Pediatric type 1 diabetes management guidelines india,glarab europe,genetic susceptibility to type 2 diabetes and obesity pdf,jubilee family medicine and diabetes center edinburg - You Shoud Know


More often than not, the school list will also include Kleenex, Lysol wipes, animal crackers and oh yes, the approximate number of 48 individual glue sticks.  Really, do kids eat those glue sticks or what???
In our Naturally Sweet Sisters house, I also pick up things like sharps disposal containers, alcohol wipes, test kits for the locker and class rooms, glucose tabs and oh yes, the approximate number of 48 mini juice boxes. Thank you to the diabetes monster for making me throw those extra juice boxes in my red Target shopping cart!
So what I thought I would do is create a series of things that I have found useful to use over the years for helping my kids enjoy their school year as 'kids first, diabetes second'. It made me feel proud that something that we created out of a need was actually useful to others. Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA.
Diabetic ketoacidosis and insulin resistance with subcutaneous terbutaline infusion: a case report. Science, Technology and Medicine open access publisher.Publish, read and share novel research.
Diabetic KetoacidosisMustafa Cesur1 and Irmak Sayin2[1] Ankara Guven Hospital, Department of Endocrinology and Metabolic Disease, Turkey[2] Ufuk University, Medical Faculty, Department of Internal Medicine, Turkey1. Table 2.Classification of DKAOne of the major laboratory findings in DKA is the elevation of total blood ketone concentration.
Table 3.Typical total body deficits of water and electrolytes in DKA (*Per kg of body weight)Increased amylase and lipase has been reported in 16-25 % of patients with DKA.
Table 4.Differantial diagnosis of DKAAcute renal failure can be seen in ~5-7% of all adult hospitalizations [132,133]. It is important to instruct the patient and caregivers on the proper sites of administration for insulin injections.
Medical monitoring is essential to meet the ongoing needs of the child with type I diabetes.
Physical activity plays an important role in the management of diabetes "as it potentiates the hypoglycemic effect of insulin" (Potts & Mandleco, 2007, p. Nurses Choice, Inc., is best known for establishing strong, positive partnerships with healthcare providers -- and the professionals who want to work with them. Upon registering for the challenge you are virtually inserted into a day in the life of professional snowboarder Sean Busby – someone who has lived with Type 1 Diabetes for the last nine years. According to JDRF, Type 1 diabetes (T1D) is an autoimmune disease in which a person’s pancreas stops producing insulin, a hormone that enables people to get energy from food.
During our experience we received 34 text messages, most of which had to do with Sean working to manage his blood glucose levels. According to Medical News Today, blood glucose refers to sugar that is transported through the bloodstream to supply energy to all the cells in our bodies.
DKA is caused by reduced insulin levels, decreased glucose use, and increased gluconeogenesis from elevated counter regulatory hormones, including catecholamines, glucagon, and cortisol. A flowchart for the management of DKA in children and adolescents from the ADA guideline is shown in Figure 2.3 A growing problem is the development of type 2 diabetes in obese children. The pathogenesis causing to hyperglycemia and ketoacidosis in DKA (Data adapted from reference [17])4. Protocols for the management of patients with DKA (Data adapted from reference 10) Table 5.
A 15 years old male patient firstly diagnosed T1DM with DKA infected by rhino-orbita-cerebral mucormycozis (Picture from the reference [218])7.6.
IntroductionA chronic autoimmune destruction of the pancreatic beta cells results in decreasing endogenous insulin secretion and the clinical manifestation of type 1 diabetes mellitus (T1DM).
Assessment of increased ketonemia is usually performed by the nitroprusside reaction which provides a semiquantitative estimation of acetoacetate and acetone levels.
It shares the common feature of an increased anion gap metabolic acidosis but can be easily differentiated from DKA by the absence of hyperglycemia or ketonemia. However, the hypotension results from a loss of electrolyte solution and it is more physiological to replace with crystalloid.
Insulin is administered by subcutaneous injections (figure A, B) or a portable insulin pump (figure C). Insulin is administered into the subcutaneous fat which is found in the abdomen, back of the arms, legs, and above the buttocks.
Home blood glucose monitoring is available for convenience and facilitation of self-management. We work with proficiency, understanding, flexbility and a continuous pursuit of excellence. The challenge, which is presented by Lilly Diabetes in conjunction with National Diabetes Awareness Month, is open for participation through the end of November. The messages, which are presented in a stream of consciousness style, are intended to convey what it is like to manage one’s blood glucose testing, insulin injections, and dietary choices with T1D. It occurs when the body’s immune system attacks and destroys the insulin-producing cells in the pancreas, called beta cells. It comes on suddenly, causes dependence on injected or pumped insulin for life, and carries the constant threat of devastating complications. While it goes without saying that unless you are living with T1D you can never really know the challenges of the disease, initiatives such as these help to promote education and awareness.
Check out some of our highlighted text messages from Sean Busby and the challenge below or support National Diabetes Awareness Month by participating. Making sure I have all my diabetes supplies for tomorrow (meter, lancet device, test strips, and glucose tabs). Intravenous insulin and fluid replacement are the mainstays of therapy, with careful monitoring of potassium levels. The beta-hydroxybutyrate level may not normalize during the first one to two days of treatment.
Blood glucose should be evaluated every one to two hours until the patient is stable, and the blood urea nitrogen, serum creatinine, sodium, potassium, and bicarbonate levels should be monitored every two to six hours depending on the severity of DKA.3 Cardiac monitoring may be warranted for patients with significant electrolyte disturbances. Hyperchloremia is a common but transient finding that usually requires no special treatment.Cerebral edema is a rare but important complication of DKA.
Although DKA is less common in these patients than among those with type 1 diabetes, it does occur.
Most patients with DKA will need lifetime insulin therapy after discharge from the hospital. The clinical onset of the disease is often acute in children and adolescents and diabetic ketoacidosis (DKA) is present in 20-74% of the patients [1-7].
The major complications of hypothermia are acute renal failure, aspiration pneumonia, rhabdomyolysis, acute respiratory distresss syndrome and acute pancreatitis [83]. The nitroprusside test (both in urine and in serum) is highly sensitive, but it does not recognize the main metabolic product in ketoacidosis; beta-hydroxybutyrate. Amylase elevations could be related with subtle injury to pancreatic acinar cells which causes release of this enzyme to the circulation, release of salivary gland amylase or suboptimal excretion in the urine [128]. A recent Cochrane review did not support the use of colloid in preference to crystalloid fluid [153].
Medical treatment will include daily injections of insulin, blood glucose monitoring and management, following a meal plan, exercise, self-management skills. The frequency of the injections will vary according to the prescribed treatment and the goals of management for the child. Glucose monitoring at home consists of lancing the fingertip or other appropriate area (new meters are able to test small blood samples from the forearm, thigh, or side of hand) (Potts & Mandleco, 2007).
Increasing physical activities such as exercise (walking, running, jogging) assists in decreasing blood glucose levels and improves glucose control.
While its causes are not yet entirely understood, scientists believe that both genetic factors and environmental triggers are involved. The primary differential diagnosis for hyperglycemia is hyperosmolar hyperglycemic state (Table 23,20), which is discussed in the Stoner article21 on page 1723 of this issue. Treatment also should be directed at the underlying cause of the DKA, including antibiotics for suspected or identified infection. C-peptide levels may be helpful for determining the type of diabetes and guiding subsequent treatment. The mechanism of hypothermia complicated by DKA is unclear, but the inability of glucose to endocytose due to insulin deficit which leads to a lack of substrate for cellular heat production has been proposed [84]. In conclusion this assay is insufficient to determine the severity of ketoacidosis [10,31].
There is little correlation between the presence, degree or isoenzyme type of hyperamylasemia and the presence of gastrointestinal symptoms (nausea, vomiting, and abdominal pain) or pancreatic imaging studies [129]. The pH and anion gap can be found usually mild abnormal, however blood sugar is typically normal.
Now, a typical meal plan will provide balanced nutrition such as grains, breads, fruit, vegetables, and meats, beans, eggs, cheese, and legumes. For instance, some individuals with higher levels of activity may be allowed a larger meal plan or lower doses of insulin.
In one study10 of ketoacidosis, amylase was elevated in 21 percent and lipase in 29 percent of patients. Although it is important to monitor urinary output, urinary catheterization is not advised routinely.INPATIENT VS.
Even with appropriate intervention, DKA is associated with significant morbidity and possible mortality in diabetic patients in the pediatric age group [8]. A characteristic elevated J point on the electrocardiogram (ECG) (Osborn wave) may be observed when markedly hypothermia occurs [85-87]. Measurement of serum ?- hydroxybutyrate may be an alternative to determine ketoacidosis [96).
Increase in lipase may be related with release of nonpancreatic lipolytic enzymes into the circulation due to malignant tumors, to acute cholecystitis or esophagitis.
If proper site selection and rotation are not utilized, the individual receiving the injections may suffer from lipoatrophy (indentation or atrophy of subcutaneous fat) or lipohypertrophy (lumpiness or hypertrophy of subcutaneous fat) specifically at the sites of injection (Potts & Mandleco, 2007). There is nothing you can do to prevent T1D, and—at present—nothing you can do to get rid of it.
My fingers never get a rest from my lancet device. Nighttime hypoglycemia is never totally out of my mind, but I’m feeling pretty sleepy.
Infection, insulin omission, and other problems that may have precipitated ketoacidosis should be treated. Metabolic states in which acidosis is predominant include lactic acidosis and ingestion of drugs such as salicylates and methanol.Abdominal pain may be a symptom of ketoacidosis or part of the inciting cause of DKA, such as appendicitis or cholecystitis. If pancreatitis is suspected, contrast-enhanced computed tomography (CT) may be useful for diagnosis in selected patients. Patients typically improve mentally with initial treatment of DKA, but then suddenly worsen. The thermoregulatory system could be impaired in diabetic patients with autonomic neuropathy and reduced muscle mass or adipose tissue related with malnutrition. Other possible mechanism are; renal insufficiency, delayed blood withdrawal, hypertriglyceridemia or subclinical pancreatitis [130].
Lactic acidosis occasionally contributes to metabolic acidosis in patients hospitalized for either uncomplicated diabetes or DKA [137]. The insulin pump provides the child or teen with a more discrete and managable method of controlling their condition. Therefore for this reason the mechanics of rotating sites with each injection should be taught to the patient and caregivers administering the injections.
The breakdown of food groups is 50-60% of the calories derived from carbohydrates, 10-20% from protein, and 20-30% from fats. After administration or consumption of any food listed above, wait 15 minutes and recheck the blood glucose levels. Myocardial infarction is a precipitating cause of diabetic ketoacidosis that is especially important to look for in older patients with diabetes.
If the patient has significant hypertriglyceridemia, it can falsely lower glucose and sodium measurements by dilution.
The triad of uncontrolled hyperglycemia, metabolic acidosis and increased total body ketone concentration characterizes DKA [10]. The anion gap is calculated by subtracting the sum of chloride(Cl) and bicarbonate (HCO3) concentration from the sodium (Na) concentration: [Na - (Cl +HCO3)]. Pancreatic enzyme levels reach a peak 12-24 hours after initiation of treatment for DKA [131]. Current pumps are approximately the size of a pager and contain a syringe that can hold up to 300 unites of insulin (Potts & Mandleco, 2007).


Treatment of suspected cerebral edema should not be delayed for these tests to be completed. In addition to possible acute complications, it may also influence the later outcome of diabetes [11].2. It occurs in the setting of decreased tissue oxygen delivery which triggers non-oxidative metabolism of glucose to lactic acid. The pump works by delivering insulin via a tiny catheter that is placed every 2 to 3 days into subcutaneous fat. Lipoatrophy is uncommon today with the use of purified insulin preparations available and is "treated by injecting insulin into the edges of the area of atrophy" (Potts & Mandleco, 2007, p. Education to prevent recurrence should be offered to all patients, including how to manage sick days and when to call a physician. In more severe cases, seizures, pupillary changes, and respiratory arrest with brain-stem herniation may occur.
EpidemiologyWorldwide, an estimated 65 000 children under 15 years old develop T1DM each year, and the global incidence in children continues to increase at a rate of 3% a year [12,13].
Abdominal pain on presentation could be a result of the DKA or an indication of a precipitating cause of DKA, particularly in younger patients or in the absence of severe metabolic acidosis [91,92].
In clinical trials mixed acid–base disorders have been showed in DKA [97,98], but it is very rare the presentation of DKA with alkalaemia.
Differential diagnosis Other causes of metabolic acidosis and ketosis must be differentiated from DKA.
When co-existent with DKA, the anion gap typically exceeds that attributable to lactate alone. In patients with renal or cardiac failure, monitoring of serum osmolality and frequent assessment of cardiac, renal and mental status must be performed during fluid resuscitation to avoid iatrogenic fluid overload [10,37,148]. The pump is programmed to deliver the insulin continuously throughout the day and night, in small amounts. Treatment options, glucagon preparation and administration of IM glucagon should be taught to the caregivers. The first case has been reported in 1970, defined as ‘diabetic ketoalkalosis’ [99] and it was followed by other case reports. An immediate bolus of insulin is programmed to be delivered  with each snack and meal.
Lipohypertrophy occurs more commonly and is a result of trauma to the injection sites from repeated injections to the same area. Medical assistance is required for administration of IV glucose and other measures to prevent further complications. If dextrose is not given, further ketosis may occur.INSULINAn intravenous insulin drip is the current standard of care for diabetic ketoacidosis, primarily because of the more rapid onset of action. Laboratory findings The initial laboratory evaluation should include determination of plasma glucose, blood urea nitrogen, creatinine, electrolytes (with calculated anion gap), osmolality, serum and urinary ketones and urinalysis, as well as initial arterial blood gases and a complete blood count [93].
This bolus is based on the dose of insulin that is essential for the carbohydrate consumption and the individual's blood glucose level. Studies29 comparing intravenous insulin with subcutaneous or intramuscular insulin have found a quicker decrease in glucose and ketone levels, but no improvement in morbidity and mortality. If laboratory measurement of serum potassium is delayed an ECG should be performed for baseline evaluation of potassium status [94,95]. For main therapy it should be performed to optimise tissue perfusion and to treat underlying conditions [17,136].When there is insufficient carbohydrate availability, starvation ketosis may occur by result of physiologically appropriate lipolysis and ketogenesis to provide fuel substrates. Several studies have shown that pump therapy reduces episodes of severe hypoglycemia in pediatric populations as well as increases client satisfaction (Potts & Mandleco, 2007). 29 311 new cases of T1DM were diagnosed in children before their 15th birthday during a 15-year period between 1989-2003. An increased WBC count is response to stress is characteristic of DKA and is not indicative of infection.
Recent studies have reported from normal or near normal [101] to elevated [31,3] hepatic glucose production rates.
Blood glucose and arterial pH are found to be usually in normal level and the anion gap is at most mildly elevated. If there is evidence of infection, chest X-ray and urine, sputum, throat or blood cultures should also be obtained [93].
This factor possibly contributes to the wide range of plasma glucose levels in DKA that are independent of the severity of ketoacidosis [96].
Although ketonuria may be apparent in urine analysis, modest ketonemia is typical in blood examination [17,136].Chronical alcohol abuse may be the reason of alcoholic ketosis for ethanol is the predominant caloric source for days or weeks. Insulin therapy Insulin lowers the serum glucose concentration (by decreasing gluconeogenesis and glycogenolysis, increasing tissue glucose uptake) and arrests ketone production (by reducing lipolysis and glucagon secretion). If present trends continue, prevalent cases younger than 15 years will rise by 70% in 2020 [15].
The severity of DKA is classified as mild, moderate, or severe based on the severity of metabolic acidosis (blood pH, bicarbonate, and ketones) and the presence of altered mental status as shown in Table 2.
Although the bicarbonate level typically is low, it may be normal or high in patients with vomiting, diuretic use, or alkali ingestion. Lispro and aspart (NovoLog) insulin are more expensive and do not work faster than regular insulin when given intravenously. Due to nausea or vomiting caused by a precipitating illness or by worsening ketoacidosis itself, a decrease in caloric intake occurs. Patients are usually present in normoglycemic or hypoglycemic state on submission, although some have rarely mild hyperglycemia [136].Toxic ingestions sometimes need to be differentiated and history of the patients with laboratory studies may help for the differantial diagnosis. There was major concern about; physiologic or low dose insulin therapy was superior to pharmacologic dose regimen and the administration of regular insulin via continuous intravenous infusion or by frequent subcutaneous or intramuscular injections [10,157-160]. Approximately 115 000 patients admitted to the hospital because of DKA in one year in USA [17]. If patients continue to take sufficient amounts of insulin in this situation may maintain euglycemia.
Salicylate, methanol and ethylene glycol each produce an increased anion gap metabolic acidosis without hyperglycemia or ketosis. Several randomized controlled studies have shown that physiologic or low dose insulin therapy was superior to pharmacologic dose regimen and low-dose insulin therapy is effective regardless of the route of administration in DKA [118,159,160].
There were no significant differences in outcomes between the aspart and intravenous insulin regimens.
In a Turkish study conducted among the patients with diabetic adults who admitted to the hospital, the ratio of T1DM was found to be 6.6% and DKA was 38% of the group [18]. But ketone body formation cannot be stopped, so they present as DKA accompanied with only mild elevations of blood glucose or normoglycemia [103-105]. In clinical practice most patients are treated with low dose, intravenous regular insulin until resolution of DKA [30].
Example: Regular insulin may be mixed with Lispro insulin=stable when mixed with Lente and NPH. A similar study29 comparing subcutaneous lispro insulin in a medical ward with an intravenous insulin drip in the intensive care unit showed similar outcomes, except for a 40 percent reduction in cost for patients treated in the medical ward. Euglycemic DKA can be associated with other conditions such as; near total glycogen depletion [106,107], accelerated lipolysis [108] and free fatty acid production [109], less effectiveness of insulin suppressing lipolysis and ketogenesis during fasting and when there is sufficient circulating fluid volume to maintain glucose excretion [110]. The administration of continuous intravenous infusion of regular insulin is preferred because of its short half-life and easy titration and the delayed onset of action and prolonged half-life [107,127,160].
In women with diabetes, pregnancy is also a condition that is associated with euglycemic ketoacidosis [111,112] as pregnancy is considered to be a state of accelerated starvation [113] with increased lipolysis and ketone body production in the presence of increased insulin insensitivity [114]. It is characterized by a low serum bicarbonate concentration with subsequent chloride retention. If the patient is on an insulin pump, it should be stopped, and the patient should be switched to an intravenous infusion.31If an intravenous infusion pump is not available, insulin can be given intramuscularly.
At presentation leukocytosis with cell counts in the 10,000 –15,000 mm3 range is commonly seen in DKA and may not be indicative of an infection.
The most occurrence ages of DKA are between the 18-44 years (56%), than 45-65 years (24%) continues with only 18% of patients <20 years of age. But leukocytosis with cell counts 25,000 mm3 may indicate infection and require further evaluation [115]. Carbonic anhydrase inhibitor therapy, rapid dilution of plasma bicarbonate by infused saline may be considered as the other varying reasons [143,144]. If plasma glucose does not decrease by 50–75 mg in the first hour, the insulin infusion should be increased every hour until a steady glucose decline is achieved. In ketoacidosis, leukocytosis may be correlated to elevated levels of cortisol and norepinephrine which is attributed to stress [116]. DKA can be easily differentiated from this condition by the presence of an increased anion gap and hyperglycemia. On admission serum sodium is usually low because of the osmotic flux of water from the intracellular to the extracellular space as a result of hyperglycemia.
In complicated diabetics, especially in diabetic nephropathy, if there is hypoalbunemia, it can affect the apparent anion gap, since albumin is negatively charged protein contibuting 50-60% to the normal anion gap. Half of all deaths in diabetic patients younger than 24 years of age are caused from DKA [26,27]. An increased or even normal serum sodium concentration in the presence of hyperglycemia indicates severe degree of free water loss. Potassium should be started as soon as adequate urine output is confirmed and the potassium level is less than 5 mEq per L.3 Usually 20 to 30 mEq (20 to 30 mmol) of potassium is given for each liter of fluid replacement. TreatmentSuccessful treatment of DKA requires correction of dehydration, hyperglycemia and electrolyte imbalances, identification of comorbid precipitating events and above all, frequent patient monitoring. Once hyperglycemia is corrected, 12-24 hours of intravenous insulin treatment is sufficient to clear ketones from the circulation [51].Subcutaneous rapid-acting insulin analogs (lispro and aspart) offer an efficacious and cost-effective alternative to continuous intravenous infusions in the treatment of DKA [162-164].
PathogenesisThere are some factors as a reason of acute metabolic complications in diabetic patiens. Because there are no studies on patients with a pH level below 6.9, giving bicarbonate as an isotonic solution still is recommended. These factors are insulin deficiency as the initial primary event in progressive beta-cell failure, its failure in a patient with established disease or its ineffectiveness when insulin action is antagonized by physiological stress such as sepsis and in the context of counterregulatory hormone (catecholamines, cortisol, glucagon, and growth hormone) excess.
Serum potassium concentration may be increased because of an extracellular shift of potassium caused by insulin deficiency, hypertonicity and acidemia [117]. These hormonal changes increase glucose production from glycogenolysis and gluconeogenesis and impair glucose utilization by peripheral tissues, resulting in hyperglycemia, osmotic diuresis, electrolyte loss, dehydration, decreased glomerular filtration (further compounding hyperglycemia) and hyperosmolarity. There were no differences in length of hospital stay, total amount of insulin needed for resolution of hyperglycemia or ketoacidosis. Fluid therapy The most important initial therapeutic intervention is fluid replacement followed by insulin administration. Patients treated with insulin analogs were managed in the open medical wards which reduced cost of hospitalization by 30% [162-164].
This is augmented by transient insulin resistance due to the hormone imbalance itself as well as the elevated free fatty acid concentrations [8,10,26,28-39]. So patients with low normal or low serum potassium concentration should be monitored closely. This approach is not widely used for many reasons, including titration difficulties with longer half-life preparations, requirement for hourly nursing interventions and lack of staff experience compared to that with standard insulin infusions. Uncontrolled hepatic fatty acid oxidation in the liver to ketone bodies (beta-hydroxybutyrate and acetoacetate) results ketonemia and metabolic acidosis [40]. If necessary appropriate potassium replacement should be done [93].Insulin mainly affects glucose metabolism, but also protein and lipid metabolism. Initial fluid therapy is directed toward expansion of the intravascular, interstitial and intracellular volume (all of which are reduced in hyperglycemic crises), to establish tissue perfusion for insulin to reach cells [148] and restoration of renal perfusion. However, until these studies are confirmed outside the research arena, patients with severe DKA, hypotension, anasarca or associated severe critical illness should be managed with intravenous regular insulin in the intensive care unit [93]. The pathogenesis causing to hyperglycemia and ketoacidosis are schematized in Figure 1 [30].A number of clinical studies showed that the hyperglycemia in patients with hyperglycemic crises is associated with a severe inflammatory state characterized by an elevation of proinflammatory cytokines tumor necrosis factor alpha (TNF-?) and interleukin-6, and -8 (IL-6,8), C-reactive protein, reactive oxygen species, and lipid peroxidation, as well as cardiovascular risk factors, plasminogen activator inhibitor-1 and free fatty acids in the absence of obvious infection or cardiovascular pathology. In the literature there are many cases of DKA presented with severe hyperlipidemia [118,119]. The goal of fluid resuscitation is to replace half of the estimated water deficit over the first 12-24 hours and adding for the ongoing losses (eg: vomiting) [51]. Insulin therapy and hydration recover these parameters to near-normal values within 24 hours [41]. In patients with newly diagnosed T1DM presenting with DKA there is an absolute insulin deficiency that causes increased lipolysis and free fatty acid accumulation to the liver, decreased in utilization and excretion which results with hyperlipidemia.
Replacement fluids may decrease the blood glucose by up to 23% because of increased renal perfusion and loss of glucose in urine [149] Hyperglycemia can reduce serum sodium by causing an osmotically driven shift of water from intracellular to extracellular compartments.


In addition to this, patients with fever or infections and higher metabolic requirements may need 15% to 20% more insulin than the usual dose [165].In rare cases of patients with allergy to human insulin presenting with hyperglycemic crisis, desensitization to human insulin may be performed before treatment with human insulin. Recent studies focused on the role of interleukin-1 beta (IL-1?), interleukin-12 (IL-12) and interferon-gamma (IFN-?). In addition to alterations in magnesium metabolism from DKA, many patients with diabetes have taken medications such as diuretics that also may lower magnesium levels.
As demonstrated in vitro, these cytokines can directly influence beta cell function and viability [42]. As it is related with increased morbidity and mortality, clinicians must be aware of this complication.
PotassiumDespite a total body potassium deficit resulting from the glycosuric osmotic diuresis, mild-to-moderate hyperkalemia is common in patients with hyperglycemic crises upon initial presentation because of proteolysis, acidosis, and insulin deficiency [10,167]. Symptoms of magnesium deficiency are difficult to recognize and overlap with symptoms caused by deficiencies of calcium, potassium, and sodium. Subsequent choice for fluid replacement depends on hemodynamics, the state of hydration, serum electrolyte levels and urinary output. Insulin therapy, correction of acidosis and volume expansion decrease serum potassium concentration [10].
Paresthesias, tremor, carpopedal spasm, agitation, seizures, and cardiac dysrhythmias all are reported symptoms. Therefore, these should be monitored for hyperlipidemia and if there is clinical evidence, for pancreatitis [120-123]. Fluid resuscitation should be individualized according to the patient’s degree of dehydration, mental status and underlying diseases such as congestive heart failure or renal failure [51]. Checking magnesium levels and correcting low levels should be considered in patients with DKA. Prior to DKA management the levels of IL- 6, IL-8, IL-10,WBC and cortisol were elevated, but all parameters were reduced within 120 hours after DKA management [43]. Pseudonormoglycemia [124] and pseudohyponatremia [125] may occur in DKA in the presence of severe chylomicronemia. Glucose, an osmotic diuretic, may produce a high urine output even in severely dehydrated patients.
Figure 1.The pathogenesis causing to hyperglycemia and ketoacidosis in DKA (Data adapted from reference [17])Recent studies have reported that an upregulated production of and interleukin-18 (IL-18) could be an important pathogenic event in the dysregulated production of IFN-? and other type 1 cytokines thought to predispose T1DM [44-46] and the potential role of IL-18 in the pathophysiology of the chronic complications of diabetes mellitus [7-11]. On the admission in patients with DKA, serum phosphate level is usually elevated because of an extracellular shift of phosphate caused by insulin deficiency, hypertonicity and increased catabolism. Serum sodium is falsely lowered by 1.6 mEq for every 100 mg per dL increase in blood glucose. But the potential role of IL-18 in the acute complications of diabetes mellitus such as DKA is controversial.
As a result, urine output should not be considered a reliable predictor of volume status in hyperglycemic states [152]. Hyponatremia needs to be corrected only when the sodium level is still low after adjusting for this effect. Bicarbonate therapyThe hepatic metabolism of free fatty acids generates ketoanions, such as beta-hydroxybutyrate and acetoacetate [171,172]. Impaired tissue perfusion due to volume contraction and the adrenergic response to the often severe underlying precipitating illness result in lactate production [173]. Acute kidney injury leads to accumulation of other unmeasured anions, such as sulphate, urate and phosphate [174]. All these, together with hyperchloremia which predominates during the recovery phase of DKA [175], contribute to the development of acidemia, which often is severe [176,177].Metabolic acidemia can impair myocardial contractility, reduce cardiac output, affect oxyhemoglobin dissociation and tissue oxygen delivery, inhibit intracellular enzymes, such as phosphofructokinase, alter cellular metabolism, and result in vital organ dysfunction [178-181]. But based on currently available evidence, several deleterious effects of bicarbonate therapy have been reported, such as increased risk of hypokalemia, decreased tissue oxygen uptake, cerebral edema and development of paradoxical central nervous system acidosis [182]. Serum IL-18 levels was significantly higher in patients with DKA than those in patients without DKA while C-peptide levels were markedly lower in patients with DKA. These results point that serum IL-18 levels are elevated and correlated with C-peptide levels and ICA in patients with T1DM, with marked increase in T1DM with DKA. Clinicans should be aware of the risk of DKA in diabetic patients with high serum IL-18 [47]. The procoagulant and inflammatory states may be due to nonspecific phenomena of stress and may partially explain the association of hyperglycemic crises with a hypercoagulable state [48].
Precipitating factorsA careful search for precipitating factors should be made, as correction of these contributes to improved outcomes and less frequent recurrences.The most common precipitating factor in the development of DKA is infection [37,49,50] including viral syndromes, urinary tract infections, pelvic inflammatory disease, pneumonia, mucormycosis, malignant otitis externa (with pseudomonas aeruginosa), periodontal abscess and dental infection [51].
New-onset T1DM or discontinuation of insulin in T1DM frequently leads to the development of DKA. In young patients with T1DM, psychological problems complicated by eating disorders may be a contributing factor in 20% of recurrent ketoacidosis. Randomized studies showed that phosphate replacement have no any additional benefit on the clinical outcome [126,183] and in contrast, phosphate replacement may trigger hypocalcemia and hypomagnesemia [183,184]. Hypophosphatemia can cause hemolysis, refractory acidosis, reduced cardiac output, respiratory muscle weakness, rhabdomyolysis, central nervous system depression, seizures, coma or acute renal failure. Additional prospective studies are needed to document reduction of DKA incidence with the use of continuous subcutaneous insulin infusion devices [54]. Drugs that affect carbohydrate metabolism, such as corticosteroids, thiazides, sympathomimetic agents and pentamidine may precipitate the development of DKA [10]. The association between antipsychotic drugs, especially with atypical antipsychotics and hyperglycemia and even DKA have been reported in some cases [55,56].
Transition to subcutaneous insulinWhen DKA has resolved, patients who are appropriate for oral intake can be started on a multiple dose insulin regimen with a long acting insulin (e.g.
There are reports of hyperglycemia, convulsions and glycosuria in overdosage of nalidixic acid [58-61]. To ensure adequate plasma insulin levels and to avoid hyperglycemia and ketonemia intravenous insulin infusion should be continued for 1–2 hours after the subcutaneous insulin is given. Interferon-alpha (IFN-?), a natural protein with anti-viral, anti-proliferative and immunomodulatory effects is routinely administered in chronic hepatitis C (CHC). Patients who are inappropriate for oral intake the treatment should be continued with an infusion of intravenous fluids and insulin [10,17,49,93,187]. Classical IFN-? has been correlated with the development of a variety of autoimmune disorders including Hashimoto thyroiditis, immune-mediated thrombocytopenia, hemolytic anemia, psoriasis, rheumatoid arthritis, systemic lupus erythematosus, primary biliary cirrhosis and sarcoidosis.
A multiple-dose subcutaneous combination regimen is preferred, as it is related with less hypoglycemia and provides a better physiologic pattern of control than other regimens. Patients with known diabetes, whose blood glucose monitoring are in the normal ranges before DKA, may start with dose of insulin they are receiving [160].In the past human insulin (NPH and regular) were usually given in two or three doses per day. With the development of new analogue insulins, basal-bolus regimens with basal (glargine and detemir) and rapid-acting (lispro, aspart, or glulisine) insulin treatments became a major concern in the treatment of DKA. A prospective randomized trial compared with a split mixed regimen of NPH plus regular insulin twice daily treatment and a basal-bolus regimen, including glargine once daily and glulisine before meals following the resolution of DKA.
Glycemic control were similar between the two groups but the study showed that treatment with basal-bolus insulin regimen was associated with a lower rate of hypoglycemic events (15%) than the rate in those treated with NPH and regular insulin (41%).
High titers of glutamic acid decarboxylase, antinuclear and thyroid (thyroid peroxidase and thyroglobulin) antibodies were detected [65]. Somatostatin therapy in the management of resistant diabetic ketoacidosisAs a inhibiting hormone for counterregulatory hormones, somatostatin may be used in the treatment of DKA. Until 2005, 35 cases of IFN-? related T1DM had been reported in the medical literature [64,66-69]. Somatostatin analogues have been successfully used in the treatment of diabetes associated autonomic neuropathy and they have also been shown to decrease the requirements for insulin [188,189]. DKA was reported in a few classical IFN-? related cases [70-73], in three pegylated IFN-? related cases [65,74,75].
Continuous subcutaneous octreotide infusion suppresses counterregulatory hormones, increases insulin-mediated glucose metabolism by enhancing glucose storage and reduces energy expenditure [189].
The development of DKA and the permanent insulin dependency may be related with a rapidly developing T helper-1-mediated pathogenic mechanism [72].
The incidence of diabetes is less frequent among the patients of nephrotic syndrome in comparison to organ transplant recipients. Octreotide led to a marked suppression of beta-hydroxybutyrate, acetoacetate and glucagon levels and an associated diminution of bicarbonate consumption and the fall in pH [190]. Cytomegalovirus infection [78,79], protease inhibitor treatment [80,81] and highly active antiretroviral therapy (via immune restoration) may precipitate DKA in HIV-infected patients [82].5. In conclusion, for patients who do not respond to conventional DKA treatment, somatostatin could be added to therapy. History and physical examinationThe acute DKA episode in T1DM evoluation should be done rapidly. MonitoringSuccessful management and early intervention for complications require close monitoring. The symptoms of poorly controlled diabetes may be present for several days, but the metabolic changes typical of ketoacidosis usually occurs within a short time (typically 24 h).
Occasionally, the entire symptomatic presentation may evolve or develop more acutely and the patient may present with DKA with no prior clues or symptoms. The clinicians should be made a flow chart to obtain all relevant incidents regarding the patient’s condition and clinical outcome [192]. For DKA, the typical clinical findings includes a history of polyuria, polydipsia, weight loss, vomiting, dehydration, weakness and mental status change. Physical examination may include poor skin turgor, Kussmaul respirations, tachycardia and hypotension. For example, patients with initially low potassium, more frequent (hourly) K measurements should be made with ECG monitoring [194,195] or if patient’s neurological status is unstable and has a high risk of cerebral edema, more frequent neurologic and vital sign checks (20-30 minutes) should be made [192]. Close monitoring of arterial blood gases and serum or urine ketones should not be used as predictor of clinical improvement. Despite of successfull treatment by arresting ketogenesis, ketone levels may be considered unchanged or high, as beta-hydroxybutyrate converts to acetoacetate and conventional (nitroprusside) testing detects only acetoacetate and acetone [135].
For avoid this problem laboratory measurement or the use of a bedside fingerstick sample monitor for beta-hydroxybutyrate can be made.
It is reasonable to reduce laboratory monitoring frequency when acidosis resolves, the anion gap falls to near normal limits while response to glycemic therapy becomes noticeable [135]. Complications of diabetic ketoacidosis or it’s treatmentMost of the diabetes-related morbidity and mortality in T1DM can be attributed to complications of DKA.
As ketoacidosis is corrected, a rapid decline in plasma glucose levels can be occur and this may cause the blood glucose drop to hypoglycemia levels.
Hypoglycemia leads to the release of counter-regulatory hormones and this results with rebound ketosis which can lengthen the duration of treatment. In addition to this, severe hypoglycemia can cause cardiac arrhythmias, seizure or loss of consciousness, brain injury including coma or death.
Rhabdomyolysis and renal failureAcute renal failure (ARF) is an uncommon complication of DKA and rarely requires renal replacement therapy and it may be severe and potentially life threatening [196,197]. Prolonged profound ketoacidosis and insulin infusions can lead to severe hypophosphatemia, mainly as a result of intracelluar phosphate shifting [198-201].
Peripheral venous thrombosisIn DKA treatment, patients may require central vascular access for intensive fluid replacement. However, this route of vascular access causes many complications [206] like venous thromboembolism (VTE) [207]. Children with thrombophilia, malignancy, congenital cardiac disease, acute infection, trauma and surgery have a high risk for complications of central venous catheter (CVC) related VTE [206]. In the medical literature there have been few reported cases CVC related VTE in DKA children without known risk factors.
Thus, DKA and its treatment may promote a prothrombotic state and activation of vascular endothelium, predisposing to thrombosis.
Whilst, DKA has not been identified as an isolated risk factor for CVC-related VTE in adults [211]. PancreatitisAcute pancreatitis is a well known complication of DKA in adults [212] but is unusual in childhood.
Although hypertriglyceridemia is a known cause of acute pancreatitis and elevated triglyceride concentrations are frequent during DKA, an association between elevated triglyceride concentrations in DKA and pancreatic enzyme elevation or pancreatitis have not be showned in the previous studies [213,215]. The mechanism responsible for pancreatic enzyme elevation in DKA has thus remained unclear.



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