Treatment Of Diabetic Ketoacidosis Research Articles

A DIFFERENT PERSPECTIVE OF ELEVATED LACTATE IN PEDIATRIC PATIENTS WITH DIABETIC KETOACIDOSIS.

This study aims to determine the frequency and prognostic significance of lactic acidosis in children with diabetic ketoacidosis (DKA) admitted to the pediatric intensive care unit. The study was carried out retrospectively by examining the patients admitted to the pediatric intensive care unit for the treatment of DKA. The ages of the patients ranged from 2 to 18 years. The patients with the following parameters were enrolled in the study: serum blood glucose>200 mg/dL, ketonuria presence, venous blood gas pH ≤7.1, bicarbonate <15. A total of 56 patients were included in the study with a mean age of 111.07 ± 51.13 months. The recovery time from DKA was 16.05 ± 6.25 h in the group with low lactate level and it was 13.57 ± 8.34 h in the group with high lactate level with no statistically significant difference. There was a negative correlation between lactate levels and the recovery time from DKA. Lactic acidosis is common in DKA, and unlike other conditions, such as sepsis, it is not always a finding of poor prognosis that predicts the severity of the disease or mortality. We think that high lactate may even protect against possible brain edema-cerebral damage in DKA.

Effect of Potassium Infusions on Serum Levels in Children during Treatment of Diabetic Ketoacidosis.

A retrospective study was done to determine the effect of potassium (K + ) infusions on serum levels in children admitted to the pediatric intensive care unit (PICU) with diabetic ketoacidosis (DKA). Eighty-two percent of 92 cases studied received 40 mEq/L K + infusion over the treatment period of median 13.0 (interquartile range [IQR]: 7-18) hours. The median K + value at the end of this period was 3.9 (IQR: 3.4-4.2) mEq/L. There were 31 data points of low K + values (<3.5 mEq/L) and 4 high values (>5.5 mEq/L) during this treatment period. The K + infusions of 40 mEq/L may be sufficient to normalize serum K + when treating DKA.

Treatment of paediatric diabetic ketoacidosis (DKA) with subcutaneous rapid-acting insulin: a UK centre, retrospective review of safety and efficacy data

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Diabetic Ketoacidosis Management in the Emergency Department: Implementation of a Protocol to Reduce Variability and Improve Safety.

Emergency departments (EDs) are the primary venue for diagnosis and initiation of treatment of diabetic ketoacidosis (DKA). Typically managed in an intensive care unit (ICU), in many medical centers, limited ICU bed availability necessitates DKA-extended ED management until sufficient improvement for admission to a non-ICU bed. Although DKA treatment is well established, coordinating safe and effective extended care in a busy ED is complex. Recurrent problems in this high-risk transition of care led us to improvement efforts. We studied the impact of a standardizing ED DKA management in two phases: rollout of a DKA pathway in our computerized order entry system followed by audit and feedback. We evaluated adherence, clinical process, operational, and safety measures following these interventions. Adherence to the pathway was initially slow, improving significantly after audit and feedback. We observed mixed improvements in clinical processes, no changes in operational metrics (as expected), and reductions in variability for several measures. There were no deteriorations and improvements in measures of safety, and a reduction in the number of adverse event reports in the postimplementation periods.

Methanol Poisoning as a Trigger for the Presentation of Diabetes Mellitus: A Case Report

Background : The clinical and laboratory manifestations of methanol poisoning and Diabetic Ketoacidosis (DKA) might be very similar. Case Presentation : A 15-year-old male, who lived in Mashhad, Iran, was referred to a medical toxicology center because of the loss of consciousness following the consumption of home-made alcohol. Laboratory tests revealed metabolic acidosis, the high blood levels of methanol, and ketonuria and glucosuria in urine analysis. The treatment of DKA and methanol poisoning was started simultaneously. Conclusion : Methanol poisoning, as physical stress or because of pancreatitis as a complication, could be a trigger for diabetes in susceptible individuals, and physicians should be aware of the similarity of presentation of these situations.

Sepsis in Latent Autoimmune Diabetes in Adults with Diabetic Ketoacidosis: A Case Report.

BACKGROUND:This case report intends to highlight the challenge in diagnosing type 1 diabetes on an adult patient. Latent Autoimmune Diabetes in Adult (LADA) types I diabetes Mellitus, which found in adulthood and characterised by progressive damage to pancreatic β cells that happened slowly. Incidence of LADA is around 2-12% of the total diabetes population. Sepsis in LADA patients will trigger diabetic ketoacidosis (DKA).CASE REPORT:We report a case of a 33-year-old woman patient presents with decreased consciousness accompanied by rapid and deep breathlessness for 1 day. Before, the patient complains of fever and cough. Physical examination found soporous, blood pressure 120/80 mmHg, pulse 110 x/minute, temperature 38.8°C, breathing 32 x/minute Kussmaul. Bronchovesicular breath crackles in both lower lung fields. leukocytes were 22,100/mm3, random blood glucose 638 mg/dL, urine ketone +++, HbA1C 17.2%, HOMA IR less than 2 units. C-peptide 0.3 ng/mL and GADAs 16.9 U/mL. Chest Xray indicated bronchopneumonia. Patients were diagnosed with diabetic ketoacidosis, LADA, and sepsis caused by bronchopneumonia. Patient treated with DKA management and sepsis. On the second day, the treatment of DKA was resolved and continued with the administration of short-acting insulin and regular long-acting.CONCLUSION:Sepsis in LADA with DKA requires fast and appropriate management. Further search is needed to diagnose LADA.

Initial management of diabetic ketoacidosis and prognosis according to diabetes type: a French multicentre observational retrospective study

BackgroundGuidelines for the management of diabetic ketoacidosis (DKA) do not consider the type of underlying diabetes. We aimed to compare the occurrence of metabolic adverse events and the recovery time for DKA according to diabetes type.MethodsMulticentre retrospective study conducted at five adult intermediate and intensive care units in Paris and its suburbs, France. All patients admitted for DKA between 2013 and 2014 were included. Patients were grouped and compared according to the underlying type of diabetes into three groups: type 1 diabetes, type 2 or secondary diabetes, and DKA as the first presentation of diabetes. Outcomes of interest were the rate of metabolic complications (hypoglycaemia or hypokalaemia) and the recovery time.ResultsOf 122 patients, 60 (49.2%) had type 1 diabetes, 28 (22.9%) had type 2 or secondary diabetes and 34 (27.9%) presented with DKA as the first presentation of diabetes (newly diagnosed diabetes). Despite having received lower insulin doses, hypoglycaemia was more frequent in patients with type 1 diabetes (76.9%) than in patients with type 2 or secondary diabetes (50.0%) and in patients with newly diagnosed diabetes (54.6%) (p = 0.026). In contrast, hypokalaemia was more frequent in the latter group (82.4%) than in patients with type 1 diabetes (57.6%) and type 2 or secondary diabetes (51.9%) (p = 0.022). The median recovery times were not significantly different between groups.ConclusionsRates of metabolic complications associated with DKA treatment differ significantly according to underlying type of diabetes. Decreasing insulin dose may limit those complications. DKA treatment recommendations should take into account the type of diabetes.

Effect of potassium infusion on serum levels in children during treatment of diabetic ketoacidosis

Purpose: Profound total body potassium deficits occur in children admitted with diabetic ketoacidosis (DKA). However, amount required to maintain normal serum concentration during treatment of DKA is largely unknown. At our institution 40 mEq/L and 60 mEq/L is administered during treatment of DKA, based on initial serum potassium. We aimed to determine the effect of these infusions on potassium levels in children during treatment of DKA. Methods: A retrospective chart review was conducted, after …

Effect of potassium infusion on serum levels in children during treatment of diabetic ketoacidosis

Effect of potassium infusion on serum levels in children during treatment of diabetic ketoacidosis

Correlation of acidosis-adjusted potassium level and cardiovascular outcomes in diabetic ketoacidosis: a systematic review.

BackgroundDuring the progress and resolution of a diabetic ketoacidosis (DKA) episode, potassium levels are significantly affected by the extent of acidosis. However, none of the current guidelines take into account acidosis during resuscitation of potassium level in DKA management, which may increase the risk of cardiovascular adverse events.ObjectiveTo assess literature regarding the adjustment of potassium level using pH to calculate pH-adjusted corrected potassium level, and to observe the relationship of cardiovascular outcomes with reported potassium level and pH-adjusted corrected potassium in DKA.MethodologySeven databases were searched from inception to January 2018 for studies which had reported people with diabetes developing diabetic ketoacidosis, in relation to prevalence or incidence, fluid resuscitation or potassium supplementation treatment, treatment or cardiovascular outcomes, and experimentation with DKA management or insulin. Quality of studies was evaluated using Cochrane Risk of Bias and Newcastle Ottawa Scale.ResultsForty-seven studies were included in qualitative synthesis out of a total of 10,292 retrieved studies. Forty-one studies discussed the potassium level and blood pH at the time of admission, ten studies discussed cardiovascular outcomes, and only four studies concurrently discussed potassium level, pH, and cardiovascular outcomes. Only two studies were graded as good on the Newcastle Ottawa Scale. The reported potassium level was well within normal range (5.8 mmol/L), whereas pH rendered patients to be moderately acidotic (7.13). Surprisingly, none of the included studies mentioned pH-adjusted corrected potassium level and, hence, this was calculated later. Although mean corrected potassium was within the normal range (3.56 mmol/L), 13 studies had corrected potassium below 3.5 mmol/L and five had it below 3.0 mmol/L. Nevertheless, with the exception of one study, none discussed cardiovascular outcomes in the context of potassium or pH-adjusted potassium level.ConclusionThe evidence surrounding cardiovascular outcomes during DKA episodes in light of a pH-adjusted corrected potassium level is scarce. A prospective observational, or preferably, an experimental study in this regard will ensure we can modify and enhance safety of existing DKA treatment protocols.

Via continuous hemodiafiltration treatment for severe diabetic ketoacidosis in 2 children

对2017年苏州大学附属儿童医院内分泌遗传代谢科和重症医学科收治的2例糖尿病酮症酸中毒危重患儿的临床表现、实验室检查及抢救治疗过程进行回顾性分析。例1，女，13岁5个月，诊断1型糖尿病、酮症酸中毒、急性肾损伤(3期)；例2，女，2个月8 d，诊断新生儿糖尿病、酮症酸中毒、高渗高血糖综合征，予常规补液、胰岛素降糖治疗效果不佳，行连续性血液透析滤过治疗后缓解；为明确病因，行基因检测，例2检出KCNJ11基因存在c.602G>A(p.R201H)杂合突变。提示对于儿童糖尿病酮症酸中毒危重患者，在常规补液、胰岛素降糖治疗效果不佳，合并其他器官功能损伤及顽固性酸中毒时，积极行连续性血液透析滤过治疗，可获得显著效果。

A Quality Initiative Reducing Adverse Outcomes in Pediatric Patients with DKA During Intrafacility Transit.

Introduction:Treatment of diabetic ketoacidosis (DKA) requires close and timely monitoring to prevent serious adverse events. This quality improvement project details how our institution improved blood glucose monitoring around hospital admission. The project aimed to increase the blood glucose assessments for children with DKA receiving insulin in the emergency department (ED) within 30 minutes before transitioning to an inpatient unit.Methods:We implemented a series of Plan-Do-Survey-Act (PDSA) cycles established by a multidisciplinary team for this project, with the primary outcome of obtaining the blood glucose level within 30 minutes before leaving the ED and secondarily preventing episodes of hypoglycemia. These PDSAs harnessed the electronic health record, to prompt and direct the medical staff, to improve blood glucose monitoring.Results:From March 2015 to November 2017, we saw 640 patients in our ED for DKA. Of these, we admitted 629 to the inpatient unit with treatment that included continuous infusion of insulin. Over this period, we increased blood glucose monitoring for these patients within 30 minutes before the transition from 56% to >90%. Following the final PDSA cycle, we observed no reported episodes of hypoglycemia.Conclusion:Using the functionality of the electronic health record, we showed significant, rapid, and sustained increases in compliance with the International Society for Pediatric and Adolescent Diabetes guideline by alerting ED staff caring for patients receiving continuous insulin around the time of care-team transitions. We believe that this program is easily replicable, cost-effective, and safety enhancing.

214-OR: Effects of Fluid Rehydration Strategy on Correction of Acidosis and Electrolyte Abnormalities in Children with Diabetic Ketoacidosis

Background: Fluid replacement to correct acidosis and electrolyte abnormalities is the cornerstone of treatment of diabetic ketoacidosis (DKA). We evaluated the rates of change in pH, pCO2, anion gap, Na, K, and Cl in children randomized to four DKA fluid treatment protocols. Methods: From a large study conducted by The Pediatric Emergency Care Applied Research Network we used data from 714 children &amp;lt;18 y old with moderate or severe DKA. In a 2-by-2 factorial design, we evaluated the effects of intravenous rehydration with 0.9% vs. 0.45% NaCl and fast vs. slow rate of fluid administration, after an initial 0.9% NaCl bolus. The fast arm assumed 10% dehydration - half replaced in 12 h + maintenance fluids, the other half replaced over subsequent 24 h + maintenance fluids. The slow arm assumed 5% dehydration replaced evenly over 48 hours + maintenance fluids. We tested for differences in the rate of change of laboratory values between treatments using stratified Van Elteren and Cochran Mantel Haenszel tests. Results: The median age, sex, and baseline laboratory characteristic of the patients did not differ by treatment arm. The rate of change of pH did not differ by the arm, however the rate of rise of pCO2 was more rapid in the fast vs. slow fluid arms during the initial 4 h. The rate of decrease in anion gap was more rapid in the fast vs. slow arms during the initial 4 h and 8 h (p&amp;lt;0.01 for all). Glucose-corrected Na remained steady for subjects assigned to 0.9% NaCl vs. those assigned to 0.45% NaCl whose glucose-corrected Na decreased at 4 and 8 h (p&amp;lt;0.01). K levels decreased and Cl increased more rapidly with 0.9% vs. 0.45% NaCl (p&amp;lt;0.01). Hyperchloremic acidosis developed in 46.1% of patients in the fast arms vs. 35.2% in the slow arms (p&amp;lt;0.01). Conclusions: In children treated for DKA, faster fluid administration led to more rapid normalization of anion gap and pCO2 than slower fluid rates. However, more rapid fluid rates were associated with increased frequency of hyperchloremic acidosis. Disclosure A. Rewers: None. N.D. Kuppermann: Other Relationship; Self; InsuCalc. M.J. Stoner: None. A. Garro: None. K. Quayle: None. J.E. Bennett: None. S. Myers: None. J.K. McManemy: None. L.E. Nigrovic: None. J.L. Trainor: None. L. Tzimenatos: None. M. Kwok: None. C.S. Olsen: None. T.C. Casper: None. S. Ghetti: None. N. Glaser: Consultant; Self; Bristol-Myers Squibb Company. Other Relationship; Self; Insucalc. Funding Eunice Kennedy Shriver National Institute of Child Health and Human Development

Severe hypokalaemia in diabetic ketoacidosis: a contributor to central pontine myelinolysis?

SummaryHypokalaemia at presentation of diabetic ketoacidosis is uncommon as insulin deficiency and metabolic acidosis shifts potassium extracellularly. However, hypokalaemia is a recognised complication of the management of diabetic ketoacidosis as insulin administration and correction of metabolic acidosis shifts potassium intracellularly. We describe the case of a 9-year-old girl with newly diagnosed type 1 diabetes mellitus presenting in diabetic ketoacidosis, with severe hypokalaemia at presentation due to severe and prolonged emesis. After commencing management for her diabetic ketoacidosis, her serum sodium and osmolality increased rapidly. However, despite maximal potassium concentrations running through peripheral access, and multiple intravenous potassium ‘corrections’, her hypokalaemia persisted. Seventy two hours after presentation, she became drowsy and confused, with imaging demonstrating central pontine myelinolysis – a rare entity seldom seen in diabetic ketoacidosis management in children despite rapid shifts in serum sodium and osmolality. We review the literature associating central pontine myelinolysis with hypokalaemia and hypothesise as to how the hypokalaemia may have contributed to the development of central pontine myelinolysis. We also recommend an approach to the management of a child in diabetic ketoacidosis with hypokalaemia at presentation.Learning points:Hypokalaemia is a recognised complication of treatment of paediatric diabetic ketoacidosis that should be aggressively managed to prevent acute complications.Central pontine myelinolysis is rare in children, and usually observed in the presence of rapid correction of hyponatraemia. However, there is observational evidence of an association between hypokalaemia and central pontine myelinolysis, potentially by priming the endothelial cell membrane to injury by lesser fluctuations in osmotic pressure.Consider central pontine myelinolysis as a complication of the management of paediatric diabetic ketoacidosis in the presence of relevant symptoms with profound hypokalaemia and/or fluctuations in serum sodium levels.We have suggested an approach to the management strategies of hypokalaemia in paediatric diabetic ketoacidosis which includes oral potassium supplements if tolerated, minimising the duration and the rate of insulin infusion and increasing the concentration of potassium intravenously (via central line if necessary).

Concurrent presentation of thyroid storm and diabetic ketoacidosis: a systematic review of previously reported cases

BackgroundSimultaneous development of thyroid storm and diabetic ketoacidosis (DKA) is a rare condition. The review aims to summarise its clinical presentation, investigation findings and treatment options.MethodsDatabases and reference lists of the selected articles were searched for case reports in English which describe concurrent presentation of thyroid storm and diabetic ketoacidosis. CARE guidelines were used for the quality assessment of the selected articles.ResultsTwenty-six cases from twenty-one articles were selected out of 198 search results. Western Pacific, and American regions contributed to 77% of the cases. Females were most affected (88%). Features of Graves’ disease like hyperthermia and tachycardia, gastrointestinal and neuro-psychiatric disturbances were the common clinical presentations. In most of the cases, previous diagnosis of diabetes mellitus preceded that of Graves’ disease (46%). Among patients having their drug compliance reported, all had poor compliance to their routine anti-thyroid (9/9) and anti-diabetic (2/2) agents. Moreover, in all cases where HbA1C (7/7) and T4 (16/16) were measured, the results were elevated and where TSH (17/17) was measured, the results were low. The recommended treatment for DKA and thyroid storm was used in most cases and methimazole was the thionamide of choice in the latest four cases reported. All cases survived except four (15%).ConclusionsConcurrent presentation of thyroid storm and diabetic ketoacidosis is rare but life-threatening. Therefore, efforts should be made to maximise patient compliance to anti-thyroid and anti-diabetic agents in treating such patients.

Robert Tattersall, a Diabetes Physician Ahead of His Time.

The clinical and research landscape in the U.K. was dominated in the 1970s and 1980s by clinician scientists. Many worked as full-time employees of the National Health Service rather than universities. During a period when health services were under less pressure than today, they were able to find sufficient time to design clinical studies to answer important research questions that occurred to them while treating their patients. They also inspired a generation of junior colleagues to join their specialty and become clinical researchers themselves. In many ways it was a golden age for clinical diabetes research in Britain. Clinician scientists within the diabetes field who attained international stature include John Ward and Peter Watkins, who made major advances in diabetic neuropathy; Harry Keen, who pioneered the use of insulin pumps and introduced microalbuminuria as a sensitive test for diabetic nephropathy; and George Alberti (1), who demonstrated how low-dose insulin could be used as a practical and effective treatment for diabetic ketoacidosis. But one individual who epitomized the clinician researcher was Robert Tattersall. His contributions were many and varied and led to improved care worldwide, while the diabetes unit he developed in Nottingham came to be recognized as one of the best in the country. Robert was born in London in July 1943, the only child of Stanley Tattersall and Edith Booth, who were psychiatrists. He was brought up in the grounds of Bucks County Mental Hospital, where his father worked in a senior administrative position. He was educated at Charterhouse School (a private boarding school) and trained in medicine at the University of Cambridge and St Thomas’ Hospital, London. After qualification he undertook his first junior post at St Thomas’ before moving to Nottingham General Hospital, where he met his future wife, Bridget Jack, while they were both doctors in …

Diabetic Ketoacidosis Treatment Outcome and Associated Factors Among Adult Patients Admitted to Medical Wards of Adama Hospital Medical College, Oromia, Ethiopia

Diabetic Ketoacidosis (DKA) is one of the most serious acute complications of diabetes mellitus. The mortality rate remains high in developing countries and among misdiagnosed and treated patients. Therefore targeting early diagnosis and effective treatment programs is vital to save the life of patients. The aim of the study is to assess diabetic ketoacidosis treatment outcome and associated factors among adult patients at Adama Hospital Medical College emergency department and medical wards, Oromia region, Ethiopia. Cross sectional study based on record review of 357 adult diabetic ketoacidosis patients was selected using simple random sampling. Data was collected using checklist from medical registrations. The data was entered and analyzed using SPSS version 20 and EPI-info version 7 statistical packages. Majority of the patients (65.30%) had two or more episodes of diabetic ketoacidosis and the main reasons for recurrent diabetic ketoacidosis were infectious illness (69.50%) and insulin discontinuation (14.80%). Regarding treatment outcomes of diabetic ketoacidosis patients, majority of them (84.90%) discharged with improved. Those diabetic ketoacidosis patients treated with more than six liters fluid replacement in the 1st 24 hours had better treatment outcome by two times as compared to less than three liters fluid replacement (AOR=2.41 (1.58-10.02). Similarly, those patients who got more than sixty international unit insulin doses in the 1st 24hrs had better treatment outcome by ten times (AOR=10.68 (3.88- 20.64)) when compared to less than forty international unit insulin administration. In addition, DKA patients who got supplemental potassium showed five times treatment outcome improvement (AOR= 5.30 (2.11-13.32) than for those potassium replacement was not done. Even if majority of diabetic ketoacidosis patients treated at Adama Hospital Medical College emergency room and medical wards were discharged with improvement, early treatment of infection, ample fluid replacement and insulin dose adjustment during illness need to be encouraged.

Diabetic Ketoacidosis Treatment Outcome and Associated Factors Among Adult Patients Admitted to Medical Wards of Adama Hospital Medical College, Oromia, Ethiopia

Diabetic Ketoacidosis (DKA) is one of the most serious acute complications of diabetes mellitus. The mortality rate remains high in developing countries and among misdiagnosed and treated patients. Therefore targeting early diagnosis and effective treatment programs is vital to save the life of patients. The aim of the study is to assess diabetic ketoacidosis treatment outcome and associated factors among adult patients at Adama Hospital Medical College emergency department and medical wards, Oromia region, Ethiopia. Cross sectional study based on record review of 357 adult diabetic ketoacidosis patients was selected using simple random sampling. Data was collected using checklist from medical registrations. The data was entered and analyzed using SPSS version 20 and EPI-info version 7 statistical packages. Majority of the patients (65.30%) had two or more episodes of diabetic ketoacidosis and the main reasons for recurrent diabetic ketoacidosis were infectious illness (69.50%) and insulin discontinuation (14.80%). Regarding treatment outcomes of diabetic ketoacidosis patients, majority of them (84.90%) discharged with improved. Those diabetic ketoacidosis patients treated with more than six liters fluid replacement in the 1st 24 hours had better treatment outcome by two times as compared to less than three liters fluid replacement (AOR=2.41 (1.58-10.02). Similarly, those patients who got more than sixty international unit insulin doses in the 1st 24hrs had better treatment outcome by ten times (AOR=10.68 (3.88- 20.64)) when compared to less than forty international unit insulin administration. In addition, DKA patients who got supplemental potassium showed five times treatment outcome improvement (AOR= 5.30 (2.11-13.32) than for those potassium replacement was not done. Even if majority of diabetic ketoacidosis patients treated at Adama Hospital Medical College emergency room and medical wards were discharged with improvement, early treatment of infection, ample fluid replacement and insulin dose adjustment during illness need to be encouraged.

SAT-594 A Metabolic Muddle : Thyrotoxicosis Causing Diabetic Ketoacidosis

INTRODUCTION: Diabetic Ketoacidosis (DKA) is a metabolic state developing in diabetic patients whenever a stressor shifts the metabolism towards ketogenesis with resultant metabolic acidosis. Common stressors for DKA are infections and medication non-compliance. We present a peculiar case of DKA which was precipitated by thyrotoxicosis. CASE DESCRIPTION: 32-year-old female with past medical history of Type 1 Diabetes Mellitus presented for evaluation of nausea, vomiting and chest pain. She reported as being compliant with her insulin regimen. Physical examination showed rapid breathing and acetone breath. Initial blood tests revealed elevated blood sugars at 745 MG/DL with a high anion gap metabolic acidosis. Beta hydroxybutyrate levels were elevated suggesting diabetic ketoacidosis. Rest of the workup to identify the precipitating cause, including urinalysis, EKG, Chest X ray had been negative. Another striking feature noted on patient's examination was bilateral exophthalmos. No thyroid enlargement was appreciated. A thyroid function panel was ordered which demonstrated elevated free T4 at 3.42 NG/DL (normal range 0.7-1.9 NG/DL), T3 at 26.01 PG/ML (normal range 1.7-3.71 PG/ML) and a depressed TSH level <0.01 mcIU/mL (normal range 0.35-.5 mcIU/ml) suggesting primary hyperthyroidism. Our patient improved upon administration of IV fluids and insulin with resultant closure of anion gap and resolution of DKA. Tachycardia persisted despite the resolution of DKA. Treatment was begun with propylthiouracil and propranolol to control thyrotoxicosis with remarkable improvement at the time of discharge. DISCUSSION: Treatment of Diabetic Ketoacidosis requires a thorough investigation of the precipitating event. In clinical practice, the most common triggers are noted to be infections like pneumonia and urinary tract infections, missed or inadequate insulin dose and myocardial infarction. Hyperthyroidism is rarely considered as a culprit for the same. In literature, there is only mention of few cases of hyperthyroidism causing DKA. Hyperthyroidism affects glucose and insulin metabolism in multiple ways. In untreated hyperthyroidism, proinsulin processing becomes abnormal resulting in a reduced C peptide to pro insulin ratio. Hyperthyroidism also leads to increased glucose absorption in the intestinal tract. Lastly, excessive thyroid hormone activity reduces the half-life of insulin via increased degradation into biologically inactive molecules. Our case emphasizes the need to consider thyrotoxicosis as an independent risk factor for development of DKA in appropriate clinical settings, especially when tachycardia persists despite resolution of DKA and infection has been ruled out. Women with Type 1 Diabetes have been found to have a higher prevalence of Graves’ disease. Correction of underlying hyperthyroidism decreases the insulin requirements in these patients.

Treatment of acute diabetic metabolic crises in adults (Update 2019) : Hyperglycemic hyperosmolar state and ketoacidotic metabolic disorders

Diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) represent potentially life-threatening situations in adults. Therefore, rapid comprehensive diagnostic and therapeutic measures with close monitoring of vital and laboratory parameters are required. The treatment of DKA and HHS is essentially the same and replacement of the mostly substantial fluid deficit with several liters of aphysiological crystalloid solution is the first and most important step. Serum potassium concentrations need to be carefully monitored to guide its substitution. Regular insulin or rapid acting insulin analogues can be initially administered as an i.v. bolus followed by continuous infusion. Insulin should be switched to subcutaneous injections only after correction of the acidosis and stable glucose concentrations within an acceptable range.