How To Stop Diabetic Ketoacidosis – Do you need to close a major “gap” in your knowledge of diabetic ketoacidosis? Look no further than our conversation with diabetes expert and regular guest Dr. Hussain Abdulatif, an award-winning clinician-educator at UAB. Join us as Dr. Abdulatif spoke to us about the diagnosis, management and social implications associated with DKA.
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The diagnosis of DKA is based on the biochemical triad of ketonemia, hyperglycemia, and acidemia along with the diagnosis of diabetes. (ISPAD Clinical Practice Consensus: DKA, 2018)
The presentation of DKA can vary greatly depending on the timing and severity of the disease. It often begins with symptoms of diabetes (polyuria, polydipsia, weight loss).
DKA is often very mild in its early stages. Often accompanied by nausea/vomiting, vague abdominal pain, but adequate urine output. Patients with DKA appear to maintain urine output due to osmotic diuresis, but in reality they are severely dehydrated. Be careful if the patient is also losing weight. Children should not lose weight, this is almost always considered a warning sign. Also, if a child has nausea/vomiting but no diarrhea, be sure to ask “is this really just gastroenteritis?” Checking urine and/or glucose is a simple and inexpensive test that helps rule out DKA in the clinic when a patient presents with this benign manifestation.
In the later stages of DKA, signs and symptoms associated with compensatory metabolic abnormalities will appear.
Students will understand the presentation, workup, and treatment of diabetic ketoacidosis. In addition, students will learn about the many social determinants of health that contribute to the development of DKA in patients with diabetes.
Snellgrove S, Abdulatif H, Chiu S, Burke J. “#22: DKA: Watch the Gap!”. Cribssiders Pediatric Podcast. https://www.thecribsiders.com/ March 31, 2021
Associate Professor of Medicine and Pediatrics and Warren Alpert School of Medicine at Brown University. Passionate about primary care, addiction treatment, medical education and the Mountain Dew Diet. Diabetic ketoacidosis (DKA) is a common and potentially life-threatening complication of type 1 diabetes. Although the mortality rate is currently relatively low, it is widely recognized that inappropriate treatment is an important cause of in-hospital mortality, morbidity, increased length of hospital stay, and high hospitalization rates. The Joint British Diabetes Society (JBDS) guidelines for the management of DKA have been widely adopted in the UK; However, he is now more than ten years old. Therefore, the release of the new guidance from JBDS, published in June 2021, is a welcome update.
Some recommendations in the original are based on expert opinion. While many of these now find support in the literature and have become standard practice, others have been modified. The main changes in the document are described below.
The guidelines now say they should be used in the care of young people aged 16-18 when they are being cared for by an adult diabetes team, arguing that it is more appropriate for them to be managed by local adult guidelines rather than a team. familiar rather than using potentially unfamiliar pediatric guidelines.
Conversely, if young adults in this age group are cared for by a pediatric team, BSPED pediatric guidelines should be followed.
The updated guidelines recommend that when blood glucose levels fall below 14 mmol/L, physicians may consider (always using appropriate clinical judgment) reducing the rate of intravenous insulin infusion to 0.05 units/kg/hour. This is done to reduce the risk of hypoglycemia and hypokalemia. While these complications can result from the late addition of dextrose solutions to medications or the incorrect administration of potassium-containing fluids, the major contributor to both complications is the use of insulin, and several pediatric studies have shown that reducing the infusion rate to these levels does not increase resolution time of DKA compared to a rate of 0.1 unit/kg/hour.
A short section on the management of DKA in patients with end-stage renal disease or dialysis has been added. Although fortunately such cases are relatively rare, some issues are worth considering, including the possibility that fluid replacement may not be necessary; increased risk of hypoglycemia due to reduced renal clearance of insulin; and possible risk of hyperkalemia.
This guide has a new section on euglycemic DKA (occurring despite normal or near-normal blood glucose) and ketosis-prone type 2 diabetes.
Euglycemic DKA is a known complication of sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy in people with type 2 diabetes and, increasingly, type 1 diabetes. This condition should be managed in the same way as hyperglycemic DKA, and SGLT2 inhibitors should be at least stop until recovery; the decision to restart the medication should be discussed with the person and their diabetes team.
Ketosis-prone type 2 diabetes is most common in people of Afro-Caribbean or Hispanic descent. Treatment for this condition is the same as for other people with DKA, but people can often stop taking insulin quickly after the DKA and the underlying condition go away.
This new edition aims to update the guidelines using the latest available evidence. The document has also been reorganized so that the DKA control algorithm is now in the foreground, making it more accessible.
To keep the guidelines current, it is assumed that all JBDS guidelines will be updated or revised annually. As such, it is a ‘living’ document, intended to be updated based on newly published evidence or experience, and any feedback on the recommendations is welcome. Updated guidelines are available at: https://abcd.care/resource/management-diabetic-ketoacidosis-dka-adults
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Diabetic ketoacidosis (DKA) is a serious acute complication of type 1 diabetes that is receiving increasing attention given the increased risk of DKA associated with SGLT inhibitors. Sociodemographic and modifiable risk factors identified with strong evidence of increased risk of DKA, including socioeconomic disadvantage, adolescent age (13–25 years), female sex, high HbA1
, prior DKA, and comorbid psychiatric conditions (eg, eating disorders and depression). Possible prevention strategies are suggested that include identifying people at risk based on non-modifiable socio-demographic risk factors. Structured diabetes self-management education that addresses modifiable risk factors can be used as a second risk reduction strategy. Evidence has shown that structured education leads to lower levels of DKA. Knowledge of these risk factors and sound risk reduction strategies are important to identify subgroups of people at high risk for DKA. This knowledge should also be used when considering additional treatment options for those at increased risk of DKA. Prevention of DKA in type 1 diabetes is an important clinical challenge that also needs to be addressed when SGLT inhibitors are part of therapy. Diabetic ketoacidosis (DKA) is a dreaded complication of diabetes, but fortunately, it can be prevented. Monitoring ketones is the first step. So if you’re living with type 1 diabetes, NICE guidance suggests you have access to a blood glucose meter that can also test for ketones.
But what is diabetic ketoacidosis? And how do you interpret ketone levels? The more you understand about DKA, the easier it will be to recognize symptoms early and the sooner you can take preventive measures to prevent them from getting worse.
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