Complication Of Diabetic Ketoacidosis Research Articles

Cerebral edema in an adolescent patient with diabetic ketoacidosis: a case report with a review of literature

The objective was to describe a case of cerebral edema (CE) in an adolescent patient with type 1 diabetes mellitus (DM) complicated with diabetic ketoacidosis (DKA), and to perform an analysis and review of publications devoted to this topic.Materials and methods. We describe the rare clinical case of CE complicated with DKA in the 14-year-old adolescent patient, including the dynamics of the patient’s clinical condition and laboratory test results. The topic of interest was researched through analysis of publications found in the Cochrane Library, PubMed, eLibrary.ru and Medscape databases using the following search terms: diabetic ketoacidosis, children and adolescents, cerebral edema, intensive therapy. A total of 38 publications in Russian and English were selected for being fully compliant with the purpose of this work. The features of the reported clinical case were analyzed and compared with information obtained from the current scientific literature.Results: This case demonstrates specific features presenting in the course of CE and describes aspects of the intensive treatment provided to the patient. Manifestations of severe hypokalemia and hypernatremia have been recorded as rare electrolyte disturbances in CE in the adolescent with DKA. The report demonstrates that the steps and specific parameters of the provided intensive treatment are unlikely to have triggered the development of CE in the clinic in this particular clinical case. It cannot be ruled out that the development of this complication was triggered by the delayed initiation of treatment (caused by the patient) at the prehospital stage, including the patient’s rude noncompliance with the prescribed insulin treatment scheme.Conclusions. CE is the rare but severe (with a high fatality rate) complication of DKA in patients with type 1 DM. Timely initiation of emergency care for CE may reduce risks associated with this complication and improve treatment outcomes and patient prognosis.

Signs and symptoms in the diagnosis of type 1 diabetes mellitus and interventions for the management of diabetic ketoacidosis: scoping review

Objective: To identify the most prevalent signs and symptoms in the diagnosis of Type 1 Diabetes Mellitus (DM1) in children and adolescents, as well as the signs and symptoms of Diabetic Ketoacidosis (DKA), its complications, and the nursing and medical interventions indicated for its management. Method: This is a scoping review, carried out in the LILACS, PUBMED, SCOPUS, LIVIVO, and Embase databases, with additional search in gray literature. The data were analyzed qualitatively. Results: We found 840 studies in the search, but only 10 studies met the eligibility criteria. The most frequent signs and symptoms in the diagnosis of DM1 were polydipsia (83%), polyuria (78%), and weight loss (56%). DKA symptoms were variable. The main complications of DKA were cerebral edema and death and transfer to the pediatric intensive care unit and continuous infusion of intravenous insulin were the most recommended interventions. Conclusion: Early recognition of the signs and symptoms of DM1 plays an important role in patient management, leading to rapid initiation of treatment and relevant interventions, thus preventing the occurrence of complications.

Severe Hypertriglyceridemia in a Child with Refractory, Fatal Diabetic Ketoacidosis: A Case Report with Review of Literature

Background: Diabetic ketoacidosis (DKA) is an acute life-threatening complication of diabetes. Dyslipidemia due to disturbance in glucose metabolism can cause elevation in serum triglyceride levels. Severe hypertriglyceridemia is a complication of DKA, rarely reported in children. Clinical Description: A 3-year-old girl, newly diagnosed, but untreated type 1 diabetes mellitus (DM), presented with DKA. The first blood sample showed serum as grossly milky, with highly raised levels of triglyceride (2170 mg/dL) and cholesterol (791 mg/dL). Many of the blood parameters were erroneous due to the lipemic sample. Serum amylase and lipase were normal, ruling out pancreatitis. Management and Outcome: Correction of dehydration, insulin infusion, antibiotics, and vasopressor support were started. Despite treatment with insulin and supportive care, the patient had a rapidly deteriorating course and ultimately succumbed to the illness. Conclusion: Uncontrolled, untreated DM in a child can result in decompensated DKA, which is usually associated with severe hypertriglyceridemia, and a rapidly progressive fatal course.

Rare Emergency Case of Bowel Ischaemia as a Result of Diabetic Ketoacidosis Complication: A Case Report and Literature Review of an Unusual Entity

Introduction and Importance: Diabetic ketoacidosis (DKA) is a life-threatening situation that if inadequately managed, is related to high fatality risk. It is associated with mesenteric ischaemia that necessitates early detection and intervention to enhance the prognosis for mesenteric ischaemia. Case Presentation: A 58-year-old male patient presented to our hospital with severe generalized abdominal pain, vomiting, and polyurea. On admission, he was newly diagnosed with diabetes mellitus type II (DM II) which is complicated by DKA. Days later, his abdominal pain worsened, and bowel obstruction was confirmed by both X-ray and ultrasonography of the abdomen. Due to the deterioration in the patient’s clinical condition, an emergent diagnostic laparoscopy was decided which was followed by an open laparotomy with bowel resection of the detected dilated and ischaemic bowel loops. The resected specimens, including small bowel and peritoneal wall mass, were sent for histopathological studies. Three re-look laparotomies were also performed, and the postoperative period was uneventful. Clinical Discussion: Intestinal ischaemia is a rare complication of DKA. Bowel ischaemia can be either occlusive or nonocclusive mesenteric types. It is clinically manifested by abdominal symptoms in diabetic patients. Evaluation is mainly by abdominal computed tomography (CT) and the main treatment approach is laparoscopy and/or laparotomy in combination with resection of the affected bowel loops. Conclusion: In our case report, we document an additional unusual case of intestinal ischaemia and necrosis as a DKA consequence, in a recently diagnosed DM II patient, as one of the few non-occlusive mesenteric ischaemia causes.

Ischemic-Hemorrhagic Stroke in New Onset Type 1 Diabetes Mellitus with Diabetic Ketoacidosis in a Two-Year-Old Toddler: The First Reported Case in Indonesia

Cerebral edema accounts for 90% of intracerebral complications in diabetic ketoacidosis (DKA). Stroke has been reported to account for 10% of intracerebral complications of DKA in children. It may be underrecognized because its presentation may be subtle. This case report aims to raise awareness of stroke presentation and risk factors in pediatric DKA. A previously healthy two-year-old female presented to the emergency department one day before admission with loss of consciousness and was diagnosed with DKA. The recognition of left hemiparesis was on the 9th day of hospitalization. After 14 days of hospitalization, the patient had recurrent seizures. Computed tomography and angiography revealed subacute ischemic transformative to subacute hemorrhagic stroke. During the follow-up, the symptoms of hemiparesis improved with routine physiotherapy, with some partial palsy of the third cranial nerve remaining. Risk factors for stroke in the patient were the severity of dehydration during DKA, younger age of onset, delayed DKA treatment, and iron deficiency anemia. Suspicion of stroke is necessary even if a subtle neurologic deficit occurs.

Diabetische ketoacidose: nog steeds een levensbedreigende ziekte

Diabetic ketoacidosis: still a life-threatening disease. This report details a rare occurrence of cerebral edema as a complication of diabetic ketoacidosis (DKA) in an 18-year old male. The patient presented with headache, and on further inquiry typical symptoms of DKA (polyuria, polydipsia and weight loss). During treatment his condition rapidly deteriorated resulting in neurological collapse and coma. A CT-scan revealed signs of cerebral edema. Although the exact pathophysiology is not fully understood, it is believed that both DKA-related (cytotoxic and vasogenic) and treatment-related factors play a role. Cerebral edema caused by DKA can be fatal, or result in persisting neurologic deficits. Proper use of intravenous (IV) resuscitation fluids and avoidance of IV bicarbonate and IV insulin bolus is necessary to avoid exacerbation of pre-existing cerebral edema, as described in this case report. Neurological monitoring, before and during treatment, is essential, as early detection and treatment of cerebral edema improves outcome. If clinical signs of cerebral edema, mannitol 20% or hypertonic salt IV should be administered immediately. This case emphasizes the importance of careful metabolic and neurological monitoring and adherence to appropriate treatment principles in DKA to reduce the risk of cerebral edema. Increasing awareness of this complication among healthcare providers can help intervene in a timely manner and improve outcome for the patient.

Diabetic Ketoacidosis Complications and Management in Pediatrics: A Narrative Review

Diabetic ketoacidosis (DKA) is an endocrine emergency that affects both newly diagnosed and long-term type I diabetic patients as a result of decreasing insulin levels in the blood, insulin resistance, and elevated levels of counter-regulatory hormones. A common and deadly acute consequence in kids with diabetes mellitus is diabetic ketoacidosis. When type I diabetes is newly diagnosed, it can be accompanied by diabetic ketoacidosis. It can also happen when type I diabetes is already present, such as when the demands of an acute illness are more than usual or when insulin administration is decreased as a result of missed doses or insulin pump failure. Furthermore, there are more reports of diabetic ketoacidosis events in kids with type II diabetes mellitus. Although the diagnosis is typically simple in a patient with established diabetes and the anticipated symptoms, a sizable portion of patients with new-onset diabetes initially present with diabetic ketoacidosis. Children with diabetic ketoacidosis are typically treated in an emergency room for the first time. The differential diagnosis of pediatric metabolic acidosis must take diabetic ketoacidosis into account as a significant factor. The pathogenesis, therapy, and probable consequences of this illness will be explained to emergency medicine doctors in this review) Heddy, 2021). The management of pediatric patients draws attention to the uncommon but fatal occurrence of cerebral edema and the excessive use of fluid boluses that may or may not be related to it. Guidelines for managing DKA in adults should not be applied to children and adolescents. The diagnosis of DKA is based on clinical suspicion and subsequent laboratory confirmation: Hyperglycemia (sugar level greater than 11 mmol/L): diabetes warning sign. pH 7.3 and 15 mmol/L of bicarbonate indicate metabolic acidosis. Ketosis, which may include ketonuria or ketonaemia. The severity of DKA depends on the acidity level: Mild: pH 7.3 and/or 15 mmol/L of bicarbonate; Moderate: pH 7.2 and/or 10 mmol/L of bicarbonate. Ketoacidosis associated with diabetes (DKA) Extremely severe: pH 7.1 and/or 5 mmol/L of bicarbonate. DKA can have various deadly consequences. Acute hypoglycemia (during treatment or as a result of utilizing an excessive amount of insulin pump) Cerebral edema, Acute hypokalemia, Acute hypoglycemia, Spontaneous pneumonia. A, B, and C for initial CPR If at all possible, weigh the patient and then use that weight in all calculations. Use an estimated weight from a centile chart or a weight from a recent medical visit as an alternative. Make sure the airway is open. Insert an airway if a child is unconscious (Glasgow Coma Scale Score of 8). In the event that the patient is vomiting or has a reduced level of awareness, insert NGT, aspirate, and place on free drainage. B. An oxygen-only face mask. Draw blood when an IV cannula is in place. Only if the patient is shocked (poor peripheral pulses, poor capillary filling with tachycardia, and/or hypotension) should you provide a bolus of 10 ml/kg 0.9% sodium chloride. Repeat the fluid bolus only after contacting a doctor or pediatric endocrinologist if shock symptoms continue.

Severe diabetic ketoacidosis complicated with severe dyslipidemia, cerebral edema and acute kidney injury in a pediatric girl with type 1 diabetes mellitus: a case study

Diabetic ketoacidosis (DKA) is a life-threatening acute metabolic complication occurring in patients with type 1 diabetes, due to an insulin deficiency. Moderate hypertriglyceridemia is commonly observed in DKA but severe hypertriglyceridemia with a triglyceride level exceeding 10 g/l is very rarely reported. Acute kidney injury (AKI) is a serious condition which still carries a mortality of around 50%. Cerebral edema is a devastating complication of DKA which is leading cause of diabetes-related death in the pediatric population. Newly diagnosed diabetes, younger age, first episode of DKA, severity of DKA at presentation, and administration of bicarbonate are predictive of cerebral edema in DKA. We present a case of 8-year-old girl who presented with severe DKA, whose clinical course was complicated by renal failure, severe dyslipidemia and cerebral edema.

Abstract #1394296: The First Reported Case of Lorlatinib-Associated Diabetic Ketoacidosis

Lorlatinib is a third-generation tyrosine kinase inhibitor that inhibits anaplastic lymphoma kinase (ALK) and c-ros oncogene 1 (ROS1). Although 2-10% of patients with non-small cell lung cancer developed hyperglycemia in phase 2 and 3 studies of lorlatinib, only one case has subsequently reported hyperglycemia >500 mg/dL, and no cases of diabetic ketoacidosis (DKA) have been previously reported. Phase 1 trials in neuroblastoma are ongoing. A 34-year-old woman with ALK-mutated paraspinal neuroblastoma presented with DKA 14 months after initiation of lorlatinib. Prior to starting lorlatinib, her hemoglobin A1c had been 5.0% (n: < 5.7%). After 12 months of therapy, her A1c increased to 7.8%, prompting the initiation of metformin 500 mg daily. However, two months later she was admitted for DKA with a blood glucose of 591 mg/dL (n: 65-99 mg/dL), CO2 17 mmol/L (n: 20-30 mmol/L), anion gap 18 (n: 8-12), moderate serum ketones, and 3+ ketonuria. Her A1c was 14.8%, C-peptide was 1.2 ng/mL (n: 1.1-4.3 ng/mL), and her glutamic acid decarboxylase-65 and islet antigen-2 autoantibodies were negative. She was also found to be incidentally positive for COVID-19 but was asymptomatic without any oxygen requirement. The patient’s DKA was successfully treated with IV insulin infusion, and she was discharged after 3 days with insulin glargine 27 units twice daily and insulin aspart 16 units with meals. One month later, her hemoglobin A1c had improved to 9.4%, and the patient’s oncologist discontinued lorlatinib due to sustained remission of her neuroblastoma and her complication of DKA. After stopping lorlatinib, her blood glucose rapidly improved, and she self-discontinued all her insulin in the following 3 weeks. One month later, she was seen in endocrine clinic only taking metformin 500 mg twice daily with fasting and post-prandial blood glucose ranging 86-107 mg/dL. This is the first reported case of DKA associated with lorlatinib. This case highlights the importance of close glucose monitoring and the risk of severe hyperglycemia and DKA while on lorlatinib therapy. Discontinuation of lorlatinib results in rapid improvement of glycemic control, and glucose-lowering treatments should be promptly deescalated to avoid hypoglycemia.

Subarachnoid Hemorrhage as a Complication of Diabetic Ketoacidosis in Early Onset Type 1 Diabetes Melitus in Limited Resource Settings

Background: Diabetic ketoacidosis (DKA) is one of the most frequent causes of morbidity and mortality in type 1 diabetes mellitus (T1DM). Neurological complications that can occur in DKA patients are cerebral edema followed by ischemic and hemorrhagic strokes. Hemorrhagic strokes have higher mortality than ischemic strokes in T1DM patients. Case: An 11-year-old patient came to the emergency room with complaints of decreased consciousness since morning. During the previous 2 days the patient had nausea and vomiting. There was no history of trauma or fever. About 2 days before admission patient showed decrease of consciousness. On physical examination, he was found to be in a coma, kussmaul breathing, mydriatic pupil, and with kussmaul breathing. Laboratory examination showed hyperglycemia, leukocytosis, hyponatremia, ketonuria, and C-peptide of 0,560 ng/ml. Head CT-Scan showed subarachnoid hemorrhage and cerebral edema. The patient showed a positive response after rehydration, administration of mannitol, and blood sugar regulation with an insulin pump. Discussion: DKA is one of the manifestations of T1DM. DKA is confirmed by hyperglycemia, blood pH below 7.3 manifesting with kussmaul breathing and the presence of ketones in blood and urine tests. DKA is treated with rehydration and insulin administration. SAH is a rare manifestation of DKA. The diagnosis of SAH can be confirmed by neuroimaging examination. Management of SAH could be done through close monitoring of blood pressure, prevention of increased intracranial pressure, and surgical approach. Conclusion: Subarachnoid hemorrhage is a neurological complication that rarely happens in DKA and could be caused by several factors such as hypotensive episode, hyperketonemic state, arteriovenosus malformation rupture, and endothelial perturbation. Neuroimaging could detect early neurological complication in DKA.

Clinical Characteristics and Outcomes of Diabetic Ketoacidosis in Patients With Type 2 Diabetes using SGLT2 Inhibitors.

Sodium glucose cotransporter 2 inhibitors (SGLT2i) use is associated with an increased risk of diabetic ketoacidosis (DKA). This study evaluated and compared the DKA characteristics and outcomes of users and non-users of SGLT2i. We retrospectively studied patients with type 2 diabetes mellitus (T2DM) admitted with DKA to Tawam Hospital, Al Ain City, UAE between January 2017 and March 2021. Demographic data, clinical, and laboratory findings were extracted from the electronic medical records. A total of 55 patients with T2DM (62% UAE nationals, 50% women) were admitted with DKA. The average age was 54.0 ± 18.9 years and average diabetes duration of 15.7 ± 15.1 years. Seventeen patients (31%) were using SGLT2i. Infection was the main precipitating factor for DKA in (8 out of 17) SGLT2i users. Compared to non-users, SGLT2i users had lower systolic blood pressure (119.9 vs 140 mmHg; P = .012) and serum glucose levels (16.2 vs 24.9 mmol/L; P < .001) and higher Na level (137.5 vs 132.6 mmol/L; P = .005). Additionally, 56.3% of SGLT2i users had euglycemic DKA compared to 2.6% of nonusers (P < .001). Acute kidney injury (AKI) occurred more in SGLT2i users compared to non-users (94.1% vs 67.6%, P = .043). Further analysis revealed that SGLT2i users were about five times more likely to have prolonged hospital length of stay (⩾14 days) when compared with non-users (adjusted OR: 4.84; P = .035). Overall, there was no difference between the two groups with regards to DKA complications and mortality. SGLT2i related DKA is associated with lower blood glucose levels, lower SBP, worse hypovolemia, increased risk of AKI, and longer hospital stay when compared to non SGLT2i related episodes. Since the benefits of SGLT2 inhibitors far outweigh potential risks, there is a need to raise healthcare professionals and patients' awareness about this potential association.

The Evaluation and Management of Pediatric Diabetic Ketoacidosis: A Comprehensive Review.

Diabetic ketoacidosis (DKA) is a common, serious acute complication in children with diabetes mellitus (DM). DKA can accompany new-onset type 1 insulin-dependent DM, or it can occur with established type 1 DM, during the increased demands of an acute illness or with decreased insulin delivery due to omitted doses or insulin pump failure. In addition, DKA episodes in children with type 2 DM are being reported with greater frequency. Although the diagnosis is usually straightforward in a known diabetes patient with expected findings, a sizable proportion of patients with new-onset DM present with DKA. The purpose of this comprehensive review is to acquaint clinicians with details regarding the pathophysiology, treatment caveats, and potential complications of DKA.

PMON01 Alpelisib (PI3-K Inhibitor) Induced Severe Insulin Resistance Complicated by Diabetic Ketoacidosis (DKA) with Rapid Reversal Following Discontinuation: A Case Report

Abstract Background Alpelisib is a phosphatidylinositol-3-kinase (PI3K) inhibitor, recently approved for treatment of metastatic breast cancer with PIK3CA mutation. The PI3K is involved in insulin signaling pathway and is responsible for translocation of GLUT-4 transporters in insulin responsive tissues and thus modulates insulin sensitivity. Impairment of PI3K pathway results in insulin resistance. Hyperglycemia is a known side effect of alpelisib, however there are only 5 reported cases of alpelisib induced DKA in literature. We describe a patient with Type 2 DM and metastatic breast cancer started on alpelisib with resultant rapid worsening of insulin resistance requiring substantially increased doses of insulin ultimately leading to DKA. She later had rapid reversal of insulin resistance with discontinuation of alpelisib. The degree and rapid onset/reversal of insulin resistance is highlighted in this case. Case 59-year-old female with Type-2 DM, metastatic breast cancer with PIK3CA mutation was started on alpelisib 300mg daily after inadequate response to other agents. Her insulin regimen prior to starting was degludec(U100) 35 units daily and humalog(U100) 30 units with meals. In the first week of starting alpelisib, her continuous glucose monitor(CGM) showed a dramatic increase in glucose values &amp;gt;400 mg/dL accompanied with polyuria and polydipsia. Anti-GAD and Islet-cell-antibodies were negative with C-peptide of 1.55 ng/mL with glucose of 378 mg/dL. Patient was hospitalized with DKA during month 4 of treatment after continuous up titration of her insulin therapy outpatient. With resolution of DKA, patients’ glucoses were well controlled when transitioned to a regimen of degludec 50 units and humalog 12 units with meals. Once alpelisib was restarted during this hospitalization, patient's glucoses increased from 140mg/dL to &amp;gt;400 mg/dL in just 4 hours after administration. Patient was ultimately discharged on a significantly higher dose insulin regimen of degludec 140 units daily and humalog 85 units TID as well as metformin and dulaglutide. A restaging scan demonstrated progression of her cancer and alpelisib was hence discontinued. We instructed the patient to decrease the dose of insulin from the day alpelisib is discontinued to degludec 10 units (.15 units/kg) and a correction scale with meals to assess new insulin requirements. Within the first 24 hours, patient's glucose improved significantly and remained well controlled with degludec 10 units daily and Humalog 5 units with meals. Conclusion The degree of alpelisib induced insulin resistance is often severe with significant increase in insulin requirements. The time to onset and reversal of alpelisib induced insulin resistance is often rapid and providers need to anticipate a rapid increase in insulin requirements within a few days of starting alpelisib and adjust doses promptly to prevent potential complication of DKA. Providers should also anticipate a rapid decrease in insulin requirements within 24 hours of discontinuation to prevent potential hypoglycemic events. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Pantoprazole Induced Acute Interstitial Nephritis in a Patient with Diabetic Ketoacidosis.

Childhood-onset type 1 diabetes mellitus (DM) is a common chronic metabolic disease associated with life-threatening complications. Diabetic ketoacidosis (DKA) is an acute complication of type 1 DM that has significant mortality mostly due to cerebral edema. Other putative complications of DKA include hypokalemia, hypophosphatemia, hypoglycemia, intracerebral and peripheral venous thrombosis, rhabdomyolysis, acute pancreatitis, and acute kidney injury (AKI) (Murdoch IA et al., Acta Paediatr 1993; 82:498-500).

Frequency of Complications in Admitted Patients of Diabetic Ketoacidosis

Objective: To determine the frequency of different complications in admitted patients of diabetic ketoacidosis (DKA). Study Design: A cross-sectional study. Place and Duration: Diabetic ward of National Institute of Child Health (NICH), Karachi Pakistan from 1st November 2020 to 31st October 2021. Methodology: A total of 253 children of either gender aged 1 to 15 years admitting with DKA and duration of diabetes mellitus ≥3 years were included. All patients were subjected to detailed history and clinical examination for DKA and its complication like hypoglycaemia, hypokalaemia, hyponatraemia, hypocalemia, hyperkalaemia. Resutls: In a total of 253 children admitted with DKA, 123 (48.6%) were girls and 130 (51.4%) boys. Mean age of patients was 6.11 ± 2.87 years, mean BMI was 20.9± 4.7 kg/m2, while mean duration of diabetes mellitus was 3.5± 1.2 years. Mean plasma glucose was 22.5±6.0 mmol/L (405±108mg/dl), mean HbA1c 10.2±2.1% while mean pH was 6.9±0.4. In a total of 253 patients with DKA, hypoglycemia was noted in 47(18.6%), hypokalemia 17 (6.7%), hyponatremia 22 (8.7%), hypocalcaemia 11 (4.35%) while hyperkalaemia was observed in 9 (3.56%) patients. Conclusion: Most of the patients admitted with DKA were aged &lt;10 years who developed complications. Hypoglycemia was the most common complication of DKA while hyponatremia the 2nd most frequent complication observed in DKA patients. Electrolytes should be investigated and managed timely to avoid unwanted outcomes among patients admitted with DKA. Keywords: Complications, diabetic ketoacidosis, diabetes mellitus, children.

Knowledge and Awareness of mothers and caregivers of Diabetic Children about clinical features and complications of Diabetic Ketoacidosis in Riyadh City: questionnaire study

Objectives: Diabetic ketoacidosis (DKA) is a life-threatening metabolic disorder in which complications can be avoidable. The purpose of this study is to describe the knowledge of the Saudi caregivers for diabetic children about Juvenile Diabetes Mellitus, its signs and symptoms and prevention and its complications in children under their care. Setting and Participants: A cross-sectional, questionnaire-based study design was conducted in Riyadh city in Saudi Arabia. A sample size of at least 412 was required. The total number of respondents that were included in the analysis was 414. The method of collection of data was done by data collectors. Results: 399 caregivers participated in this study, most of whom were Saudi (376; 94.2%), and gained a university degree (300; 75.2%). The most commonly cited symptom of DM in children was raised blood sugar (225; 56.4%), while the most cited common cause was malnutrition (223; 55.9%), and the most commonly cited manifestation of diabetes was frequent urination (354; 88.7%). Conclusion: This study showed that most type-1 diabetic caregivers had knowledge and awareness regarding DKA in Riyadh, Saudi Arabia. However, some gaps exist. Further studies would assess more factors to enhance the level of knowledge and awareness, and increase the effectiveness toward the right action and response regarding DKA. Keywords: Diabetes Mellitus, DKA, Children, Caregivers, Emergency, Saudi Arabia

Epidemiologic Characteristics of Children with Diabetic Ketoacidosis Treated in a Pediatric Intensive Care Unit in a 10-Year-Period: Single Centre Experience in Croatia.

Background and Objectives: The incidence of severe and moderate forms of DKA as the initial presentation of type 1 diabetes mellitus (T1D) is increasing, especially during the COVID-19 pandemic. This poses a higher risk of developing cerebral edema as a complication of diabetic ketoacidosis (DKA), as well as morbidity and mortality rates. The aim of this study was to determine the trend and clinical features of children treated in the last 10 years in the Pediatric Intensive Care Unit (PICU) due to the development of DKA. Materials and Methods: This retrospective study was performed in the PICU, Clinical Hospital Centre Rijeka, in Croatia. All children diagnosed with DKA from 2011–2020 were included in this study. Data were received from hospital medical documentation and patient paper history. The number of new cases and severity of DKA were identified and classified using recent International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines. Results: In this investigation period, 194 children with newly diagnosed T1D were admitted to our hospital: 58 of them were treated in the PICU due to DKA; 48 had newly diagnosed T1D (48/58); and ten previously diagnosed T1D (10/58). DKA as the initial presentation of T1D was diagnosed in 24.7% (48/194). Moderate or severe dehydration was present in 76% of the children at hospital admission. Polyuria, polydipsia, and Kussmaul breathing were the most common signs. Three patients (5.2%) developed cerebral edema, of whom one died. Conclusions: During the investigation period a rising trend in T1D was noted, especially in 2020. About one quarter of children with T1D presented with DKA at initial diagnosis in western Croatia, most of them with a severe form. Good education of the general population, along with the patients and families of children with diabetes, is crucial to prevent the development of DKA and thus reduce severe complications.

Presentations, Complications, and Challenges Encountered During Management of Type 1 Diabetes in Egyptian Children During COVID-19 Pandemic: A Single-Center Experience.

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has been associated with significant challenges pertaining to the management of children and adolescents with type 1 diabetes (T1D). Issues such as fear of infection and lockdown measures have resulted in delayed and more severe clinical presentations of this disease.ObjectivesThis study aimed at reporting the frequency and severity of diabetic ketoacidosis (DKA) and the rate of DKA complications in children with diabetes who presented to the emergency unit during COVID-19 pandemic. Furthermore, the purpose of this study was to compare the data collected from the first and second COVID-19 waves with that of the pre-COVID-19 period and describe the challenges encountered during disease management.MethodsThis cross-sectional study included all children and adolescents with T1D who presented to the emergency department at Abo El Rish Children’s Hospital, Cairo University, during the first and second COVID-19 waves. It also included data collected from the pre-COVID-19 period. Demographic and clinical data, investigations, and management details were collected from the patients’ medical records.ResultsThree hundred twenty-four Egyptian children and adolescents diagnosed with T1D were recruited. One hundred forty patients (43.2%) presented with severe DKA, and approximately 66% were newly diagnosed with T1D. The participants presented with manifestations suggestive of COVID-19, such as fever (29.5%), respiratory manifestations (7.2%), and gastrointestinal symptoms (14.7%). Thirty-seven patients were tested for severe acute respiratory syndrome coronavirus 2 infection using nasopharyngeal swabs, and four patients tested positive. Around 18% of patients developed hypokalemia during disease management. A comparison between these data and the data from previous years revealed that there was a significant increase in the number of newly diagnosed cases with more severe DKA at presentation and a higher frequency of development of hypokalemia during both COVID-19 waves.ConclusionAn increase in the frequency of newly diagnosed cases was identified during the first and the second COVID-19 waves compared with the pre-COVID-19 period. The patients presented with more severe DKA, probably due to a more delayed presentation. The frequency of hypokalemia development was also significantly higher, and the severity of DKA was associated with a longer ICU admission. Further studies are required to establish a definitive link between the COVID-19 pandemic and the severity of presentation.

Rhabdomyolysis: A rare and often-missed complication of diabetic ketoacidosis

A 19-year-old male with type 1 diabetes mellitus (diagnosed at 12 years of age) was brought to the emergency room with fever and altered sensorium. His compliance with his insulin regimen was questionable. Examination revealed a Glasgow Coma Scale of 5/15, sluggishly-reacting pupils, severe dehydration, and fever (temperature 38.8°C). Vital signs at the upper limit of normal, urethral catheter drained dark red urine with output of 1–2 ml/kg/hr. Laboratory investigations showed hyperglycemia (250 mg/dL), ketonuria (+) hematuria (+++) and proteinuria (++), and glycated hemoglobin (HbA1C) – 9.6%. Full blood count showed leukopenia, neutrophilia, and thrombocytopenia. Deranged electrolytes included hypernatremia, metabolic acidosis, and hypophosphatemia with elevated urea and blood urea nitrogen. Serum creatinine kinase (CK) was elevated. A diagnosis of diabetic ketoacidosis (DKA) with rhabdomyolysis (RM) and raised intracranial pressure was made and he was managed with adequate fluid resuscitation, osmotic diuresis, glycemic control, platelet transfusion, and antibiotics with clinical improvement. Normal CK levels were documented 3 months later. RM is a rare complication of DKA. High index of suspicion should be maintained for prompt detection and management to prevent potential complications, especially acute kidney injury.

Cerebrovascular Accident Complicating Diabetic Ketoacidosis in a Nigerian Adolescent: A Case Report and Review of the Literature

Cerebrovascular accident (CVA) is a rare neurological complication of diabetic ketoacidosis (DKA) in the paediatric population. The risk of developing CVA in DKA patients is often increased due to abnormalities in coagulation factors, platelet activation, blood volume and flow, and vascular reactivity. Cerebral oedema, the most common neurological complication of DKA, may also predispose to CVA. We report the case of a -12-year-old adolescent with DKA complicated by CVA. She developed features of right hemispheric CVA while on admission and had radiological confirmation of an ischaemic CVA. This report highlights that cerebrovascular accidents in DKA can easily be missed or confused with cerebral oedema.