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Dehydration in dka. Diabetic Ketoacidosis: Causes, Symptoms, and Treatment Strategies

by alexxlab

What are the main causes of diabetic ketoacidosis. How is DKA diagnosed and treated. Can DKA be prevented in patients with diabetes. What are the long-term complications of recurrent DKA episodes. How does COVID-19 impact diabetic ketoacidosis risk and management.

Содержание

Understanding Diabetic Ketoacidosis: A Serious Complication of Diabetes

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes that occurs when the body produces high levels of blood acids called ketones. It develops when the body can’t produce enough insulin, leading to a buildup of these acidic ketones.

DKA most commonly occurs in people with type 1 diabetes, but it can also affect those with type 2 diabetes under certain circumstances. Understanding the causes, symptoms, and treatment of DKA is crucial for diabetes management and prevention of this serious condition.

What causes diabetic ketoacidosis?

DKA is primarily triggered by:

  • Insufficient insulin production or administration
  • Illness or infection
  • Psychological or physical stress
  • Certain medications, including SGLT2 inhibitors
  • Alcohol or drug abuse

In some cases, DKA can be the first sign of previously undiagnosed diabetes.

Recognizing the Symptoms of Diabetic Ketoacidosis

Early detection of DKA symptoms is critical for prompt treatment. Common signs and symptoms include:

  • Excessive thirst and frequent urination
  • Nausea and vomiting
  • Abdominal pain
  • Weakness or fatigue
  • Shortness of breath
  • Fruity-scented breath
  • Confusion or difficulty concentrating

Is rapid breathing a sign of DKA? Yes, rapid breathing (Kussmaul respiration) is often observed in DKA patients as the body attempts to eliminate excess acids through respiration.

Diagnosis and Assessment of Diabetic Ketoacidosis

Diagnosing DKA involves a combination of clinical evaluation and laboratory tests. Key diagnostic criteria include:

  1. Blood glucose levels typically above 250 mg/dL
  2. Presence of ketones in urine or blood
  3. Arterial pH below 7.3
  4. Decreased serum bicarbonate levels (less than 18 mEq/L)

How is the severity of DKA determined? The severity of DKA is primarily assessed based on the degree of metabolic acidosis, with severe cases showing arterial pH below 7.0 and serum bicarbonate levels under 10 mEq/L.

Importance of Arterial vs. Venous Blood Samples

A study by Herrington et al. (2012) found that venous blood samples can be clinically equivalent to arterial samples for estimating pH, serum bicarbonate, and potassium concentration in critically ill patients. This finding suggests that less invasive venous sampling may be sufficient for DKA assessment in many cases.

Treatment Strategies for Diabetic Ketoacidosis

The management of DKA focuses on addressing three main issues: fluid deficit, high blood glucose, and electrolyte imbalances. Treatment typically involves:

1. Fluid Replacement

Intravenous fluid therapy is crucial to restore circulatory volume and improve tissue perfusion. The choice of fluid and rate of administration depends on the patient’s hydration status, electrolyte levels, and cardiac function.

2. Insulin Therapy

Continuous intravenous insulin infusion is the preferred method for managing DKA. A study by Umpierrez et al. (2009) compared insulin analogs to human insulin in DKA treatment and found no significant differences in outcomes, suggesting that both types can be effectively used.

3. Electrolyte Management

Potassium levels require close monitoring and replacement as needed. Other electrolytes, such as phosphate and magnesium, may also need supplementation.

When should bicarbonate therapy be considered in DKA? Bicarbonate therapy is generally reserved for cases of severe acidosis (pH < 6.9) or when there's a risk of cardiovascular instability.

Preventing Diabetic Ketoacidosis in High-Risk Patients

Prevention of DKA is a key aspect of diabetes management. Strategies include:

  • Regular blood glucose monitoring
  • Adherence to prescribed insulin regimens
  • Ketone testing during illness or stress
  • Patient education on recognizing early signs of DKA
  • Proper management of concurrent illnesses

A study by Crossen et al. (2016) highlighted the importance of outpatient care in preventing DKA hospitalizations, emphasizing the need for regular follow-ups and education.

Long-Term Complications and Outcomes of Recurrent DKA

Repeated episodes of DKA can have serious long-term consequences. These may include:

  • Increased risk of stroke in type 2 diabetes patients (Chen et al., 2017)
  • Cognitive impairment, particularly in young patients (Jessup et al., 2015)
  • Higher mortality rates (Zargar et al., 2009)
  • Increased risk of acute kidney injury in children (Hursh et al., 2017)

How does recurrent DKA affect long-term diabetes management? Recurrent DKA episodes can lead to worsened glycemic control, increased insulin resistance, and a higher risk of diabetes-related complications, underscoring the importance of prevention and proper management.

Special Considerations: DKA in the Context of COVID-19

The COVID-19 pandemic has introduced new challenges in managing diabetes and DKA. Key points include:

  • Increased risk of DKA in diabetes patients with COVID-19
  • Potential for euglycemic DKA in patients taking SGLT2 inhibitors
  • Need for adapted management strategies in COVID-19 positive patients

Bornstein et al. (2020) provided practical recommendations for managing diabetes in COVID-19 patients, emphasizing the importance of vigilant monitoring and adjusted treatment protocols.

SGLT2 Inhibitors and DKA Risk

The use of SGLT2 inhibitors has been associated with an increased risk of DKA, particularly in the context of COVID-19. Vitale et al. (2020) reported cases of euglycemic DKA in type 2 diabetes patients with COVID-19 who were taking SGLT2 inhibitors, highlighting the need for caution and close monitoring.

Advances in DKA Management and Future Directions

Recent research has led to improvements in DKA management and understanding:

  • Use of subcutaneous rapid-acting insulin analogs in mild to moderate DKA
  • Development of protocols for managing DKA in resource-limited settings
  • Exploration of closed-loop insulin delivery systems for DKA prevention
  • Investigation of immunomodulatory therapies to preserve beta-cell function in new-onset type 1 diabetes presenting with DKA

What role might artificial intelligence play in DKA management? AI could potentially assist in early detection of DKA risk factors, optimize fluid and insulin therapy, and provide personalized management strategies based on individual patient data.

Emerging Trends in DKA Epidemiology

A study by Zhong et al. (2018) observed changing trends in DKA hospital admissions, noting an increase in admissions among adults with type 2 diabetes. This shift highlights the need for expanded DKA education and prevention strategies across all diabetes types.

Understanding these trends is crucial for healthcare providers to adapt their approach to DKA management and prevention, ensuring optimal care for all diabetes patients at risk of this serious complication.

Pediatric Considerations in Diabetic Ketoacidosis

Managing DKA in children and adolescents presents unique challenges and considerations:

Cerebral Edema Risk

Glaser et al. (2008) investigated the correlation between clinical and biochemical findings and DKA-related cerebral edema in children using MRI. Their findings emphasized the importance of careful fluid management to minimize the risk of this potentially fatal complication.

Partial Remission and DKA Risk

A study by Bowden et al. (2008) found that young children (≤5 years) with type 1 diabetes have a low rate of partial remission, and DKA at diagnosis is an important risk factor. This highlights the need for early diagnosis and intervention in pediatric populations.

How does age affect DKA presentation and management in children? Younger children may present with more severe DKA due to delayed diagnosis, and they require more careful fluid and electrolyte management to prevent complications like cerebral edema.

Long-term Cognitive Effects

Jessup et al. (2015) studied the effects of DKA on visual and verbal neurocognitive function in young patients with new-onset type 1 diabetes. Their findings suggest that DKA may have lasting impacts on cognitive function, underscoring the importance of prevention and prompt treatment.

Investigating Metabolic Acidosis in DKA

The complex metabolic derangements in DKA extend beyond ketoacidosis. Mrozik and Yung (2009) conducted a retrospective audit showing that hyperchloremic metabolic acidosis slows recovery in children with DKA. This finding highlights the importance of comprehensive electrolyte management in DKA treatment.

Role of Thyroid Function in DKA

Potenza et al. (2009) explored the relationship between excess thyroid hormone and carbohydrate metabolism. Their work suggests that thyroid dysfunction can contribute to metabolic imbalances and potentially increase DKA risk, emphasizing the need for comprehensive endocrine evaluation in some DKA cases.

How does thyroid dysfunction impact DKA risk and management? Hyperthyroidism can increase insulin resistance and metabolic rate, potentially exacerbating hyperglycemia and ketosis. Conversely, hypothyroidism may mask some DKA symptoms, complicating diagnosis and management.

Technological Advancements in DKA Prevention and Management

Recent technological developments have the potential to revolutionize DKA prevention and management:

Continuous Glucose Monitoring (CGM)

CGM systems provide real-time glucose data, allowing for early detection of hyperglycemia and potential DKA. Pugliese et al. (2009) discussed the role of self-glucose monitoring in diabetes management, which has been further enhanced by CGM technology.

Ketone Monitoring Devices

Weber et al. (2009) provided an overview of ketone self-monitoring for DKA prevention. The development of home ketone testing devices, both urine and blood-based, has empowered patients to detect ketosis early and seek treatment promptly.

Insulin Pump Therapy

Advanced insulin pumps with continuous glucose monitoring integration can automatically adjust insulin delivery based on glucose trends, potentially reducing the risk of severe hyperglycemia and DKA.

How do technological advancements impact patient empowerment in DKA prevention? These technologies provide patients with more data and tools to manage their diabetes effectively, enabling early intervention and potentially reducing DKA incidence through improved glycemic control and early detection of metabolic derangements.

Global Perspectives on Diabetic Ketoacidosis

DKA remains a significant challenge in diabetes care worldwide, with variations in incidence, presentation, and outcomes across different regions:

Developing Countries

In many developing countries, DKA continues to be a leading cause of diabetes-related mortality. Zargar et al. (2009) reported on causes of mortality in diabetes mellitus from a tertiary teaching hospital in India, highlighting the significant impact of DKA in resource-limited settings.

Developed Countries

While outcomes have generally improved in developed countries, challenges remain. Lin et al. (2005) compared DKA characteristics and outcomes over a 20-year period, noting improvements in management but persistent issues with DKA incidence.

Global Initiatives

International diabetes organizations are working to standardize DKA management protocols and improve access to care globally. These efforts aim to reduce DKA-related morbidity and mortality worldwide.

How do socioeconomic factors influence DKA risk and outcomes globally? Socioeconomic disparities can affect access to diabetes care, education, and monitoring supplies, potentially increasing DKA risk in underprivileged populations. Addressing these disparities is crucial for global DKA prevention efforts.

Approach Considerations, Correction of Fluid Loss, Insulin Therapy

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History, Physical Examination, Signs and Symptoms of Hyperglycemia, Acidosis, and Dehydration

  1. Glaser NS, Marcin JP, Wootton-Gorges SL, et al. Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging. J Pediatr. 2008 Jun 25. [QxMD MEDLINE Link].

  2. Umpierrez GE, Jones S, Smiley D, et al. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care. 2009 Jul. 32(7):1164-9. [QxMD MEDLINE Link]. [Full Text].

  3. Herrington WG, Nye HJ, Hammersley MS, Watkinson PJ. Are arterial and venous samples clinically equivalent for the estimation of pH, serum bicarbonate and potassium concentration in critically ill patients?. Diabet Med. 2012 Jan. 29(1):32-5. [QxMD MEDLINE Link].

  4. Mrozik LT, Yung M. Hyperchloraemic metabolic acidosis slows recovery in children with diabetic ketoacidosis: a retrospective audit. Aust Crit Care. 2009 Jun 26. [QxMD MEDLINE Link].

  5. Bowden SA, Duck MM, Hoffman RP. Young children (12 yr) with type 1 diabetes mellitus have low rate of partial remission: diabetic ketoacidosis is an important risk factor. Pediatr Diabetes. 2008 Jun. 9(3 Pt 1):197-201. [QxMD MEDLINE Link].

  6. Potenza M, Via MA, Yanagisawa RT. Excess thyroid hormone and carbohydrate metabolism. Endocr Pract. 2009 May-Jun. 15(3):254-62. [QxMD MEDLINE Link].

  7. Taylor SI, Blau JE, Rother KI. SGLT2 Inhibitors May Predispose to Ketoacidosis. J Clin Endocrinol Metab. 2015 Aug. 100 (8):2849-52. [QxMD MEDLINE Link].

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7.2. Diabetic ketoacidosis \ ConsultantPlus

7.2. Diabetic ketoacidosis

DKA is an acute diabetic decompensation of metabolism, manifested by a sharp increase in the level of glucose and the concentration of ketone bodies in the blood, their appearance in the urine and the development of metabolic acidosis, accompanied by varying degrees of impaired consciousness or proceeding without them and requiring emergency hospitalization of the patient. The development of DKA in T1DM without treatment is deadly and, in the absence of timely assistance, quickly leads to death. Patients need immediate treatment and specialized care.

Risk factors for developing DKA in newly diagnosed patients are younger age, later diagnosis of DM, lower socioeconomic status, and living in an area with a low prevalence of type 1 diabetes mellitus (T1DM). Risk factors for developing DKA in patients with previously diagnosed diabetes include insulin deficiency for various reasons, limited access to medical services, and unrecognized insulin deficiency in patients using an insulin pump.

Biochemical diagnostic criteria for DKA are:

– Hyperglycemia (blood glucose > 11 mmol/l)

– Venous blood pH < 7.3 or serum bicarbonate < 15 mmol/l

– Ketonemia (beta-hydroxybuyrate in the blood 3 mmol / l) or moderate or significant ketonuria (2+).

Clinical signs of DKA include: dehydration, tachycardia, tachypnea, deep sighing, breath odor of acetone, nausea and/or vomiting, abdominal pain, blurred vision, confusion, drowsiness, progressive loss of consciousness, and eventually in the end, to whom.

Treatment of DKA is carried out depending on the severity of the condition:

– With minimal signs of dehydration (absence of pronounced changes in blood electrolytes), drink plenty of fluids and subcutaneous injection of insulin until glycemia normalizes.

– In case of dehydration more than 5%, nausea and vomiting, deep breathing, but without loss of consciousness, rehydration is prescribed: 0.9% NaCl solution at the rate of 10 ml / kg per hour until the symptoms of dehydration disappear, KCl is added to the solution at the rate of 40 mmol per liter of fluid until the normalization of electrolyte disturbances. ECG monitoring is carried out until T-waves normalize, blood pressure is monitored.

– With glycemia less than 17 mmol/l and with a decrease in glycemia by more than 5 mmol/l per hour, add 40% glucose solution to the dropper.

– Mandatory hourly glycemic control, control of injected and excreted fluid, hourly control of neurological status, control every 2 hours of electrolyte levels, ECG monitoring.

Treatment goals are to correct dehydration, acidosis, and ketosis, gradually restore hyperosmolality and glycemia to near-normal levels, monitor and treat complications of DKA, and identify and treat comorbidities.

– It is recommended to hospitalize patients with DM1 in specialized hospitals, where it is possible to assess and monitor vital and laboratory parameters, neurological status in order to treat DKA [105].

Recommendation grade C (level of evidence – 5)

Comment: Treatment of DKA includes: rehydration, insulin administration, elimination of electrolyte disturbances, control of acidosis, general measures, treatment of the conditions that caused DKA.

– Blood glucose, blood and/or urine ketones, blood hydrogen ion (pH), or blood buffer (bicarbonate) levels are recommended in the presence of clinical signs of DKA in order to promptly diagnose DKA [105].

Strength of recommendation C (level of evidence – 5)

– It is recommended that patients with DKA use the Glasgow scale to assess the level of consciousness [105].

Strength of recommendation C (level of evidence – 5)

– An anthropometric study (measurement of body weight and height) is recommended in patients with DKA to determine the amount of infusion therapy [105].

Recommendation grade C (level of evidence – 5)

– A physical examination (visual examination, palpation) is recommended in patients with DKA to assess the degree of dehydration [105].

Strength of recommendation C (level of evidence – 5)

Comment: Estimating the degree of dehydration is imprecise and must be based on a combination of physical signs. The most useful signs for determining 5% dehydration in young children aged 1 month to 5 years:

– increased capillary refill time (normal capillary refill 1.5 – 2 seconds)

– reduced skin turgor (inelastic skin)

Other useful signs in assessing the degree of dehydration are: dry mucous membranes, sunken eyes, no tears, weak pulse, cool extremities. More signs of dehydration are usually associated with more severe dehydration.

Dehydration of 10% is confirmed by the presence of a weak or non-palpable peripheral pulse, hypotension, oliguria.

– It is recommended in conscious patients with DKA and dehydration that 10-20 ml/kg sodium chloride** 0.9% solution be administered over 30-60 minutes to restore peripheral circulation [105].

Level of recommendation C (level of evidence – 5)

Comment: In the case of severe peripheral circulatory disorders, the initial bolus is delivered faster (for example, after 15 to 30 minutes), and a second bolus may be required to ensure adequate tissue perfusion.

– Recommended in patients with DKA complete (clinical) blood test, study of acid-base status and blood gases, study of the level of: sodium in the blood, potassium in the blood, blood chlorides, blood glucose, blood ketone bodies and / or urine, buffer substances in the blood, creatinine in the urine, urea in the urine, osmolarity (osmolality) of the blood, albumin in the blood, total and ionized calcium in the blood, inorganic phosphorus in the blood to assess the degree of electrolyte and metabolic disorders [105].

Strength of recommendation C (level of evidence – 5)

– In patients with DKA, crystalloid fluid therapy (Table 9) is recommended to correct dehydration [105].

Grade of recommendation C (level of evidence – 5)

Comment: Subsequent fluid therapy (deficiency replacement) can be performed with 0.45% to 0.9% sodium chloride solution or balanced salt solution.

It is necessary to calculate the rate of subsequent fluid administration, taking into account maintenance volumes, to replenish the estimated deficit within 24 – 48 hours.

Table 9 – Solutions for infusion therapy

– Administration of bicarbonates is not recommended in patients with DKA, except in cases of life-threatening hyperkalemia or atypically severe ketoacidosis (vpH < 6.9) with signs of impaired cardiac contractility, to prevent the development of hypokalemia and paradoxical acidosis in the CNS [105].

Level of recommendation C (level of evidence – 5)

– In patients with DKA, administration of potassium solutions (Table 9) at a rate of 40 mmol per liter of fluid to correct hypokalemia is recommended in the absence of hyperkalemia [105].

Level of recommendation C (level of evidence – 5)

– Recommended in patients with DKA after the start of infusion therapy is the introduction of short-acting insulins or their analogues for injection (Table 5) at a dose of 0.05 – 0.1 U / kg/h to correct hyperglycemia and acidosis [105].

Strength of recommendation C (level of evidence – 5)

– In patients with DKA, administration of 5% or 12. 5% ​​dextrose solutions** is recommended to correct glycemia and prevent hypoglycemia [105].

Recommendation grade C (level of evidence 5)

– ECG monitoring for abnormal T-waves is recommended in patients with DKA [105].

Strength of recommendation C (level of evidence – 5)

– Recommended in patients with DKA, to control ongoing treatment, prevent the development of DKA complications and comorbidities, monitor the following indicators [105]:

– Hourly: assessment of vital signs, neurological assessment (Glasgow scale), entered (in hours drunk) / excreted liquid, examination of blood glucose levels;

– Every 2 to 4 hours: hematocrit, acid-base balance and blood gases, blood or urine ketone bodies, blood sodium, blood potassium, blood chloride, blood inorganic phosphorus, blood creatinine urine, urea in urine;

– Every morning: body weight measurement.

Level of recommendation C (level of evidence – 5)

– Recommended in patients with DKA at the first suspicion of cerebral edema, rapid deterioration of the neurological condition, immediately use mannitol ** 0. 5 – 1 g / kg or hypertonic 3% sodium chloride solution** for the prevention and treatment of cerebral edema [105].

Strength of recommendation C (level of evidence – 5)

Comment: Patients with multiple risk factors for cerebral edema (elevated serum urea nitrogen, severe acidosis, severe hypocapnia) should be pretreated with mannitol or hypertonic saline at calculated dosages.

Dehydration in Children – Symptoms, Diagnosis and Treatment

Last viewed: 9 May 2023

Last updated: 11 August 2021

Dehydration is a common condition encountered in pediatric practice. Early signs and symptoms in infants and children are nonspecific and often go undiagnosed.

Signs and symptoms depend on age and specific etiology, but may include general irritability, thirst, reduced activity, tachycardia, capillary retention, dry mucous membranes, sunken eyes, decreased skin turgor, and decreased urine output. Specific causes of dehydration, such as diabetic ketoacidosis and acute tubular necrosis, may present with frequent urination. A careful general pediatric history and physical examination are the most accurate means of determining that a child is dehydrated.

Hypotension is a late sign of extracellular fluid volume deficiency in children and often precedes clinically significant circulatory collapse.

The initial treatment of children with mild or moderate extracellular fluid volume deficiency is oral rehydration therapy. Regardless of etiology, children with severe hypovolemia and shock should receive appropriate intravenous treatment with isotonic crystalloid solutions.

With timely diagnosis and appropriate intervention, extracellular fluid volume deficiency in children is completely reversible with a favorable prognosis.

Definition

Extracellular fluid volume deficiency is a deficiency of water and dissolved substances from the extracellular component of the total body fluid volume, which leads to a decrease in circulating blood volume. It differs from dehydration, which more specifically indicates a deficiency in total body water. The most common cause of dehydration in children is gastroenteritis, which can lead to a severe deficit in extracellular fluid volume. Deficiency in the volume of extracellular fluid can also occur secondary to bleeding, increased loss of fluid and substances dissolved in it by the kidneys, an increase in imperceptible losses, and redistribution of body fluid to extravascular tissues (third space). Symptoms of extracellular fluid volume deficiency can range from thirst (with mild deficiency) to irreversible shock and death in severe cases.

History and examination

Key diagnostic factors
  • presence of risk factors
  • thirst
  • capillary refill time >3 sec
  • reduced skin turgor
  • dry mucous membranes meninges
  • disturbance of mental state or activity level
  • tachycardia
  • abnormal diuresis
  • increased rate or depth of breathing

more key diagnostic factors

Other diagnostic factors
  • vomiting
  • diarrhea
  • abdominal pain
  • glucose abnormalities (test strips)
  • low core temperature or fever
  • a normal BP
  • bruising or signs of neglect

Other diagnostic factors

Risk factors
  • vomiting and/or diarrhea
  • age <3 years
  • trauma
  • burns >10% of body surface area
  • Type 1 diabetes mellitus
  • history of decreased oral fluid intake
  • vigorous and prolonged exercise
  • history of diuretic use

More risk factors

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Diagnostic tests

Primary indicated tests
  • clinical diagnosis

More tests that are indicated first

Tests to consider
  • serum electrolytes
  • blood glucose
  • urea/creatinine
  • complete blood count
  • urinalysis
  • specific gravity urine
  • urine osmolality
  • Urinalysis and bacteriological analysis
  • bacteriological examination of blood
  • Study of the gas composition of arterial blood
  • Ultrasound of the head or computed tomography
  • ultrasound or CT of the abdominal organs of the abdominal cavity

more research, which need to be considered

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