4. Predictors of diabetic ketoacidosis in children and adolescents with type 1 diabetes. 13. Nair KV, Does bicarbonate therapy improve the management of severe diabetic ketoacidosis? Pseudohyponatremia should be distinguished from true hyponatremia lest injudicious therapy be instituted. Hyperglycemic crises in diabetes. Thus, if the initial serum potassium is lower than 3.3 mEq/L, potassium replacement should begin immediately by an infusion of KCl at a rate of 40 mEq/h, and insulin therapy should be delayed until serum potassium is ≥3.3 mEq/L (Figure 1). Prolonged QT interval corrected for heart rate during diabetic ketoacidosis in children. Pancreas 2019; 48:126. Matteri R, Diabetic ketoacidosis. Henderson SO, Al-Mallah M, Experience from a large multicentre database. et al. Diabetes Res Clin Pract. 49. A Web-based interprofessional diabetes education course. *Serum Na+ should be corrected for hyperglycemia (for each 100 mg/dl glucose above 100 mg/dl, add 1.6 mEq to sodium value for corrected serum sodium value). Cuervo R, Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis? Arida M, Danwen Yang, MD, Focus on POCUN (Point of Care Ultrasound in Nephrology) Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis. Kitabchi AE, Prendergast JJ. Kelly AM. 1998;31(1):41–48. Noncompliance with therapy has also been reported to be a major precipitating cause for DKA in urban black and medically indigent patients. Treatment of diabetic ketoacidosis with subcutaneous insulin aspart. Kelly AM. Nair S, Although osmotic factors and other mechanisms may play a part in the development of cerebral edema, recent data suggest that cerebral edema in children with DKA is related to brain ischemia.42 In children with DKA, both hypocapnia (which causes cerebral vasoconstriction) and extreme dehydration (as determined by a high initial serum urea nitrogen concentration) were associated with increased risk for cerebral edema. Thus, the presence of abdominal pain in patients without significant metabolic acidosis needs to be investigated. Madhuri Ramakrishnan, MD, Basic Science Series Data Sources: In July 2010, an initially broad search of PubMed, Essential Evidence Plus, and sources such as the Cochrane database and Clinical Evidence was conducted using the key term diabetic ketoacidosis. American Diabetes Association. Am J Emerg Med. Acerini CL, Drugs that affect carbohydrate metabolism, such as corticosteroids, thiazides, sympathomimetic agents, and pentamidine, may also precipitate the development of DKA. Glucose level should decrease by about 50 to 70 mg per dL (2.77 to 3.89 mmol per L) per hour, and the insulin infusion should be adjusted to achieve this goal.4 Once the glucose level decreases to 200 mg per dL, the insulin infusion rate should be decreased to 0.05 to 0.1 units per kg per hour, and dextrose should be added to the intravenous fluids to maintain a glucose level between 150 and 200 mg per dL (8.32 and 11.10 mmol per L).4 Subcutaneous insulin is an effective alternative to intravenous insulin in persons with uncomplicated DKA.29 In one prospective randomized trial of 45 persons, 15 received insulin aspart (Novolog) hourly, 15 received insulin aspart every two hours, and 15 received standard intravenous infusion of regular insulin. Preethi Sekar, MD Slovis RJ, Zeni F, Waldhoer T; The cornerstone of DKA and HHS management is insulin therapy. I was on call over the weekend, it was busy, and I was called by the neuro ICU for a new consult. Bain RP. Diabetes Care. Nonadherence to medical regimens is often the cause of recurrent DKA. As most stories do, this one begins with a case. Diabetic ketoacidosis in children and adolescents with diabetes. Umpierrez GE, Hammond C. Pitchumoni CS. Neu A, Diabetes Educ. Approximately 50% of DKA admissions may be preventable with improved outpatient treatment programs and better adherence to self-care. Rothrock SG, One study showed that an elevated band count in persons with DKA had a sensitivity for predicting infection of 100 percent (19 out of 19 cases) and a specificity of 80 percent.26 Chest radiography and urine and blood cultures should be added for further evaluation of infection. Protocol for Management of Adult Patients with Diabetic Ketoacidosis. Acetone on breath and labored Kussmaul respiration may also be present on admission, particularly in patients with severe metabolic acidosis. Diabetic ketoacidosis. Alpaslan T, Vighnesh Walavalkar, MD New direction for enhancing quality in diabetes care: utilizing telecommunications and paraprofessional outreach workers backed by an expert medical team. Syndromes of ketosis-prone diabetes mellitus. 2007;76(1):51–56.... 2. Nationwide survey to compare the prevalence of transient elevation of liver transaminase during treatment of diabetic ketosis or ketoacidosis in new-onset acute and fulminant type 1 diabetes mellitus. The metabolic acidosis may lead to compensatory deep (Kussmaul) respirations, whereas increased acetone can be sensed as a fruity smell on the patient's breath. ; American Diabetes Association. Curr Diab Rep. Hoffman WH, Nair S, Components of plasma include water (typically ~93%) with suspended proteins, lipids, glucose, clotting factors, and hormones. Sari R, Neu A, During treatment of DKA, the goal is to maintain serum potassium levels between 4 and 5 mEq per L (4 and 5 mmol per L). 14. Am Fam Physician. Chetty VK, Takaike H, Sims CE, Nair S, 1999;22(1):7–9. Sayna Norouzi Katz MA. 2000;95(11):3123–3128. Acerini CL, Therefore, this test may underestimate the level of ketosis. Occult risk factor for the development of cerebral edema in children with diabetic ketoacidosis: possible role for stomach emptying. Eray O, Hyperglycemia, Diabetic Ketoacidosis (DKA) and Hyponatremia The term pseudohyponatremia is often erroneously used for hyponatremia caused by hyperglycemia, which increases the blood osmolality what results in the movement of water from the cells into the blood and therefore in dilutional hyponatremia, which is true hypertonic hypervolemic hyponatremia. Wilson DR, Kocher S, Gaboury I, 54. CORRECTION FACTOR: plasma Na+ concentration falls by ~1.6 mmol (Katz, 1973) to 2.4 mmol (Hillier et al in 1999) for every 100 mg/dL (5.55 mmol/L) increase in glucose, due to glucose-induced water efflux from cells; this “translational” hyponatremia resolves after correction of hyperglycemia. Diabetologia. Schober E, Patients with pseudohyponatremia are ”truly” normonatremic (plasma osmolality is normal). Wouters C, Diabetes Care. Grool A, Copyright 2009 American Diabetes Association. Carl GF, Jay Seltzer, MD In the fall of 2010, another search was conducted using additional key terms, such as incidence and prevalence. Chen XJ, 2005;38(2):105–106. Am J Pharm Educ. Natanong Thamcharoen, MD Arora S, 2007;71(5):93. Harrison’s Principles of Internal Medicine, 19e. Thusly, when this assumption is not true, measurement of the sodium concentration from an ABG can help clarify true vs pseudohyponatremia. ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents. Ketonemia was defined as a ketone level greater than 0.42 mmol per L.22 In a second study of point-of-care testing in the emergency department, urine dipstick testing for ketones had a sensitivity of 98 percent, specificity of 35 percent, and a positive predictive value of 15 percent. Enlarge Cerebral edema in children with diabetic ketoacidosis. 2010;16(3):358–363. 1987;5(1):1–5. Glucose is tonically active and is dissolved in plasma water. The effectiveness of intramuscular or subcutaneous administration has been shown to be similar; however, subcutaneous injections are easier and less painful. Nephrology Fellow 2010;13(5):235–245. Positive troponin in diabetic ketoacidosis without evident acute coronary syndrome predicts adverse cardiac events. Bulent C, Blum S, Alpaslan T, Narrative review: ketosis-prone type 2 diabetes mellitus. Glatter K, Austrian Diabetes Incidence Study Group.

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