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Ju HH. Euglycemic Diabetic Ketoacidosis: How Is It Different from Diabetic Ketoacidosis. Crit Care Nurs Clin North Am 2025; 37:157-165. [PMID: 39890347 DOI: 10.1016/j.cnc.2024.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2025]
Abstract
Diabetic ketoacidosis (DKA) and euglycemic DKA are both diabetes-related emergencies. Individuals with DKA can experience extremely elevated hyperglycemia exceeding 250 mg/dL. Although DKA is more frequently observed in people with type 1 diabetes (T1DM), euglycemic DKA, which is characterized by mildly elevated or nearly normal blood glucose at levels below 200 mg/dL, has recently been linked to the use of SGLT-2 inhibitors generally used for type 2 diabetes mellitus (T2DM). Without the substantial hyperglycemia associated with DKA, euglycemic DKA may be clinically overlooked. The pathophysiology, precipitating factors, clinical presentations, treatments, and evaluations of euglycemic DKA and DKA are reviewed.
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Affiliation(s)
- Hsiao-Hui Ju
- Department of Undergraduate Studies, The University of Texas at Houston (UTHealth) Cizik School of Nursing, 6901 Bertner Avenue Room #748, Houston, TX 77030, USA.
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Lee MKH, Ball PA. Euglycemic diabetic ketoacidosis in the setting of acute intracerebral hemorrhage. Surg Neurol Int 2024; 15:284. [PMID: 39246790 PMCID: PMC11380825 DOI: 10.25259/sni_295_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 07/12/2024] [Indexed: 09/10/2024] Open
Abstract
Background Diabetic ketoacidosis (DKA) is a life-threatening condition among diabetic patients characterized by metabolic anion gap (AG) acidosis of arterial pH <7.30, glucose >250 mg/dL, and positive ketones. The triggers for DKA can be infection, surgery, and, in reported cases, intraparenchymal hemorrhage (IPH). In rare cases of DKA, despite being in active ketoacidosis, glucose levels may be within normal or accepted range. Such a condition is called euglycemic DKA. It has been recently recognized in association with the use of sodium glucose co-transporter-2 (SGLT-2) inhibitors in the treatment of type 2 diabetes. Case Description An 83-year-old male taking an SGLT-2 inhibitor (empagliflozin) for type 2 diabetes presented with an IPH. His laboratory studies revealed an elevated AG acidosis, an elevated beta hydroxybutyrate, and serum glucose levels within the acceptable range. Urine studies revealed elevated ketones and glucose. The diagnosis of euglycemic DKA was made, and the patient was treated with insulin and glucose infusions. Conclusion Like hyperglycemic ketoacidosis, euglycemic DKA requires prompt recognition and immediate aggressive medical therapy, but the diagnosis can be challenging, and the treatment using insulin in the setting of a normal glucose can be counterintuitive. Euglycemic DKA can often be missed in the setting of blood glucose not being elevated. Prompt recognition and treatment are critical for successful management.
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Affiliation(s)
| | - Perry A Ball
- Department of Surgery, Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, United States
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Haddadin R, Aboujamra D, Iraninezhad H. Sodium-Glucose Cotransporter-2 Inhibitor-Induced Euglycemic Diabetic Ketoacidosis in a Type 2 Diabetic Patient. Cureus 2023; 15:e51184. [PMID: 38283482 PMCID: PMC10817760 DOI: 10.7759/cureus.51184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2023] [Indexed: 01/30/2024] Open
Abstract
Euglycemic diabetic ketoacidosis (euDKA) is a life-threatening metabolic complication typically associated with type 1 diabetes mellitus (T1DM). However, its occurrence in type 2 diabetes mellitus (T2DM) remains exceptionally rare. We present a case report detailing the unusual manifestation of euDKA in a patient with T2DM following the initiation of treatment with a sodium-glucose cotransporter-2 (SGLT-2) inhibitor. The patient, a 67-year-old female with a history of T2DM and well-controlled blood glucose levels, was commenced on an SGLT-2 inhibitor as part of her antidiabetic regimen just two weeks prior. Subsequently, the patient developed euDKA despite maintaining near-normal glycemic levels. This paradoxical presentation challenges the conventional understanding of DKA in T2DM and underscores the need for heightened clinical awareness. EuDKA associated with SGLT-2 inhibitors is an infrequently reported phenomenon, further complicating the clinical landscape. This case contributes to the growing evidence suggesting an association between SGLT-2 inhibitors and the development of euDKA in patients with T2DM. The rarity of this occurrence necessitates a thorough exploration of potential risk factors and underlying mechanisms.
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Affiliation(s)
| | - Danny Aboujamra
- Internal Medicine, St. George's University School of Medicine, Las Vegas, USA
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Chow E, Clement S, Garg R. Euglycemic diabetic ketoacidosis in the era of SGLT-2 inhibitors. BMJ Open Diabetes Res Care 2023; 11:e003666. [PMID: 37797963 PMCID: PMC10551972 DOI: 10.1136/bmjdrc-2023-003666] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/19/2023] [Indexed: 10/07/2023] Open
Abstract
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.
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Affiliation(s)
- Erica Chow
- Division of Endocrinology, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Stephen Clement
- Division of Endocrinology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Rajesh Garg
- Division of Endocrinology, Harbor-UCLA Medical Center, Torrance, California, USA
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Juneja D, Nasa P, Jain R, Singh O. Sodium-glucose Cotransporter-2 Inhibitors induced euglycemic diabetic ketoacidosis: A meta summary of case reports. World J Diabetes 2023; 14:1314-1322. [PMID: 37664476 PMCID: PMC10473945 DOI: 10.4239/wjd.v14.i8.1314] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/20/2023] [Accepted: 06/19/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are commonly prescribed to manage patients with diabetes mellitus. These agents may rarely lead to the development of euglycemic diabetic ketoacidosis (EDKA), which may complicate the disease course of these patients. AIM To analyze the demographic profile, predisposing factors, symptomology, clinical interventions and outcomes of patients presenting with EDKA secondary to SGLT2i use by reviewing the published case reports and series. METHODS We performed a systematic search of PubMed, Science Direct, Google Scholar and Reference Citation Analysis databases using the terms "canagliflozin" OR "empagliflozin" OR "dapagliflozin" OR "SGLT2 inhibitors" OR "Sodium-glucose cotransporter-2" AND "euglycemia" OR "euglycemic diabetic ketoacidosis" OR "metabolic acidosis". The inclusion criteria were: (1) Case reports or case series with individual patient details; and (2) Reported EDKA secondary to SGLT2i. Furthermore, the data were filtered from the literature published in the English language and on adults (> 18 years). We excluded: (1) Conference abstracts; and (2) Case reports or series which did not have individual biochemical data. All the case reports and case series were evaluated. The data extracted included patient demographics, clinical symptomatology, clinical interventions, intensive care unit course, need for organ support and outcomes. RESULTS Overall, 108 case reports and 17 cases series with 169 unique patients that met all the inclusion criteria were included. The majority of patients were females (54.4%, n = 92), and the commonly reported symptoms were gastrointestinal (nausea/vomiting 65.1%, abdominal pain 37.3%) and respiratory (breathlessness 30.8%). One hundred and forty-nine (88.2%) patients had underlying type II diabetes, and the most commonly involved SGLT-2 inhibitor reported was empagliflozin (46.8%). A triggering factor was reported in most patients (78.7%), the commonest being acute severe infection (37.9%), which included patients with sepsis, coronavirus disease 2019, other viral illnesses, and acute pancreatitis. 61.5% were reported to require intensive unit care, but only a minority of patients required organ support in the form of invasive mechanical ventilation (13%), vasopressors (6.5%) or renal replacement therapy (5.9%). The overall mortality rate was only 2.4%. CONCLUSION Patients on SGLT2i may rarely develop EDKA, especially in the presence of certain predisposing factors, including severe acute infections and following major surgery. The signs and symptoms of EDKA may be similar to that of DKA but with normal blood sugar levels, which may make the diagnosis challenging. Outcomes of EDKA are good if recognized early and corrective actions are taken. Hence, physicians managing such patients must be aware of this potential complication and must educate their patients accordingly to ensure early diagnosis and management.
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Affiliation(s)
- Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
- Department of Internal Medicine, College of Medicine and Health Sciences, Al Ain 15551, Abu Dhabi, United Arab Emirates
| | - Ravi Jain
- Department of Critical Care Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur 302022, Rajasthan, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
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Alduraibi RK, Alrebdi YM, Altowayan YF. Euglycemic diabetic ketoacidosis after the initiation of dulaglutide in patient with type 2 diabetes. Medicine (Baltimore) 2023; 102:e34027. [PMID: 37335652 PMCID: PMC10256347 DOI: 10.1097/md.0000000000034027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 05/26/2023] [Indexed: 06/21/2023] Open
Abstract
RATIONALE Diabetic ketoacidosis is rarely observed when the blood glucose level is <250 mg/dL. This is referred to as euglycemic diabetic ketoacidosis (EDKA). EDKA can present diagnostic and management challenges for physicians, especially when dealing with unusual triggers such as glucagon-like peptide 1 (GLP1) receptor agonists and sodium-glucose co-transporter 2 inhibitors. With this case report, we wanted to raise the knowledge and understanding of EDKA and its triggering factors. PATIENT CONCERNS A 45-year-old man was admitted to hospital for epigastric pain, loss of appetite, and vomiting 3 days after the initiation of dulaglutide. The results of laboratory examination showed EDKA. DIAGNOSES The patient was diagnosed with EDKA after the initiation of GLP1 receptor agonists. INTERVENTIONS Intravenous fluid and insulin infusion were immediately started. OUTCOME The patient was discharged after treatment. LESSONS In this case report describes the use of GLP1 receptor agonists along with Sodium-glucose co-transporter 2 inhibitors in type 2 diabetes patients whose extreme restriction of carbohydrate intake may have triggered EDKA. Therefore, physicians should use diabetes medications in a stepwise manner and advise their patients not to over-restrict their carbohydrate intake while they are being treated with GLP1 receptor agonists.
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Affiliation(s)
- Rabia Khalid Alduraibi
- Department of Endocrine and Diabetes, King Fahad Specialist Hospital, Buraydah, Saudi Arabia
| | | | - Yosef Fahad Altowayan
- Department of Internal Medicine, King Fahad Specialist Hospital, Buraydah, Saudi Arabia
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Muacevic A, Adler JR, Dâmaso F, Duarte JA, Rodrigues C. Postop Complication With Euglycemic Diabetic Ketoacidosis in a Patient Receiving Empagliflozin. Cureus 2022; 14:e33161. [PMID: 36726923 PMCID: PMC9885381 DOI: 10.7759/cureus.33161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2022] [Indexed: 01/01/2023] Open
Abstract
Euglycemic diabetic ketoacidosis (EDKA) is an uncommon diabetic complication with increasing prevalence and is associated with the use of sodium-glucose co-transporter 2 inhibitors (SGLT2i). We report the case of a 77-year-old female patient with type 2 diabetes mellitus, treated with metformin/linagliptin and empagliflozin, who initiated a slurred speech and altered level of consciousness in the postoperative period of a cholecystectomy. On observation, the patient presented with Kussmaul breathing and mucosal dryness and was ketotic. Laboratory exams showed metabolic acidosis with an elevated anion gap, normoglycemia, and positive ketonemia. Fluid replacement with dextrose solution and continuous insulin infusion were initiated, with progressive clinical and laboratory improvement. On discharge, she showed resolution of symptoms, and empagliflozin was discontinued from her usual medication. Despite the warnings of European and American medical agencies in 2015/2016, EDKA remains a challenging diagnosis due to its unspecific and insidious symptoms.
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Abstract
Diabetic ketoacidosis (DKA) is a form of a hyperglycemic emergency mainly characterized by the triad of hyperglycemia, ketosis, and anion gap metabolic acidosis. DKA may be the initial presentation in approximately 25-40 % of patients with type 1 diabetes. It may also occur in at least 34% of patients with type 2 diabetes. DKA has economic as well as medical implications. This review aims to explore and discuss diabetic ketoacidosis, its pathophysiology, clinical presentation, diagnosis, and management, including nuances in special populations such as pediatrics, obstetrics, and patients with chronic kidney disease.
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Diguisto C, Strachan MWJ, Churchill D, Ayman G, Knight M. A study of diabetic ketoacidosis in the pregnant population in the United Kingdom: Investigating the incidence, aetiology, management and outcomes. Diabet Med 2022; 39:e14743. [PMID: 34778994 PMCID: PMC7612514 DOI: 10.1111/dme.14743] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 10/19/2021] [Accepted: 11/12/2021] [Indexed: 01/10/2023]
Abstract
AIM To estimate the incidence of diabetic ketoacidosis (DKA) among pregnant women, describe its clinical features, management and outcomes and identify the risk factors for the condition. METHODS A national population-based case-control study was conducted in the UK using the UK Obstetric Surveillance System between April 2019 and September 2020 including all pregnant women with DKA irrespective of the level of blood glucose. The incidence rate of DKA in pregnancy was estimated. A case-control analysis limited to women with type 1 diabetes was performed comparing characteristics of women with DKA (cases) to those of women whose pregnancies were not complicated by DKA (controls). RESULTS In all, 82 women were identified with DKA in pregnancy; 6.3 per 100,000 maternities (95% CI: 5.0-7.9). No maternal deaths occurred, but perinatal mortality was 12/73 (16%) with 11 stillbirths and one neonatal death. DKA episodes mostly occurred in women with type 1 diabetes (85%) and in the 3rd trimester of pregnancy (71%). Episodes were mainly precipitated by infection (21%), vomiting (21%), steroid therapy (13%) and medication errors (10%). Fifteen percent of women had more than one episode of DKA during their pregnancy. Risk factors associated with DKA among women with type 1 diabetes identified through the case-control analysis were the woman and/or partner not being in a paid employment and having at least one microvascular complication of diabetes before pregnancy. CONCLUSION DKA in pregnancy was associated with high perinatal mortality and was linked with factors related to socio-economic deprivation, mental health problems and long-term difficulties with glycaemic control.
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Affiliation(s)
- Caroline Diguisto
- National Perinatal Epidemiology UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
- Pôle de gynécologie obstétrique, médecine fœtale, médecine et biologie de la reproductionCentre Olympe de GougesCHRU de ToursUniversité de ToursToursFrance
- Université de ParisCRESSINSERMINRAParisFrance
| | | | - David Churchill
- Research Institute in Healthcare ScienceUniversity of WolverhamptonThe Royal Wolverhampton Hospital NHS TrustWolverhamptonUK
| | - Goher Ayman
- National Perinatal Epidemiology UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Marian Knight
- National Perinatal Epidemiology UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
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Luo X, Ji R, Lu W, Zhu H, Li L, Hu J. Dapagliflozin-Associated Euglycemic Diabetic Ketoacidosis in a Patient Who Underwent Surgery for Pancreatic Carcinoma: A Case Report. Front Surg 2022; 9:769041. [PMID: 35284482 PMCID: PMC8906517 DOI: 10.3389/fsurg.2022.769041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/21/2022] [Indexed: 11/13/2022] Open
Abstract
Diabetic ketoacidosis (DKA), an acute and life-threatening complication of diabetes, is a metabolic disorder caused by insulin deficiency and an increase in counter-regulatory hormones. Several cases of DKA without marked hyperglycemia have been reported and are defined as euglycemic DKA (eu-DKA). The use of sodium-glucose cotransporter 2 inhibitors (SGLT2is) is associated with the occurrence of eu-DKA, of which, dapagliflozin is one of the agents. In this study, we report a case of dapagliflozin-associated eu-DKA following surgery for pancreatic carcinoma. A 57-year-old woman presented with acute abdominal pain after surgery for pancreatic carcinoma. Emergency exploratory laparotomy was performed because of suspicion of gastrointestinal perforation based on a CT scan. The surgeons observed that the stomach was significantly dilated but not perforated. Meanwhile, the patient developed shock and severe acidosis. A further examination confirmed the diagnosis of dapagliflozin-associated eu-DKA. We reviewed the precipitating factors and mechanisms of SGLT2i-associated eu-DKA and discussed the treatment and prevention of this condition. Clinicians need to be alert of the occurrence of SGLT2i-associated eu-DKA in patients treated with this drug in the perioperative period.
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Thompson BD, Kitchen A. Euglycemic Diabetic Ketoacidosis in Type 1 Diabetes on Insulin Pump, with Acute Appendicitis: A Case Report. Clin Pract Cases Emerg Med 2021; 5:136-138. [PMID: 34437030 PMCID: PMC8373175 DOI: 10.5811/cpcem.2021.1.48905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 01/11/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Recently, euglycemic diabetic ketoacidosis has been an increasing topic of discussion within emergency medicine literature. Euglycemic diabetic ketoacidosis can easily be missed, as a normal point-of-care glucose often mistakenly precludes the work-up of diabetic ketoacidosis. CASE REPORT A 16-year-old female with a past medical history of type 1 diabetes presented to the emergency department with altered mental status, vomiting, and abdominal pain. She was diagnosed with euglycemic diabetic ketoacidosis. CONCLUSION Reported cases of euglycemic diabetic ketoacidosis are most frequently attributed to sodium glucose cotransporter-2 inhibitors, but other potential causes have been discussed in the literature. In this patient, a starvation state with continued insulin use in the setting of acute appendicitis led to her condition.
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Affiliation(s)
- Brian D Thompson
- University of Massachusetts Medical School - Baystate Health, Department of Emergency Medicine, Springfield, Massachusetts
| | - Anthony Kitchen
- University of Massachusetts Medical School - Baystate Health, Department of Emergency Medicine, Springfield, Massachusetts
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Nasa P, Chaudhary S, Shrivastava PK, Singh A. Euglycemic diabetic ketoacidosis: A missed diagnosis. World J Diabetes 2021; 12:514-523. [PMID: 33995841 PMCID: PMC8107974 DOI: 10.4239/wjd.v12.i5.514] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/01/2021] [Accepted: 03/25/2021] [Indexed: 02/06/2023] Open
Abstract
Euglycemic diabetic ketoacidosis (DKA) is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose (less than 11 mmol/L). The absence of hyperglycemia is a conundrum for physicians in the emergency department and intensive care units; it may delay diagnosis and treatment causing worse outcomes. Euglycemic DKA is an uncommon diagnosis but can occur in patients with type 1 or type 2 diabetes mellitus. With the addition of sodium/ glucose cotransporter-2 inhibitors in diabetes mellitus management, euglycemic DKA incidence has increased. The other causes of euglycemic DKA include pregnancy, fasting, bariatric surgery, gastroparesis, insulin pump failure, cocaine intoxication, chronic liver disease and glycogen storage disease. The pathophysiology of euglycemic DKA involves a relative or absolute carbohydrate deficit, milder degree of insulin deficiency or resistance and increased glucagon/insulin ratio. Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones. The diagnostic workup includes arterial blood gas for metabolic acidosis, serum ketones and exclusion of other causes of high anion gap metabolic acidosis. Euglycemic DKA treatment is on the same principles as for DKA with correction of dehydration, electrolytes deficit and insulin replacement. The dextrose-containing fluids should accompany intravenous insulin to correct metabolic acidosis, ketonemia and to avoid hypoglycemia.
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Affiliation(s)
- Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
| | - Sandeep Chaudhary
- Department of Endocrinology, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
| | | | - Aanchal Singh
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
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Smith A, Holtrop J, Sadoun M. Post-Operative Euglycemic Diabetic Ketoacidosis in a Patient With SGLT-2 Inhibitor Use and Recent Sleeve Gastrectomy. Cureus 2021; 13:e14297. [PMID: 33968511 PMCID: PMC8097746 DOI: 10.7759/cureus.14297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
A 51-year-old woman with type 2 diabetes mellitus developed euglycemic diabetic ketoacidosis (euDKA) in the post-operative setting after robotic-assisted sleeve gastrectomy. She developed tachycardia on post-operative day (POD) 1 before developing altered mental status and tachypnea on POD 2. The diagnosis was ultimately made by discovering ketonuria in the setting of anion gap metabolic acidosis despite repeatedly normal blood glucose levels. Pre-operatively, her blood glucose levels were managed with sodium-glucose co-transporter-2 (SGLT-2) inhibitor-containing combination pill, Invokamet®, as well as basal-bolus insulin regimen consisting of aspart (NovoLog®) and glargine-lixisenatide (Soliqua®). SLGT-2 inhibitors have been associated with an increased risk of euDKA, particularly in the context of severe bodily stressors such as surgery. EuDKA is a difficult diagnosis to make because of the lack of characteristic severe hyperglycemia that is typical of DKA. Clinicians should be mindful of euDKA in the post-operative setting of diabetic patients, particularly for those on SGLT-2 inhibitors.
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Affiliation(s)
- Alexander Smith
- Department of Endocrinology, Wayne State University School of Medicine, Detroit, USA
| | - John Holtrop
- Department of Surgery, Ascension St. John Hospital, Detroit, USA
| | - Moutamn Sadoun
- Department of Surgery, Ascension St. John Hospital, Detroit, USA
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Long B, Lentz S, Koyfman A, Gottlieb M. Euglycemic diabetic ketoacidosis: Etiologies, evaluation, and management. Am J Emerg Med 2021; 44:157-160. [PMID: 33626481 DOI: 10.1016/j.ajem.2021.02.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Diabetic ketoacidosis is an endocrine emergency. A subset of diabetic patients may present with relative euglycemia with acidosis, known as euglycemic diabetic ketoacidosis (EDKA), which is often misdiagnosed due to a serum glucose <250 mg/dL. OBJECTIVE This narrative review evaluates the pathogenesis, diagnosis, and management of EDKA for emergency clinicians. DISCUSSION EDKA is comprised of serum glucose <250 mg/dL with an anion gap metabolic acidosis and ketosis. It most commonly occurs in patients with a history of low glucose states such as starvation, chronic liver disease, pregnancy, infection, and alcohol use. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, which result in increased urinary glucose excretion, are also associated with EDKA. The underlying pathophysiology involves insulin deficiency or resistance with glucagon release, poor glucose availability, ketone body production, and urinary glucose excretion. Patients typically present with nausea, vomiting, malaise, or fatigue. The physician must determine and treat the underlying etiology of EDKA. Laboratory assessment includes venous blood gas for serum pH, bicarbonate, and ketones. Management includes resuscitation with intravenous fluids, insulin, and glucose, with treatment of the underlying etiology. CONCLUSIONS Clinician knowledge of this condition can improve the evaluation and management of patients with EDKA.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States of America.
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, VT, United States of America
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States of America
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL 60612, United States of America
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Mumtaz H, Shafiq MA, Batool H, Naz T, Ambreen S. Diabetic Ketoacidosis in an Euglycemic Patient. Cureus 2020; 12:e10065. [PMID: 33005499 PMCID: PMC7522057 DOI: 10.7759/cureus.10065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Sampani E, Sarafidis P, Dimitriadis C, Kasimatis E, Daikidou D, Bantis K, Papanikolaou A, Papagianni A. Severe euglycemic diabetic ketoacidosis of multifactorial etiology in a type 2 diabetic patient treated with empagliflozin: case report and literature review. BMC Nephrol 2020; 21:276. [PMID: 32669085 PMCID: PMC7364613 DOI: 10.1186/s12882-020-01930-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 07/06/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT-2) inhibitors are a relatively novel class of oral medications for the treatment of Type 2 DM with a generally acceptable safety profile. However, these agents have been associated with rare events of a serious and potentially life-threatening complication named euglycemic diabetic ketoacidosis (euDKA). euDKA is not identical with the typical diabetic ketoacidosis, as it often presents with serious metabolic acidosis but only mild to moderate glucose and anion gap elevation. CASE PRESENTATION We report a case of a 51-year old female with Type 2 DM treated with an SGLT-2 inhibitor, developing severe metabolic acidosis with only mild blood glucose elevation after a routine surgery. A careful evaluation of involved factors led to the diagnosis of euDKA, followed by cautious application of simple therapeutic measures that resulted in complete restoration of acidosis and glycemic control in less than 48-h. CONCLUSIONS Euglycemic ketoacidosis is a rare but rather serious complication of SGLT-2 inhibitors use, often with a multifactorial etiology. Its atypical presentation requires a high level of awareness by physicians as early recognition of this complication can quickly and safely restore acid-base balance.
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Affiliation(s)
- Erasmia Sampani
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece.
| | - Chrysostomos Dimitriadis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece
| | - Efstratios Kasimatis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece
| | - Dimitra Daikidou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece
| | - Konstantinos Bantis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece
| | - Alexios Papanikolaou
- 2nd Department of Obstetrics and Gynecology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece
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Abstract
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.
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Affiliation(s)
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
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18
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β-Hydroxybutyrate dehydrogenase decorated MXene nanosheets for the amperometric determination of β-hydroxybutyrate. Mikrochim Acta 2020; 187:277. [PMID: 32314063 DOI: 10.1007/s00604-020-04258-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Abstract
MXene nanosheets of type Ti3C2Tx were modified with β-hydroxybutyrate dehydrogenase and then used as a biosensor for amperometric sensing of β-hydroxybutyrate. The MXene and the nanocomposite were characterized by X-ray photoelectron spectroscopy, field-emission scanning electron microscopy, X-ray diffraction, and Fourier transform infrared spectroscopy. The MXene has a layered structure and proved to be an excellent immobilization matrix providing good compatibility with the enzyme β-hydroxybutyrate dehydrogenase. The MXene-based biosensor, best operated at a potential of - 0.35 V (vs. Ag/AgCl), displays a wide linear range (0.36 to 17.9 mM), a sensitivity of 0.480 μA mM-1 cm-2, and a low detection limit (45 μM). The biosensor was successfully applied to the determination of β-hydroxybutyrate in (spiked) real serum samples. Graphical abstract Schematic representation of the synthesis and decoration of Mxene 2D sheets with β-hydroxybutyrate dehydrogenase for the amperometric determination of β-hydroxybutyric acid.
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Muppidi V, Meegada S, Challa T, Siddamreddy S, Samal S. Euglycemic Diabetic Ketoacidosis in a Young Pregnant Woman Precipitated by Urinary Tract Infection. Cureus 2020; 12:e7331. [PMID: 32313772 PMCID: PMC7164719 DOI: 10.7759/cureus.7331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Diabetic ketoacidosis (DKA) is a life-threatening diabetic complication and medical emergency. Euglycemic DKA (EKDA) is a variant of DKA with normal range glucose levels. The condition can be difficult to diagnose due to the misleading euglycemic levels. Pregnancy, infection, low-calorie intake, and use of insulin are some of the common etiologies of EDKA. We report a case of a young, pregnant female, with type I diabetes mellitus, in her third trimester admitted with EKDA. The EKDA was triggered by urinary tract infection (UTI), and the patient had other etiologies that have predisposed her to EKDA. Along with the case presentation, we discuss the common etiologies, pathophysiology, and management of EKDA. Euglycemic DKA is a life-threatening emergency that needs to be recognized early and treated aggressively, especially in pregnant patients, to avoid deleterious effects to maternal and fetal health.
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Affiliation(s)
| | - Sreenath Meegada
- Internal Medicine, The University of Texas Health Science Center/Christus Good Shepherd Medical Center, Longview, USA
| | - Tejo Challa
- Internal Medicine, The University of Texas Health Science Center/Christus Good Shepherd Medical Center, Longview, USA
| | - Suman Siddamreddy
- Internal Medicine, Baptist Health Medical Center, North Little Rock, USA
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Diaz-Ramos A, Eilbert W, Marquez D. Euglycemic diabetic ketoacidosis associated with sodium-glucose cotransporter-2 inhibitor use: a case report and review of the literature. Int J Emerg Med 2019; 12:27. [PMID: 31488052 PMCID: PMC6727509 DOI: 10.1186/s12245-019-0240-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 08/15/2019] [Indexed: 02/07/2023] Open
Abstract
Background The sodium-glucose cotransporter-2 (SGLT2) inhibitors are the newest class of anti-hyperglycemic medications used in the treatment of diabetes mellitus. Their increasing use has been driven by their apparent cardiovascular and renal benefits. They have been associated with a small but significantly increased risk of diabetic ketoacidosis (DKA). Many of the cases of DKA associated with SGLT2 inhibitor use present with normal or minimally elevated serum glucose levels, often delaying the diagnosis. Case presentation A 44-year-old woman with diabetes mellitus presented to our emergency department complaining of 3 days of generalized weakness. The SGLT2 inhibitor canagliflozin had been added to her medication regimen 4 weeks earlier, and she had stopped using insulin 2 weeks prior to presentation. Laboratory evaluation revealed a metabolic acidosis with an elevated anion gap and the presence of serum acetone, despite a minimally elevated serum glucose of 163 mg/dL. The patient was treated for euglycemic DKA with intravenous infusions of insulin and dextrose, with resolution of her symptoms in 3 days. Conclusions The SGLT2 inhibitors are a novel class of anti-hyperglycemic medications that are being used with increasing frequency in the treatment of diabetes mellitus. They are associated with a small but significantly increased risk of DKA. Many of the patients presenting with DKA associated with SGLT2 inhibitor use will have normal or minimally elevated serum glucose levels. This unusual presentation of DKA can be diagnostically challenging.
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Affiliation(s)
- Alexis Diaz-Ramos
- Department of Emergency Medicine, University of Illinois College of Medicine at Chicago, 1819 West Polk St. 469 COME, Chicago, IL, 60612, USA
| | - Wesley Eilbert
- Department of Emergency Medicine, University of Illinois College of Medicine at Chicago, 1819 West Polk St. 469 COME, Chicago, IL, 60612, USA.
| | - Diego Marquez
- University of Illinois College of Medicine at Chicago, 1853 West Polk St. MC 785, Chicago, IL, 60612, USA
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21
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Dhatariya KK. Defining and characterising diabetic ketoacidosis in adults. Diabetes Res Clin Pract 2019; 155:107797. [PMID: 31344382 DOI: 10.1016/j.diabres.2019.107797] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/21/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023]
Abstract
AIMS Diabetic ketoacidosis (DKA) remains one of the most frequently encountered diabetes related emergencies, and despite updates in management and increasing standardisation of care, still has an appreciable morbidity and mortality. This review focusses on the pathophysiology and epidemiology of DKA, but also on the importance of having a standardised definition. METHODS Relevant data were reviewed where there was available basic science or clinical papers published in peer-reviewed international journals on DKA. These included consensus documents and national or international guidelines. RESULTS The prevalence of DKA varies around the world, but part of this could be down to the way the condition is defined. Examples of this difference include the recent studies on sodium glucose co-transporter inhibitors in people with type 1 and type 2 diabetes which have all been associated with increased rates of DKA, but have highlighted how differences in definitions can make comparisons between agents very difficult. CONCLUSIONS DKA should only be diagnosed when all three components are present - the 'D', the 'K' and the 'A'. In addition, the definitions used to diagnose DKA should be standardised - in particular for clinical trials.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY, UK; Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK.
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Barski L, Eshkoli T, Brandstaetter E, Jotkowitz A. Euglycemic diabetic ketoacidosis. Eur J Intern Med 2019; 63:9-14. [PMID: 30910328 DOI: 10.1016/j.ejim.2019.03.014] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/14/2019] [Accepted: 03/19/2019] [Indexed: 02/07/2023]
Abstract
Euglycemic DKA (eu-DKA) is a life-threatening emergency. It may occur in patients with both type 1 and type 2 DM, and characterized by milder degrees of hyperglycemia with blood glucose level < 200 mg/dl, which can result in delayed diagnosis and treatment with potential for adverse metabolic consequences. Following the wide introduction of the sodium glucose transporter 2 inhibitors (SGLT2i) in therapeutic practice for DM type 2 treatment the amount of eu-DKA increased and therefore, interest to this entity rose. Other causes associated with eu-DKA include pregnancy, decreased caloric intake, heavy alcohol use, insulin use prior to hospital admission, cocaine abuse, pancreatitis, sepsis, chronic liver disease and liver cirrhosis. Patients with eu-DKA as well as with DKA need immediate referral for emergency evaluation and treatment. The treatment includes rapid correction of dehydration, correction electrolyte abnormalities, and use of insulin drip until the anion gap, and bicarbonate levels normalize. Increased glucose administration using higher percentages of dextrose (10 or 20%) are required to facilitate the concomitant administration of the relatively large amounts of insulin that are needed to correct the severe acidosis in these patients.
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Affiliation(s)
- Leonid Barski
- Department of Internal Medicine F, Soroka Univerity Medical Center, Beer-Sheva, Israel.
| | - Tamar Eshkoli
- Endocrinology Unit, Soroka Univerity Medical Center, Beer-Sheva, Israel
| | - Evgenia Brandstaetter
- Department of Internal Medicine F, Soroka Univerity Medical Center, Beer-Sheva, Israel
| | - Alan Jotkowitz
- Department of Internal Medicine F, Soroka Univerity Medical Center, Beer-Sheva, Israel
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23
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Millar R, Harding A. Review article: Accelerated starvation of childhood: Have I judged ketones? Emerg Med Australas 2019; 31:314-320. [PMID: 30916481 DOI: 10.1111/1742-6723.13276] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 02/14/2019] [Accepted: 02/17/2019] [Indexed: 12/19/2022]
Abstract
Acute ketosis is an important physiological mechanism to prevent irreversible neurological damage from hypoglycaemia during starvation, and represents a significant metabolic stress. A cohort of children adapt to relatively short periods of reduced caloric intake by generating large quantities of ketone bodies. When excessive, the gastrointestinal symptoms of starvation ketosis such as nausea and pain may create a vicious cycle that delays spontaneous resolution. The presence of ketones can be dismissed as a normal feature of childhood metabolism, sometimes even when extreme. A broader understanding of this process under the banner of 'accelerated starvation of childhood' is helpful for clinicians managing acute illness in children. We advocate that children less than 7 years of age with a history suggestive of accelerated starvation of childhood should be screened by emergency clinicians for ketosis using a simple and cheap bedside capillary test, even if glucose levels are greater than 2.6 mmol/L. Identification and appropriate management of ketosis may alleviate the distressing gastrointestinal symptoms associated with many minor illnesses, and potentially prevent hypoglycaemia in some children. Appropriate advice to carers may be helpful to prevent further episodes. Illustrative case examples from our own practice are provided.
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Affiliation(s)
- Robert Millar
- The University of Melbourne, Melbourne, Victoria, Australia.,Austin Hospital, Melbourne, Victoria, Australia.,Epworth Hospital, Melbourne, Victoria, Australia
| | - Anton Harding
- The University of Melbourne, Melbourne, Victoria, Australia.,Austin Hospital, Melbourne, Victoria, Australia.,Epworth Hospital, Melbourne, Victoria, Australia.,Royal Children's Hospital, Melbourne, Victoria, Australia
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24
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Yu X, Zhang S, Zhang L. Newer Perspectives of Mechanisms for Euglycemic Diabetic Ketoacidosis. Int J Endocrinol 2018; 2018:7074868. [PMID: 30369948 PMCID: PMC6189664 DOI: 10.1155/2018/7074868] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 07/18/2018] [Accepted: 09/09/2018] [Indexed: 12/12/2022] Open
Abstract
Euglycemic diabetic ketoacidosis (EDKA) was considered a rare condition with its specific definition and precipitating factors. However, with the wide use of sodium glucose cotransporter 2 (SGLT-2) inhibitors, the newest class of antidiabetic agents, EDKA has come back into the spotlight. Relevant cases are increasingly being reported along with insights into the mechanism of EDKA. It seems increasingly clear that EDKA is more common than we used to believe. The SGLT-2 inhibitor-associated EDKA also indicates a necessary review of our previous understanding of "diabetic" ketoacidosis, since the SGLT-2 inhibitor predisposes patients to DKA in a "starvation" way. Actually, there are growing reports about starvation-induced ketoacidosis as well. The previously "exclusive" nomenclature and cognition of these entities need to be reexamined. That the hormonal interactions in DKA may differ from the severity of insulin deficiency also may have served in the scenario of EDKA. The SGLT-2 inhibitors are newly approved in China. The main purpose of this work is to have a better understanding of the situation and update our knowledge with a focus on the pathogenesis of EDKA.
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Affiliation(s)
- Xiaofang Yu
- Department of Endocrinology, Ningbo Medical Center Lihuili Hospital, Ningbo 315040, China
| | - Saifei Zhang
- Department of Endocrinology, Ningbo Medical Center Lihuili Hospital, Ningbo 315040, China
| | - Long Zhang
- Department of Endocrinology, Ningbo Medical Center Lihuili Hospital, Ningbo 315040, China
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25
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Sleiwah A, McBride M, Black CE. Euglycaemic ketoacidosis: a potential new hazard to plastic surgery day case and inpatient procedures. BMJ Case Rep 2017; 2017:bcr-2017-220253. [PMID: 28794087 DOI: 10.1136/bcr-2017-220253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
A woman aged 44 underwent elective standard abdominoplasty and bilateral mastopexy (superiorly based pedicle with vertical scar) following weight loss of 8.5 stone (53.9 kg) over a 5-year period. She had type 2 diabetes and her antidiabetic medications included metformin, liraglutide and empagliflozin. Towards the end of the first postoperative day, she reported gradual onset of nausea, vomiting and abdominal pain. Her condition continued to deteriorate overnight, becoming tachycardic and tachypnoeic. Urgent investigations showed severe diabetic ketoacidosis with euglycaemia. She was managed with fluid resuscitation, insulin infusion and intravenous sodium bicarbonate in the high dependency unit. She made a complete clinical and biochemical recovery and was discharged on day 9 postoperatively. This case illustrates a diagnostic challenge of a serious life-threatening complication of diabetes in the postoperative period associated with a novel class of antidiabetic medications, sodium-glucose cotransporter 2 inhibitors.
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Affiliation(s)
- Aseel Sleiwah
- Department of Plastic Surgery, The Ulster Hospital, Belfast, UK
| | - Michael McBride
- Department of Plastic Surgery, The Ulster Hospital, Belfast, UK
| | - Claire E Black
- Department of Plastic Surgery, Royal Victoria Hospital, Belfast, UK
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26
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Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am 2017; 101:587-606. [PMID: 28372715 PMCID: PMC6535398 DOI: 10.1016/j.mcna.2016.12.011] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events. This article reviews the epidemiology, pathogenesis, diagnosis, and management of hyperglycemic emergencies.
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Affiliation(s)
- Maya Fayfman
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA
| | - Francisco J Pasquel
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA.
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27
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Ayed S, Bouguerba A, Ahmed P, Barchazs J, Boukari M, Goldgran-Toledano D, Bornstain C, Vincent F. Les pièges de l’acidocétose diabétique. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1113-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Thawabi M, Studyvin S. Euglycemic Diabetic Ketoacidosis, a Misleading Presentation of Diabetic Ketoacidosis. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2015. [PMID: 26199928 PMCID: PMC4488998 DOI: 10.4103/1947-2714.157490] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Context: Diabetic ketoacidosis (DKA) is one of the most serious complications of diabetes. It is characterized by a triad of increased total body ketone concentration, metabolic acidosis, and uncontrolled hyperglycemia. Hyperglycemia is a key diagnostic criterion of DKA; however, in some rare cases, normal glucose levels can be present. Case Reports: We describe two patients with type 1 diabetes mellitus (DM1); one who presented with a Bartholin's gland abscess and the other with acute pancreatitis. Both patients had maintained adequate hydration and continued to take their insulin without sufficient carbohydrate intake in the previous days prior to presentation. Despite their normal serum glucose levels upon presentation, they were found to have ketonemia and acidosis consistent with DKA. If only the serum glucose level was taken into consideration, while ignoring the rest of their biochemical profiles and failing to obtain ketone levels, the diagnoses would have been missed. Conclusion: Euglycemic DKA is usually seen in otherwise healthy patients with type 1 diabetes mellitus who have decreased carbohydrate intake in the presence of adequate hydration and a degree of insulin intake. Recognition of this entity by the emergency provider is crucial when patients with DM1 present with a picture of DKA, regardless of their blood sugar.
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Affiliation(s)
- Mohammad Thawabi
- Department of Internal Medicine, Saint Michael's Medical Center, Newark, New Jersey, USA
| | - Sarah Studyvin
- Department of Internal Medicine, Saint Michael's Medical Center, Newark, New Jersey, USA
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29
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Baş VN, Uytun S, Torun YA. Diabetic euglycemic ketoacidosis in newly diagnosed type 1 diabetes mellitus during Ramadan fasting. J Pediatr Endocrinol Metab 2015; 28:333-5. [PMID: 25423670 DOI: 10.1515/jpem-2013-0497] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 09/29/2014] [Indexed: 11/15/2022]
Abstract
Real euglycemic diabetic ketoacidosis [DKA; blood glucose <200 mg/dL (11.1 mmol/L)] is rare, and long-lasting starvation conditions due to intervening diseases in type 1 diabetes mellitus patients may also cause it. Euglycemic DKA is also reported in insulin-dependent diabetics with depression, alcoholics, glycogen storage diseases, and chronic liver disease apart from pregnant cases. This case report is presented to emphasize the importance of evaluation of acid-base state, urine glucose, and ketone values at the application in all newly diagnosed type 1 diabetic patients with normal glucose levels by defining euglycemic DKA that resulted from long-lasting starvation during Ramadan fasting in a newly diagnosed 14-year-old male patient.
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30
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Prater J, Chaiban JT. Euglycemic Diabetic Ketoacidosis with Acute Pancreatitis in a Patient Not Known to Have Diabetes. AACE Clin Case Rep 2015. [DOI: 10.4158/ep14182.cr] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Akbay S, Yel A, Yıldırımer Ü, Can Ş, Dündar B. Diabetic ketoacidosis presenting with pseudonormoglycemia in a 15-year-old girl with type 1 diabetes mellitus. J Clin Res Pediatr Endocrinol 2013; 5:133-5. [PMID: 23748069 PMCID: PMC3701921 DOI: 10.4274/jcrpe.905] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Pseudonormoglycemic diabetic ketoacidosis (DKA) is a rare condition and has been reported only in a few adult patients. We present a 15-year-old girl with a 9-year history of type 1 diabetes who presented with euglycemic and extreme hypertriglyceridemia. The acidosis and hypertriglyceridemia resolved with intravenous insulin therapy and rehydration. Hyperlipidemia was the apparent cause of pseudonormoglycemia in this patient. The findings in the present case demonstrate that also in children, DKA can rarely occur without abnormal blood glucose levels. Assessment of the acid-base status, urinary glucose, and ketone readings is therefore important in all diabetic patients who are unwell at admission and have normal glucose levels. In such patients, hyperlipidemia may cause pseudonormoglycemia. An awareness of this rare treatable life-threatening condition is important.
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Affiliation(s)
- Sinem Akbay
- İzmir Tepecik Training and Research Hospital, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Arda Yel
- İzmir Tepecik Training and Research Hospital, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Ülkü Yıldırımer
- İzmir Tepecik Training and Research Hospital, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Şule Can
- İzmir Tepecik Training and Research Hospital, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Bumin Dündar
- İzmir Katip Çelebi University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
,* Address for Correspondence: İzmir Katip Çelebi University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey Phone: +90 232 469 69 69 E-mail:
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Le Neveu F, Hywel B, Harvey JN. Euglycaemic ketoacidosis in patients with and without diabetes. PRACTICAL DIABETES 2013. [DOI: 10.1002/pdi.1769] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Bhakhri BK. Normal Blood Glucose Level at Presentation does not Rule out Diabetic Ketoacidosis in a Sick Child. CAN J EMERG MED 2012; 14:72-3. [DOI: 10.2310/8000.2012.110569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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35
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Nyenwe EA, Kitabchi AE. Evidence-based management of hyperglycemic emergencies in diabetes mellitus. Diabetes Res Clin Pract 2011; 94:340-51. [PMID: 21978840 DOI: 10.1016/j.diabres.2011.09.012] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Revised: 09/02/2011] [Accepted: 09/12/2011] [Indexed: 11/26/2022]
Abstract
The hyperglycemic emergencies, diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are potentially fatal complications of uncontrolled diabetes mellitus. The incidence of DKA and the economic burden of its treatment continue to rise, but its associated mortality rate which was uniformly high has diminished remarkably over the years. This Improvement in outcome is largely due to better understanding of the pathogenesis of hyperglycemic emergencies and the application of evidence-based guidelines in the treatment of patients. In this article, we present a critical review of the evidence behind the recommendations that have resulted in the improved prognosis of patients with hyperglycemic crises. A succinct discussion of the pathophysiology and important etiological factors in DKA and HHS are provided as a prerequisite for understanding the rationale for the effective therapeutic maneuvers employed in these acute severe metabolic conditions. The evidence for the role of preventive measures in DKA and HHS is also discussed. The unanswered questions and future research needs are also highlighted.
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Affiliation(s)
- Ebenezer A Nyenwe
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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Savage MW, Dhatariya KK, Kilvert A, Rayman G, Rees JAE, Courtney CH, Hilton L, Dyer PH, Hamersley MS. Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabet Med 2011; 28:508-15. [PMID: 21255074 DOI: 10.1111/j.1464-5491.2011.03246.x] [Citation(s) in RCA: 194] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The Joint British Diabetes Societies guidelines for the management of diabetic ketoacidosis (these do not cover Hyperosmolar Hyperglycaemic Syndrome) are available in full at: (i) http://www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/The-Management-of-Diabetic-Ketoacidosis-in-Adults; (ii) http://www.diabetes.nhs.uk/publications_and_resources/reports_and_guidance; (iii) http://www.diabetologists-abcd.org.uk/JBDS_DKA_Management.pdf. This article summarizes the main changes from previous guidelines and discusses the rationale for the new recommendations. The key points are: Monitoring of the response to treatment (i) The method of choice for monitoring the response to treatment is bedside measurement of capillary blood ketones using a ketone meter. (ii) If blood ketone measurement is not available, venous pH and bicarbonate should be used in conjunction with bedside blood glucose monitoring to assess treatment response. (iii) Venous blood should be used rather than arterial (unless respiratory problems dictate otherwise) in blood gas analysers. (iv) Intermittent laboratory confirmation of pH, bicarbonate and electrolytes only. Insulin administration (i) Insulin should be infused intravenously at a weight-based fixed rate until the ketosis has resolved. (ii) When the blood glucose falls below 14 mmol/l, 10% glucose should be added to allow the fixed-rate insulin to be continued. (iii) If already taking, long-acting insulin analogues such as insulin glargine (Lantus(®), Sanofi Aventis, Guildford, Surry, UK) or insulin detemir (Levemir(®), Novo Nordisk, Crawley, West Sussex, UK.) should be continued in usual doses. Delivery of care (i) The diabetes specialist team should be involved as soon as possible. (ii) Patients should be nursed in areas where staff are experienced in the management of ketoacidosis.
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Affiliation(s)
- M W Savage
- North Manchester General Hospital, Diabetes Centre, Delauneys Road, Manchester M8 5RB,
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Abstract
Diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus (DM), occurs more commonly in children with type 1 DM than type 2 DM. Hyperglycemia, metabolic acidosis, ketonemia, dehydration and various electrolyte abnormalities result from a relative or absolute deficiency of insulin with or without an excess of counter-regulatory hormones. Management requires careful replacement of fluid and electrolyte deficits, intravenous administration of insulin, and close monitoring of clinical and biochemical parameters directed towards timely detection of complications, including hypokalemia, hypoglycemia and cerebral edema. Cerebral edema may be life threatening and is managed with fluid restriction, administration of mannitol and ventilatory support as required. Factors precipitating the episode of DKA should be identified and rectified. Following resolution of ketoacidosis, intravenous insulin is transitioned to subcutaneous route, titrating dose to achieve normoglycemia.
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Lee SH, Park JH, Hong MK, Hyeon S, Kim MY, Lee SE, Ahn J, Kim J. True euglycemic diabetic ketoacidosis in a person with type 2 diabetes and Duchenne muscular dystrophy. Diabetes Res Clin Pract 2011; 92:e7-8. [PMID: 21216484 DOI: 10.1016/j.diabres.2010.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Accepted: 12/06/2010] [Indexed: 11/20/2022]
Abstract
True euglycemic diabetic ketoacidosis is a rare complication of diabetes. We describe a case of diabetic ketoacidosis in a male with type 2 diabetes and Duchenne muscular dystrophy. He presented with normal plasma glucose as a consequence of starvation, reduced muscle mass and increased body fat.
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Affiliation(s)
- Seok Hong Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul 156-755, Republic of Korea
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Affiliation(s)
- M W Savage
- Diabetes and Endocrinology Centre, North Manchester Diabetes Centre, Manchester.
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Baena MG, Cayón M, Ortego-Rojo J, Aguilar-Diosdado M. Diabetic ketoacidosis associated with severe hypoglycemia. J Endocrinol Invest 2010; 33:358-9. [PMID: 20386088 DOI: 10.1007/bf03346601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Oliver R, Jagadeesan P, Howard RJ, Nikookam K. Euglycaemic diabetic ketoacidosis in pregnancy: An unusual presentation. J OBSTET GYNAECOL 2009; 27:308. [PMID: 17464819 DOI: 10.1080/01443610701241100] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- R Oliver
- King George Hospital, Ilford, UK.
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Starvation-induced true diabetic euglycemic ketoacidosis in severe depression. J Gen Intern Med 2009; 24:129-31. [PMID: 18975036 PMCID: PMC2607495 DOI: 10.1007/s11606-008-0829-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Revised: 07/02/2008] [Accepted: 09/30/2008] [Indexed: 12/21/2022]
Abstract
True euglycemic diabetic ketoacidosis [blood glucose <200 mg/dl (11.1 mmol/l)] is relatively uncommon and in type 1 diabetes can be caused by starvation of any cause in conjunction with an intercurrent illness. We report a case of euglycemic diabetic ketoacidosis precipitated by starvation resulting from severe depression in a patient with type 1 diabetes. He was acidotic with ketonuria, but his blood glucose was only 105 mg/dl (5.8 mmol/l). He was rehydrated, the acidosis was corrected, and his depression was later treated. This case involves the complex interplay among type 1 diabetes, depression, ketoacidosis, and starvation physiology resulting in glucose concentrations in keeping with euglycemic diabetic ketoacidosis. The case also highlights that even in the absence of hyperglycemia, acid/base status should be assessed in an ill patient with diabetes, and in cases of euglycemic diabetic ketoacidosis, the diagnosis of depression should be considered as a cause for suppressed appetite and anorexia.
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Guo RX, Yang LZ, Li LX, Zhao XP. Diabetic ketoacidosis in pregnancy tends to occur at lower blood glucose levels: case-control study and a case report of euglycemic diabetic ketoacidosis in pregnancy. J Obstet Gynaecol Res 2008; 34:324-30. [PMID: 18588610 DOI: 10.1111/j.1447-0756.2008.00720.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE The occurrence of diabetic ketoacidosis (DKA) during pregnancy is considered a medical emergency. The aims of the present study were to evaluate the incidence of DKA in pregnant and non-pregnant women with diabetes; to compare the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women; and to show a case of euglycemic DKA in pregnancy. METHODS The subjects consisted of 90 cases of DKA in pregnant women with diabetes and 286 cases of non-pregnant female inpatients receiving treatment for diabetes during 2001 to 2005 in our hospital. The incidence of DKA in pregnant and non-pregnant women with diabetes and the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women were compared. RESULTS DKA had a higher incidence in pregnant women with diabetes (8/90, 8.9%) than in non-pregnant women with diabetes (9/286, 3.1%) (P < 0.05). The blood glucose levels (mmol/L) in pregnant women with DKA were significantly lower than those in non-pregnant women with DKA (16.3 +/- 4.6 vs 27.5 +/- 4.8, P < 0.001). A case of euglycemic DKA in pregnancy was described whose serum glucose level was only 6.9 mmol/L. CONCLUSIONS DKA in pregnant women with diabetes may occur more frequently, and at lower blood glucose levels than DKA in non-pregnant women with diabetes.
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Affiliation(s)
- Rui-Xia Guo
- Department of Obstetrics and Gynecology, the First Affiliated Hospital, Zheng Zhou University, Zheng Zhou, China.
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Hanas R, Lindgren F, Lindblad B. Diabetic ketoacidosis and cerebral oedema in Sweden--a 2-year paediatric population study. Diabet Med 2007; 24:1080-5. [PMID: 17672863 DOI: 10.1111/j.1464-5491.2007.02200.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM The aim of this study was to investigate diabetic ketoacidosis (DKA) and cerebral oedema in the Swedish paediatric diabetes population, and to measure laboratory parameters during treatment. METHODS The Swedish National Paediatric Diabetes Registry (SWEDIABKIDS) indicates that 16% of patients < 18 years during 2000 to 2004 had DKA at onset of diabetes. Data from 1999 and 2000 was collected retrospectively from all of Sweden by questionnaire. RESULTS We identified 292 cases of DKA (pH < 7.30) in 265 children (149 at diabetes onset), aged 0.8-19.9 years. The incidence of DKA in patients with previously diagnosed diabetes was 1.4/100 patient years in 1999 and 1.7/100 in 2000. Two patients, both 11 years old with newly diagnosed diabetes, had overt symptoms of cerebral oedema and one developed neurological sequelae. This corresponds to an incidence of 0.68% (2/292) with no mortality. Symptoms of subclinical cerebral oedema after admission (headache, vomiting, lethargy) were recorded in a further 16 cases. In two of these mannitol was given, and both recovered within 1-2 h. Laboratory data was available from 253/292 episodes. During treatment for DKA, hypokalaemia (< 3.5 mmol/l) was significantly more common at onset of diabetes than in patients with established diabetes (65 vs. 28%, P < 0.001; initial prescription of potassium was 20 mmol/l). CONCLUSIONS We conclude that 16% of children with new-onset diabetes presented with DKA at diagnosis and that the incidence of DKA in children with established diabetes was 1.6/100 patient years. Cerebral oedema occurred in 0.68% of the DKA episodes.
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Affiliation(s)
- R Hanas
- Department of Paediatrics, Uddevalla Hospital, Uddevalla, Sweden.
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Edge JA, Roy Y, Bergomi A, Murphy NP, Ford-Adams ME, Ong KK, Dunger DB. Conscious level in children with diabetic ketoacidosis is related to severity of acidosis and not to blood glucose concentration. Pediatr Diabetes 2006; 7:11-5. [PMID: 16489969 DOI: 10.1111/j.1399-543x.2006.00143.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To ascertain whether initial depression of conscious level in children with diabetic ketoacidosis (DKA) is related to hyperosmolality, acidosis or other factors. METHODS In 225 episodes of DKA without evidence of cerebral edema, we examined the relationship between conscious level and initial biochemical variables. We contrasted these findings with those in 42 children who later developed cerebral oedema. RESULTS On admission, 42/225 (19%) had mild (pH 7.26-7.35); 96 (44%) moderate (pH 7.11-7.25); and 80 (37%) severe DKA (pH <or= 7.10). Conscious level: alert and oriented (group 1, n=123), drowsy but oriented when woken (group 2, n=62), semi-conscious or confused/agitated (group 3, n=9), comatose (group 4, n=4). Glasgow Coma Score (GCS) was available in 65. pH varied significantly with conscious level; group 1, 7.20+/- 0.11(mean+/- SD); group 2, 7.10+/- 0.16; group 3, 6.96+/- 0.11; group 4, 6.88+/- 0.09 (anova, p<0.001). Blood glucose (BG) was not different between the groups. GCS was related to pH (r(s) = 0.49, p < 0.001), but not to BG or electrolyte levels. Age, sex, plasma sodium, corrected sodium and osmolality also varied with conscious level in a univariate model. Using multivariate analysis comparing groups 1 with groups 2-4, lower pH and younger age were the only independent determinants of impaired conscious level (p<0.001, p=0.036). Conscious level in the children with cerebral edema was also closely related to pH and not to other biochemical variables. pH was lower at each conscious level in the children with later cerebral edema. CONCLUSIONS In children with DKA, initial conscious level is closely related to pH and weakly to age, but not to BG or plasma sodium level. Thus cerebral function in DKA is related to severity of acidosis even when there is no evidence of cerebral edema.
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Affiliation(s)
- Julie A Edge
- Department of Paediatrics, John Radcliffe Hospital, Oxford, UK.
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Abstract
Diabetic ketoacidosis is an important complication of diabetes in children and is the most frequent diabetes-related cause of death in childhood. The pathophysiology of this condition can be viewed as an exaggeration of the normal physiologic mechanisms responsible for maintaining an adequate fuel supply to the brain and other tissues during periods of fasting and physiologic stress. The optimal therapy has been a subject of controversy, particularly because the most frequent serious complication of diabetic ketoacidosis-cerebral edema-and the relationship of this complication to treatment are incompletely understood. In this article, the author reviews the pathophysiology of diabetic ketoacidosis and its complications and presents an evidence-based approach to the management of this condition.
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Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, School of Medicine, University of California-Davis, 2516 Stockton Boulevard, Sacramento, CA 95817, USA.
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Abstract
Diabetic ketoacidosis (DKA) is the most common hyperglycemic emergency in patients with diabetes mellitus. DKA most often occurs in patients with type 1 diabetes, but patients with type 2 diabetes are susceptible to DKA under stressful conditions, such as trauma, surgery, or infections. DKA is reported to be responsible for more than 100 000 hospital admissions per year in the US, and accounts for 4-9% of all hospital discharge summaries among patients with diabetes. Treatment of patients with DKA uses significant healthcare resources and accounts for 1 out of every 4 healthcare dollars spent on direct medical care for adult patients with type 1 diabetes in the US. Recent studies using standardized written guidelines for therapy have demonstrated a mortality rate of less than 5%, with higher mortality rates observed in elderly patients and those with concomitant life-threatening illnesses. Worldwide, infection is the most common precipitating cause for DKA, occurring in 30-50% of cases. Urinary tract infection and pneumonia account for the majority of infections. Other precipitating causes are intercurrent illnesses (i.e., surgery, trauma, myocardial ischemia, pancreatitis), psychological stress, and non-compliance with insulin therapy. The triad of uncontrolled hyperglycemia, metabolic acidosis and increased total body ketone concentration characterizes DKA. These metabolic derangements result from the combination of absolute or relative insulin deficiency and increased levels of counter-regulatory hormones (glucagon, catecholamines, cortisol, and growth hormone). Successful treatment of DKA requires frequent monitoring of patients, correction of hypovolemia and hyperglycemia, replacement of electrolyte losses, and careful search for the precipitating cause. Since the majority of DKA cases occur in patients with a known history of diabetes, this acute metabolic complication should be largely preventable through early detection, and by the education of patients, healthcare professionals, and the general public. The frequency of hospitalizations for DKA has been reduced following diabetes education programs, improved follow-up care, and access to medical advice. Novel approaches to patient education incorporating a variety of healthcare beliefs and socioeconomic issues are critical to an effective prevention program.
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Affiliation(s)
- Guillermo E Umpierrez
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA.
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Matta MP, Melki V, Bessière-Lacombe S, Hanaire-Broutin H. What are capillary blood ketone levels in type 1 diabetic patients using CSII in normal conditions of insulin delivery? DIABETES & METABOLISM 2004; 30:543-7. [PMID: 15671924 DOI: 10.1016/s1262-3636(07)70153-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of the study was to determine the normal level of capillary ketonemia in type 1 diabetic patients on continuous subcutaneous insulin infusion (CSII). RESEARCH DESIGN AND METHODS A total of 36 type 1 diabetic patients treated by external pump were studied for 2 to 3 weeks. Patients were instructed to self monitor capillary glucose and capillary ketone bodies at least 4 times per day with a handheld Medisense Optium meter and check for urinary ketone bodies in the morning and when blood glucose exceeded 2.5 g/l with a semiquantitative test. Data were collected and analysed for each period of time defined as the time interval between two changes of the infusion site. A period was considered "normal" when no problem causing any impairment in insulin delivery was detected. RESULTS 186 periods of 2.1 +/- 0.9 days were recorded; 119 were considered normal. 1281 coupled values of glucose and betahydroxybutyrate were analysed during the so called normal periods. Mean percentage of ketonemia of 0, 0.1, 0.2, > or =0.3 mmole/l were 81.3%, 13%, 3.7% and 2% respectively whereas mean glucose level (g/l) was 1.49 +/- 0.7, 1.48 +/- 0.7, 1.59 +/- 0.8 and 1.89 +/- 0.9 respectively. Only 0.9% of betahydroxybutyrate values were > or =0.3 mmole/l when blood glucose exceeded 2.5 g/l. CONCLUSION Our study indicates that ketonemia self monitoring can be a valuable tool to screen insulin deficiency in patients on CSII with a low risk of false positive if we consider a threshold of 0.3 mmole/l for ketone bodies.
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Affiliation(s)
- M P Matta
- Department of Diabetology and Metabolic Diseases, University Hospital of Rangueil, CHU Ranguiel, 1 avenue J. Poulhes, Toulouse Cedex 09, France.
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Taboulet P, Haas L, Porcher R, Manamani J, Fontaine JP, Feugeas JP, Gautier JF. Urinary acetoacetate or capillary ??-hydroxybutyrate for the diagnosis of ketoacidosis in the Emergency Department setting. Eur J Emerg Med 2004; 11:251-8. [PMID: 15359197 DOI: 10.1097/00063110-200410000-00003] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We compared the semiquantitative measurement of acetoacetate using urinary dipsticks with the bedside quantitative fingerprick measurement of the principal ketone bodies 3-beta-hydroxybutyrate, for the diagnosis of ketoacidosis. METHODS This is a one year retrospective study of patients who presented with hyperglycemia levels of 250 mg/l or greater in the Emergency Department setting. We compared the sensitivity, specificity, and predictive value of ketonuria and ketonemia for the diagnosis of ketoacidosis (urine or blood ketone bodies, blood bicarbonates <20 mmol/l, anion gap >16 meq/l) in a sample of patients for whom the levels of ketone bodies in the blood and urine as well as serum electrolytes were available. RESULTS We studied 355 hyperglycemic patients. The median time between arrival and dipstick testing was 21 min, and was greater than 2 h in more than 10% of cases. Comparison between ketonuria and ketonemia was performed in 173 patients (6% with diabetic ketoacidosis). Ketonuria equal to or less than one cross or a 3-beta-hydroxybutyrate value lower than 3 mmol/l enabled ketoacidosis to be excluded (negative predictive value 100%). At two-cross cutoff points for ketonuria and at the 3 mmol/l cutoff point for ketonemia, the two tests had the same sensitivity (100%), but the specificity of 3-beta-hydroxybutyrate (94%) was significantly higher (P<0.0001) than that of ketonuria (77%). The best positive predictive value for ketonemia was obtained at the 5 mmol/l cutoff point (100%) and for ketonuria at the three-cross cutoff point (26%). At the three-cross cutoff point for ketonuria and at the 5 mmol/l cutoff point for ketonemia, the two tests had the same negative likelihood ratio (0.1), but the positive likelihood ratio of 3-beta-hydroxybutyrate (infinite) was higher than that of ketonuria. CONCLUSION The measurement of 3-beta-hydroxybutyrate in capillary blood is faster and more effective than the use of dipsticks in the urine to detect ketoacidosis in the Emergency Department setting.
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Affiliation(s)
- Pierre Taboulet
- Department of Emergency Medicine, Hopital Saint-Louis, University of Paris VII, Paris, France.
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