce tubular injury and kidney inflammation. Therefore, a thorough knowledge of incidence of AKI, risk factors, and outcomes in pediatric DKA is desirable to improve its management and outcomes.
OBJECTIVE
To synthesize currently available evidence on the incidence, risk factors, and outcomes of AKI in children with DKA.
DATA SOURCES
We searched three electronic databases (EMBASE, PubMed, and Web of Science) from inception to September 2022 for original studies reporting AKI in children with DKA. Search strategies for the individual databases were drafted using free text words and MeSH incorporating "acute kidney injury" and "diabetic ketoacidosis."
STUDY ELIGIBILITY CRITERIA
Cohort and cross-sectional studies reporting AKI in children with type 1 DM and DKA were included.
PARTICIPANTS AND INTERVENTIONS
Children (aged less than 18 years) with type 1 DM and DKA.
STUDY APPRAISAL AND SYNTHESIS METHODS
The critical appraisal tool of NHLBI for cohort studies was used to assess the quality of the studies. We estimated the pooled incidence of AKI with 95% CI in children with DKA using a random effects model. The primary outcome was the pooled incidence of AKI during the DKA episodes.
RESULTS
Twenty-one studies assessing 4087 children (4500 DKA episodes) reported AKI during DKA episodes. The pooled incidence of any stage of AKI during the DKA episode was 47% (95% CI: 40 to 55). Severe AKI was observed in 28% (21 to 35) of DKA episodes; however, only 4% (1 to 11%) of children with AKI received dialysis. Low serum bicarbonate, low corrected sodium, higher blood sugar, and high blood urea nitrogen at presentation have been reported to be associated with the development of AKI.
CONCLUSION
AKI developed in almost half of the DKA episodes, and every fourth DKA episode was associated with severe AKI. The recovery rate from DKA-associated AKI appears to be high; however, further studies are needed to assess the exact impact of AKI on long-term outcomes.
REGISTRATION
PROSPERO (CRD42022303200). A higher resolution version of the Graphical abstract is available as Supplementary information.
Topics: Humans; Child; Diabetic Ketoacidosis; Incidence; Cross-Sectional Studies; Renal Dialysis; Diabetes Mellitus, Type 1; Acute Kidney Injury; Hyperglycemia; Kidney; Retrospective Studies
PubMed: 36705755
DOI: 10.1007/s00467-023-05878-1 -
Diabetes/metabolism Research and Reviews Sep 2021Diabetic ketoacidosis (DKA) is an acute metabolic complication characterized by hyperglycaemia, ketones in blood or urine, and acidosis.
BACKGROUND
Diabetic ketoacidosis (DKA) is an acute metabolic complication characterized by hyperglycaemia, ketones in blood or urine, and acidosis.
OBJECTIVE
The aim of this study was to characterize features of patients hospitalized for DKA, to identify triggers for DKA and to evaluate the long-term effects of DKA on glycaemic control, complications of diabetes, re-hospitalizations, and mortality.
METHODS
Historical prospectively collected data of patients hospitalized to medical wards for DKA between 2011 and 2017. Data regarding comorbidities, mortality, triggers, and re-hospitalizations for DKA were also collected.
RESULTS
The cohort consisted of 160 patients (mean age 38 ± 18 years, 43% male). One fifth of the patients (34 patients, 21%) were newly diagnosed with diabetes, and DKA was their first presentation of the disease. Among the 126 patients with pre-existing diabetes, the common identified triggers for DKA were poor compliance to treatment (22%) and infectious diseases (18%). During over 7 years of follow-up, mortality rate was 9% (15 patients), and re-hospitalization for DKA rate was 31% (50 patients). Risk factors for re-hospitalization for DKA included young age (OR = 1.02, 95% CI, 1.00-1.04), pre-existing diabetes compared to DKA as the first presentation (OR = 5.4, 95% CI, 1.7-18), and poorer glycaemic control before initial hospitalization (10.5 ± 2.5% vs. 9.4 ± 2.2%; OR = 0.8, 95% CI [0.68-0.96]) and after discharge (10.3 ± 2.4% vs. 9.0 ± 1.9%; OR = 0.73, 95% CI [0.61-0.87]). Laboratory tests during the initial hospitalization, smoking, alcohol, or comorbidities did not increase the risk for re-hospitalization for DKA.
CONCLUSIONS
The risk for readmission for DKA is higher for young patients with long duration of diabetes, poor compliance of insulin treatment and poorly controlled diabetes.
Topics: Adult; Cohort Studies; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Female; Hospitalization; Humans; Hyperglycemia; Male; Middle Aged; Retrospective Studies; Risk Factors; Young Adult
PubMed: 32942337
DOI: 10.1002/dmrr.3408 -
Clinical Hemorheology and... 2021Diabetic ketoacidosis (DKA) is a medical emergency with a high mortality rate and is associated with severe metabolic acidosis and dehydration. DKA patients have an...
BACKGROUND
Diabetic ketoacidosis (DKA) is a medical emergency with a high mortality rate and is associated with severe metabolic acidosis and dehydration. DKA patients have an increased risk of arterial and venous thromboembolism, however little is known about this metabolic derangement in the first 24 hours of admission and to assess its effect on coagulation. We therefore utilised a novel functional marker of clot microstructure (fractal dimension - df) to assess these changes within the first 24 hours.
METHODS
Prospective single centre observational study to demonstrate whether the tendency of blood clot formation differs in DKA patients.
RESULTS
15 DKA patients and 15 healthy matched controls were recruited. Mean df in the healthy control group was 1.74±0.03. An elevated df of 1.78±0.07 was observed in patients with DKA on admission. The mean pH on admission was 7.14±0.13 and the lactate was 3.6±2.0. df changed significantly in response to standard treatment and was significantly reduced to 1.68±0.09 (2-6& h) and to 1.66±0.08 at 24& h (p < 0.01 One-way ANOVA). df also correlated significantly with lactate and pH (Pearson correlation coefficient 0.479 and -0.675 respectively, p < 0.05).
CONCLUSIONS
DKA patients at presentation have a densely organising less permeable thrombogenic clot microstructure as evidenced by high df. These structural changes are due to a combination of dehydration and a profound metabolic acidosis, which was reversed with treatment. These changes were not mirrored in standard clinical markers of thromboge-nicity.
Topics: Biomarkers; Case-Control Studies; Diabetic Ketoacidosis; Female; Fractals; Hemorheology; Humans; Male; Middle Aged; Prospective Studies; Thrombosis
PubMed: 32925001
DOI: 10.3233/CH-200957 -
Expert Opinion on Drug Safety Jun 2020Sodium-glucose co-transporters 2 (SGLT-2) inhibitors are a relatively novel class of oral medications for the treatment of Type 2 Diabetes Mellitus, which lower plasma... (Review)
Review
INTRODUCTION
Sodium-glucose co-transporters 2 (SGLT-2) inhibitors are a relatively novel class of oral medications for the treatment of Type 2 Diabetes Mellitus, which lower plasma glucose by inhibiting glucose reabsorption in the proximal renal tubule. Apart from their hypoglycemic action, recent data suggest these agents have additional major cardioprotective and nephroprotective properties.
AREAS COVERED
This review summarizes the existing data on epidemiology, pathophysiology, and treatment of euglycaemic ketoacidosis (euDKA) as a complication of SGLT-2 inhibitor use.
EXPERT OPINION
Although SGLT-2 inhibitors have a relatively good adverse event profile, they have been associated with the serious and potentially life-threatening metabolic complication of euDKA. Data from major outcome trials suggest that the rate of DKA is quite low. However, the rate of DKA could be generally underestimated in clinical trials due to the atypical presentation of ketoacidosis, and even more so in real-life conditions. Management of this serious metabolic complication requires a proper understanding of its pathophysiology as well as increased awareness and early recognition of the potential risk factors involved. Following this, the institution of an array of simple supportive measures, could safely restore normal acid-base balance in most patients.
Topics: Animals; Blood Glucose; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Humans; Hypoglycemic Agents; Sodium-Glucose Transporter 2 Inhibitors
PubMed: 32521174
DOI: 10.1080/14740338.2020.1764532 -
Medicina 2024Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that are increasingly used in cancer treatments. As experience in the use of immunotherapy increases, more... (Review)
Review
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that are increasingly used in cancer treatments. As experience in the use of immunotherapy increases, more is known about its safety profile and immune-mediated adverse effects. Among them is diabetic ketoacidosis (DKA), a rare but serious fatal complication of treatment. In this paper we describe the cases of three patients who presented with episodes of DKA during treatment with ICIs, two of which manifested with fulminant forms, leading to an acute course with initially normal glycosylated hemoglobin values. In addition, we conducted a review of the literature on DKA associated with ICIs in order to highlight the importance of noticing these potentially fatal complications and promptly establishing appropriate therapy.
Topics: Humans; Diabetic Ketoacidosis; Antibodies, Monoclonal; Immunotherapy; Drug-Related Side Effects and Adverse Reactions; Diabetes Mellitus
PubMed: 38271940
DOI: No ID Found