-
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 -
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 -
BMJ Open Diabetes Research & Care Oct 2023Euglycemic diabetic ketoacidosis (EDKA) is an emerging complication of diabetes associated with an increasing use of sodium-glucose transporter type 2 (SGLT-2) inhibitor... (Review)
Review
Euglycemic diabetic ketoacidosis (EDKA) is an emerging complication of diabetes associated with an increasing use of sodium-glucose transporter type 2 (SGLT-2) inhibitor drugs. This review highlights the growing incidence of EDKA and its diagnostic challenges due to the absence of hallmark hyperglycemia seen in diabetic ketoacidosis (DKA). The paper presents a classification system for the severity of EDKA, categorizing it into mild, moderate, and severe based on serum pH and bicarbonate levels. Another classification system is proposed to define stages of EDKA based on anion gap and ketones at the time of diagnosis and during the treatment period. A treatment algorithm is proposed to guide clinicians in managing EDKA. This treatment algorithm includes monitoring anion gap and ketones to guide insulin and fluid management, and slower transition to subcutaneous insulin to prevent a relapse. Increased awareness of EDKA is essential for a timely diagnosis because an early diagnosis and treatment can improve clinical outcomes.
Topics: Humans; Diabetic Ketoacidosis; Sodium-Glucose Transporter 2 Inhibitors; Diabetes Mellitus, Type 2; Insulin; Ketones
PubMed: 37797963
DOI: 10.1136/bmjdrc-2023-003666 -
Medicina (Kaunas, Lithuania) Mar 2022Diabetes mellitus is a public health problem that affects millions of people worldwide regardless of age, sex, and ethnicity. Electrolyte disturbances may occur as a... (Review)
Review
Diabetes mellitus is a public health problem that affects millions of people worldwide regardless of age, sex, and ethnicity. Electrolyte disturbances may occur as a consequence of disease progression or its treatment, in particular potassium disorders. The prevalence of hypokalemia in diabetic individuals over 55 years of age is up to 1.2%. In patients with acute complications of diabetes, such as diabetic ketoacidosis, this prevalence is even higher. Potassium disorders, either hypokalemia or hyperkalemia, have been associated with increased all-cause mortality in diabetic individuals, especially in those with associated comorbidities, such as heart failure and chronic kidney disease. In this article, we discuss the main conditions for the onset of hypokalemia in diabetic individuals, briefly review the pathophysiology of acute complications of diabetes mellitus and their association with hypokalemia, the main signs, symptoms, and laboratory parameters for the diagnosis of hypokalemia, and the management of one of the most common electrolyte disturbances in clinical practice.
Topics: Diabetes Mellitus; Diabetic Ketoacidosis; Heart Failure; Humans; Hyperkalemia; Hypokalemia; Prevalence
PubMed: 35334607
DOI: 10.3390/medicina58030431 -
Diabetes Care Dec 2021Certain chronic comorbidities, including diabetes, are highly prevalent in people with coronavirus disease 2019 (COVID-19) and are associated with an increased risk of... (Review)
Review
Certain chronic comorbidities, including diabetes, are highly prevalent in people with coronavirus disease 2019 (COVID-19) and are associated with an increased risk of severe COVID-19 and mortality. Mild glucose elevations are also common in COVID-19 patients and associated with worse outcomes even in people without diabetes. Several studies have recently reported new-onset diabetes associated with COVID-19. The phenomenon of new-onset diabetes following admission to the hospital has been observed previously with other viral infections and acute illnesses. The precise mechanisms for new-onset diabetes in people with COVID-19 are not known, but it is likely that a number of complex interrelated processes are involved, including previously undiagnosed diabetes, stress hyperglycemia, steroid-induced hyperglycemia, and direct or indirect effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the β-cell. There is an urgent need for research to help guide management pathways for these patients. In view of increased mortality in people with new-onset diabetes, hospital protocols should include efforts to recognize and manage acute hyperglycemia, including diabetic ketoacidosis, in people admitted to the hospital. Whether new-onset diabetes is likely to remain permanent is not known, as the long-term follow-up of these patients is limited. Prospective studies of metabolism in the setting of postacute COVID-19 will be required to understand the etiology, prognosis, and treatment opportunities.
Topics: COVID-19; Diabetes Mellitus; Diabetic Ketoacidosis; Humans; Hyperglycemia; Prospective Studies; SARS-CoV-2
PubMed: 34625431
DOI: 10.2337/dc21-1318 -
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 -
JAMA Network Open Nov 2020Saline (0.9% sodium chloride), the fluid most commonly used to treat diabetic ketoacidosis (DKA), can cause hyperchloremic metabolic acidosis. Balanced crystalloids, an... (Clinical Trial)
Clinical Trial Comparative Study Randomized Controlled Trial
IMPORTANCE
Saline (0.9% sodium chloride), the fluid most commonly used to treat diabetic ketoacidosis (DKA), can cause hyperchloremic metabolic acidosis. Balanced crystalloids, an alternative class of fluids for volume expansion, do not cause acidosis and, therefore, may lead to faster resolution of DKA than saline.
OBJECTIVE
To compare the clinical effects of balanced crystalloids with the clinical effects of saline for the acute treatment of adults with DKA.
DESIGN, SETTING, AND PARTICIPANTS
This study was a subgroup analysis of adults with DKA in 2 previously reported companion trials-Saline Against Lactated Ringer's or Plasma-Lyte in the Emergency Department (SALT-ED) and the Isotonic Solutions and Major Adverse Renal Events Trial (SMART). These trials, conducted between January 2016 and March 2017 in an academic medical center in the US, were pragmatic, multiple-crossover, cluster, randomized clinical trials comparing balanced crystalloids vs saline in emergency department (ED) and intensive care unit (ICU) patients. This study included adults who presented to the ED with DKA, defined as a clinical diagnosis of DKA, plasma glucose greater than 250 mg/dL, plasma bicarbonate less than or equal to 18 mmol/L, and anion gap greater than 10 mmol/L. Data analysis was performed from January to April 2020.
INTERVENTIONS
Balanced crystalloids (clinician's choice of Ringer lactate solution or Plasma-Lyte A solution) vs saline for fluid administration in the ED and ICU according to the same cluster-randomized multiple-crossover schedule.
MAIN OUTCOMES AND MEASURES
The primary outcome was time between ED presentation and DKA resolution, as defined by American Diabetes Association criteria. The secondary outcome was time between initiation and discontinuation of continuous insulin infusion.
RESULTS
Among 172 adults included in this secondary analysis of cluster trials, 94 were assigned to balanced crystalloids and 78 to saline. The median (interquartile range [IQR]) age was 29 (24-45) years, and 90 (52.3%) were women. The median (IQR) volume of isotonic fluid administered in the ED and ICU was 4478 (3000-6372) mL. Cumulative incidence analysis revealed shorter time to DKA resolution in the balanced crystalloids group (median time to resolution: 13.0 hours; IQR: 9.5-18.8 hours) than the saline group (median: 16.9 hours; IQR: 11.9-34.5 hours) (adjusted hazard ratio [aHR] = 1.68; 95% CI, 1.18-2.38; P = .004). Cumulative incidence analysis also revealed shorter time to insulin infusion discontinuation in the balanced crystalloids group (median: 9.8 hours; IQR: 5.1-17.0 hours) than the saline group (median: 13.4 hours; IQR: 11.0-17.9 hours) (aHR = 1.45; 95% CI, 1.03-2.03; P = .03).
CONCLUSIONS AND RELEVANCE
In this secondary analysis of 2 cluster randomized clinical trials, compared with saline, treatment with balanced crystalloids resulted in more rapid resolution of DKA, suggesting that balanced crystalloids may be preferred over saline for acute management of adults with DKA.
TRIAL REGISTRATION
ClinicalTrials.gov Identifiers: NCT02614040; NCT02444988.
Topics: Acidosis; Adult; Cluster Analysis; Cross-Over Studies; Crystalloid Solutions; Diabetic Ketoacidosis; Electrolytes; Emergency Service, Hospital; Female; Fluid Therapy; Humans; Infusions, Intravenous; Insulin; Intensive Care Units; Isotonic Solutions; Male; Middle Aged; Outcome Assessment, Health Care; Saline Solution, Hypertonic; Time Factors
PubMed: 33196806
DOI: 10.1001/jamanetworkopen.2020.24596 -
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 -
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 -
Journal of Veterinary Emergency and... Jul 2021To determine whether basal-bolus administration of glargine insulin is a safe and effective alternative treatment compared to the standard continuous rate infusion (CRI)...
OBJECTIVES
To determine whether basal-bolus administration of glargine insulin is a safe and effective alternative treatment compared to the standard continuous rate infusion (CRI) protocol.
DESIGN
Prospective randomized clinical trial.
SETTING
University teaching hospital.
ANIMALS
Twenty cats diagnosed with diabetic ketoacidosis (DKA).
INTERVENTIONS
The cats were block-randomized to either a CRI protocol using regular insulin (CRI-group; n = 10) or a basal-bolus SC and IM glargine protocol (glargine-group, n = 10). Baseline blood gases, electrolytes, glucose, and β-hydroxybutyrate (β-OHB) concentrations were measured at the time of admission and later at predefined intervals until reaching the primary endpoint of the study, defined as a β-hydroxybutyrate concentration < 2.55 mmol/L.
MEASUREMENTS AND MAIN RESULTS
The main outcome measure was time (h) to resolution of ketonemia. Secondary outcome measures were time until first improvement of hyperglycemia and ketonemia, decrease of glucose to ≤13.9 mmol/L (250 mg/dL), resolution of acidosis, consumption of first meal, and discharge from hospital. Additionally, occurrence of treatment-associated adverse events and death were compared. Seventeen cats (85%) survived to discharge, with no difference in survival between groups (P = 1.0). Median times to β-OHB < 2.55 mmol/L were 42 (CRI-group) and 30 (glargine-group) hours, respectively (P = 0.114). Median times to first improvement of hyperglycemia (glargine-group: 2 h; CRI-group: 6 h; P = 0.018) and until discharge from hospital (glargine-group: 140 h; CRI-group: 174 h; P = 0.033) were significantly shorter in the glargine-group. No significant differences were observed in any other parameter under investigation (P > 0.05).
CONCLUSIONS
Basal-bolus administration of glargine insulin appears to be an effective and safe alternative to the current standard CRI-protocol for the management of DKA in cats. The positive outcomes and simplicity make it a viable option for the treatment of feline DKA.
Topics: Animals; Blood Glucose; Cat Diseases; Cats; Clinical Trials, Veterinary as Topic; Diabetic Ketoacidosis; Hyperglycemia; Hypoglycemic Agents; Insulin; Insulin Glargine; Prospective Studies
PubMed: 33945208
DOI: 10.1111/vec.13062