Management Of Diabetic Ketoacidosis Research Articles

Addressing olanzapine-induced diabetic ketoacidosis in a major depressive disorder case

This case study highlights a critical incidence of olanzapine-induced diabetic ketoacidosis (DKA) in a 36-year-old female patient treated for major depressive disorder with psychotic features. The patient developed severe DKA after the initiation of olanzapine, despite initially normal metabolic parameters and a low starting dose. This report underscores the acute metabolic derangement facilitated by olanza- pine, necessitating a comprehensive and urgent medical approach. The clinical intervention involved discontinuing olanzapine and initiating a multidisciplinary treatment strategy, which included medical management of DKA and psychiatric adjustments using alternatives with a lower metabolic risk. This case emphasizes the necessity for regular metabolic monitoring and the potential need for tailored psychiatric medication strategies to prevent severe side effects, highlighting the unpredictability of antipsychotic- induced metabolic disturbances and advocating for a holistic, patient-centered approach in psychiatric care.

Sodium bicarbonate and intubation in severe diabetic ketoacidosis: are we too quick to dismiss them?

Management of diabetic ketoacidosis (DKA) has internationally established guidelines. However, management of severe, refractory DKA with multiple contributors to acidosis, and management of DKA in patients with altered mentation, remain ambiguous. Use of sodium bicarbonate and intubation in DKA are unpopular treatment practices, but warrant consideration in these unique clinical scenarios. This paper describes a 61-year-old Sri Lankan female who presented with severe DKA, seizures and altered level of consciousness. In her case, the acidosis was secondary to DKA, hyperlactatemia, hyperchloraemic acidosis and acute kidney injury (AKI). Intravenous sodium bicarbonate was used in the management of acidosis. She was intubated due to altered level of consciousness with inadequate respiratory drive to compensate for metabolic acidosis. The outcome in her case was favorable. Intravenous sodium bicarbonate in DKA should be considered for patients with severe, refractory acidosis with hemodynamic instability, hyperkalemia and compounding acidosis due to normal anion gap acidosis or AKI. Intubation should be considered for patients with obtunded mentation unable to achieve respiratory compensation and obtunded mentation where reversal of DKA is unlikely to improve consciousness. Both strategies should be personalized with consideration of individual risk vs benefit.

Assessing variation in complications and outcomes of diabetic ketoacidosis management in the United Kingdom: a multicentre quality improvement initiative

Assessing variation in complications and outcomes of diabetic ketoacidosis management in the United Kingdom: a multicentre quality improvement initiative

Evaluating adherence to national diabetic ketoacidosis management guidelines within six hospitals across the UK

Evaluating adherence to national diabetic ketoacidosis management guidelines within six hospitals across the UK

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.

Guidelines for the management of diabetic ketoacidosis (DKA) have been poorly adopted and implemented, resulting in a lack of improvement in outcomes

Guidelines for the management of diabetic ketoacidosis (DKA) have been poorly adopted and implemented, resulting in a lack of improvement in outcomes

Effectiveness of a standardized scenario in teaching the management of pediatric diabetic ketoacidosis (DKA) to residents: a simulation cross-sectional study

BackgroundDiabetic ketoacidosis (DKA) is a frequent manifestation at the onset of type 1 diabetes mellitus in children, possibly associated with a wide range of complications, often as a consequence of wrong or delayed treatment. Due to its complex and risky management, direct exposure to real situations alone is not sufficient to achieve adequate skills in pediatric DKA for residents. Simulation could be a valuable aid, allowing to practice a standardized scenario of a complex real-world situation. We aimed to test the effectiveness of a standardized scenario of pediatric DKA in teaching its recognition and treatment.MethodsWe develop a standardized scenario able to guide step-by-step the learners through the flowchart of DKA management and considering alternative evolutions in the case of possible deviations from guidelines. It was a real-life simulation with the use of a high-fidelity pediatric simulator. It was played by 78 pediatrics 20 and emergency medicine residents. At the end of the simulation, a validated questionnaire was administered to collect feedback from participants regarding the impact of the simulation on learning. All materials to reproduce the DKA scenario are provided.ResultsOverall, the scenario was rated as realistic (mean score 4.37 ± 0.68, from 1 to 5) and relevant to professional training (4.72 ± 0.47), useful in increasing confidence in interpreting laboratory tests (3.97 ± 0.65), group organization and communication strategies (3.49 ± 0.94), and managing the treatment of DKA (3.46 ± 0.92).ConclusionsThe use of a standardized scenario of pediatric DKA may be a valid tool to reinforce theoretical knowledge in residents, both in pediatrics and in emergency medicine, and to directly and safely practice pediatric DKA management.

A Re-audit of the Management of Diabetic Ketoacidosis (DKA): The Importance of the Seven-Day Working Inpatient Diabetes Specialist Nurse Service.

Background Diabetic ketoacidosis (DKA) is a life-threatening metabolic emergency due to insulin deficiency in patients with diabetes mellitus. The United Kingdom national survey and local audits of the management of DKA have revealed several areas of suboptimal care, and room for improvement, necessitating the need for intensified education, updating local guidelines, and increased recruitment of seven-day working inpatient diabetes specialist nurses. Therefore, this project aimed to re-audit our adherence to the DKA treatment guidelines. Methodology A retrospective re-audit examining patient admissions with DKA between October 2022 and September 2023. A list of 18 standards/criteria, adopted from the Joint British Diabetes Society (JBDS) DKA treatment guidelines was used for this re-audit. Results were compared with that of the previous audit. Results We had 126 patients admitted with DKA between October 2022 and September 2023. There were 62 males and 64 females with an average (range) age of 46.5 (19-92) years. Eighty percent had type 1 diabetes, and common precipitating factors for admission included infection and poor adherence to insulin treatment. The median (IQR) length of hospital stay was 2.1 (1.0-5.1) days. Compared to the previous audit, improvements occurred in 11 of 18 standards/criteria. This included timely commencement of intravenous fluids and fixed-rate insulin, commencing glucose infusion to prevent hypoglycemia,potassium replacement, continuation of long-acting insulin during treatment, timely conversion to variable-rate insulin infusion, and conversion to the usual subcutaneous insulin regimen. Additionally, 124 patients (98.4%) were reviewed at least once by the inpatient diabetes specialist nurses (DSN) during their admission. Complications of treatment, namely, iatrogenic hypoglycemia and transient hypokalemia occurred in 13 (10.3%) and 40 (31.7%) patient admissions, respectively. Conclusions This re-audit demonstrated improved adherence to the guidelines during several steps in the management of DKA. It also demonstrated room for improvement regarding other aspects of care. The importance of continued education, accurate documentation, and the presence of seven-day working inpatient DSN cover cannot be overemphasized.

Evaluation of a Protocol Change Promoting Lactated Ringers Over Normal Saline in the Treatment of Diabetic Ketoacidosis.

Current guidelines recommend normal saline (NS) for fluid resuscitation in the management of patients presenting with diabetic ketoacidosis (DKA). However, previous prospective studies have demonstrated improvement in patient-specific outcomes, including time to DKA resolution, when balanced crystalloid fluids are used. We conducted a single institution, retrospective cohort study of adult patients admitted with DKA before and after a protocol change within our institution, which shifted the default resuscitative and maintenance fluid in our DKA management protocol from NS to lactated Ringer's solution (LR). The primary outcome was time from DKA clinical presentation until DKA resolution. The secondary outcome was time to discontinuation of DKA protocol insulin drip. Of 246 patients meeting inclusion criteria, 119 were in the NS group (preprotocol change, where NS was the default resuscitative fluid) and 127 to the LR group (postprotocol change, where LR was the default resuscitative fluid). Time to DKA resolution was significantly decreased in the LR group (mean = 17.1 hours; standard deviation [SD] = 11.0) relative to the NS group (mean = 20.6 hours; SD = 12.2; P = .02). Duration of DKA protocol insulin drip was shorter in the LR group (mean = 16.0 hours; SD = 8.7) compared with the NS group (mean = 21.4 hours; SD = 12.5; P < .001). In this retrospective cohort study, protocolized DKA intravenous fluid management with LR resulted in shorter time to resolution of DKA and reduced duration of DKA protocol insulin drip.

Revised one-bag IV fluid protocol for pediatric DKA: a feasible approach and retrospective comparative study.

This study compared the effectiveness of the traditional and revised one-bag protocols for pediatric diabetic ketoacidosis (DKA) management. This single-center retrospective cohort study included children diagnosed with DKA upon admission between 2012 and 2019. Our institution reevaluated and streamlined the traditional one-bag protocol (revised one-bag protocol). The revised one-bag protocol rehydrated all pediatric DKA patients with dextrose (5 g/100 ml) containing 0.45% NaCl at a rate of 3500 ml/m2 per 24 h after the first 1 h bolus of normal saline, regardless of age or degree of dehydration. This study examined acidosis recovery times and the frequency of healthcare provider interventions to maintain stable blood glucose levels. The revised one-bag protocol demonstrated a significantly shorter time to acidosis recovery than the traditional protocol (12.67 and 18.20 h, respectively; p < 0.001). The revised protocol group required fewer interventions for blood glucose control, with an average of 0.25 dextrose concentration change orders per patient, compared to 1.42 in the traditional protocol group (p < 0.001). Insulin rate adjustments were fewer in the revised protocol group, averaging 0.52 changes per patient, vs. 2.32 changes in the traditional protocol group (p < 0.001). The revised one-bag protocol for pediatric DKA is both practical and effective. This modified DKA management achieved acidosis recovery more quickly and reduced blood glucose fluctuations compared with the traditional one-bag protocol. Future studies, including randomized controlled trials, should assess the safety and effectiveness of the revised protocol in a broad range of pediatric patients with DKA.

Continuous Ketone Monitoring via Wearable Microneedle Patch Platform.

Ketone bodies (KBs), especially β-hydroxybutyrate (BHB), have gained tremendous attention as potential biomarkers as their presence in bodily fluids is closely associated with health and wellness. While a variety of blood fingerstick test strips are available for self-testing of BHB, there are major needs for wearable devices capable of continuously tracking changing BHB concentrations. To address these needs, we present here the first demonstration of a wearable microneedle-based continuous ketone monitoring (CKM) in human interstitial fluid (ISF) and illustrate its ability to closely follow the intake of ketone drinks. To ensure highly stable and selective continuous detection of ISF BHB, the new enzymatic microneedle BHB sensor relies on a gold-coated platinum working electrode modified with a reagent layer containing toluidine blue O (TBO) redox mediator, β-hydroxybutyrate dehydrogenase (HBD) enzyme, a nicotinamide adenine dinucleotide (NAD+) cofactor, along with carbon nanotubes (CNTs), chitosan (Chit), and a poly(vinyl chloride) (PVC) outer protective layer. The skin-worn microneedle sensing device operates with a miniaturized electrochemical analyzer connected wirelessly to a mobile electronic device for capturing, processing, and displaying the data. Cytotoxicity and skin penetration studies indicate the absence of potential harmful effects. A pilot study involving multiple human subjects evaluated continuous BHB monitoring in human ISF, against gold standard BHB meter measurements, revealing the close correlation between the two methods. Such microneedle-based CKM offers considerable promise for dynamic BHB tracking toward the management of diabetic ketoacidosis and personal nutrition and wellness.

A Narrative Review on Diabetic Ketoacidosis in Children.

Diabetic ketoacidosis (DKA) is a life-threatening complication in children with diabetes mellitus. There are considerable differences in the management approaches for DKA between different countries. One of the main areas of differences between guidelines is the administration of fluid, with most guidelines adopting a restrictive approach. This is based on the concern over cerebral oedema, a lethal sequela allegedly to be caused by excessive fluid administration. However, in recent years, new clinical studies suggest that there is no causal relationship between intravenous fluid therapy and DKA-related cerebral injury. The British Society of Paediatric Endocrinology updated its guideline in 2020 to adopt a more permissive approach to fluid administration, which has sparked controversy among some paediatricians. The purpose of this article is to provide a narrative review on the management of DKA. A PubMed search was performed with clinical queries using the key term "diabetic ketoacidosis". The search strategy included randomized controlled trials, clinical trials, meta-analyses, observational studies, guidelines, and reviews. The search was restricted to English literature and the age range of 18 years and younger. Moreover, we reviewed and compared major guidelines. The management of DKA involves early recognition, accurate diagnosis, meticulous fluid and insulin treatment with close monitoring of blood glucose, ketones, electrolytes, renal function, and neurological status. There is still limited clinical evidence to support either a restrictive or permissive approach in the fluid management of paediatric DKA patients. Clinicians should exercise caution when applying different guidelines in their clinical practice, considering the specific circumstances of individual paediatric patients.

Management and Challenges of Diabetic Ketoacidosis in Pregnancy: A Multidisciplinary Approach

Management and Challenges of Diabetic Ketoacidosis in Pregnancy: A Multidisciplinary Approach

Diabetic Ketoacidosis in Type 1 Diabetes Mellitus

Introduction: Diabetic ketoacidosis (DKA) is a state of metabolic decompensation/disorder characterized by the triad of hyperglycemia, acidosis and ketosis, caused by absolute or relative insulin deficiency and increased counter-regulatory hormones. Immediate therapy in DKA patients determines the patient's prognosis Case Report: A 19-year-old male treated in the internal medicine ward of Dr. M djamil Padang with diabetic ketoacidosis, type 1 DM, and Abscess capitis. The patient was treated with rehydration and intravenous insulin infusion can show clinical improvement. Conclusion: The diagnosis in patients is based on anamnesis, physical examination and supporting examinations. Immediate therapy is needed in the management of DKA in patients. After DKA is resolved, look for the causes of the risk of DKA. On the third day of treatment the patient's condition improved clinically and the laboratory.

Chloride as a Prognostic Factor in Children with Diabetic Ketoacidosis: A Retrospective Cohort Study

Introduction: In the management of Diabetic Ketoacidosis (DKA), importance is given to electrolytes such as sodium and potassium, but not chloride. There is evidence that high chloride levels can lead to Acute Kidney Injury (AKI). However, chloride as a prognostic factor has not been thoroughly investigated. Aim: To evaluate the role of chloride as a prognostic factor in the treatment of children with DKA. Materials and Methods: This retrospective cohort study collected data from 22 children with severe DKA, aged under 14 years, admitted to the Department of Paediatrics, SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India, between January 2016 and October 2020. Data included demographic details, blood glucose, arterial blood gas, renal function tests, serum electrolytes at admission and at 24 hours, and outcome parameters. All children received regular monitoring and standard treatment as per the International Society for Paediatric and Adolescent Diabetes (ISPAD) guidelines. The children were divided into two groups: Recovery within 48 hours (Group-A) and more than 48 hours (Group-B). Electrolyte and renal parameters after 24 hours of treatment were compared. Univariate analysis was performed using Statistical Package for Social Sciences (SPSS) version 21.0. Student's t-test, Chisquare test, and odds ratio were used for statistical analysis. A p-value of &lt;0.05 was considered significant. Results: Among the 22 children, 50% recovered within 48 hours, while the remaining half took more than 48 hours. A total of 13 had hyperchloraemia at 24 hours (59%). The mean serum chloride at 24 hours was 115.91 mmol/L in Group-B compared to 106.09 mmol/L in Group-A (p=0.0079*). Two developed AKI, requiring renal replacement therapy and ventilatory support, and eventually died. Conclusion: In the present study, children with severe DKA who developed hyperchloraemia after 24 hours of admission, following fluid resuscitation with 0.9% normal saline and subsequent standard treatment, took a longer time to recover

Treatment Outcome and Associated Factors among Type 1 Diabetic Children Admitted with DKA in Bahir Dar City Public Referral Hospital, Northwest, Ethiopia: A Cross-sectional Study.

Background. Outcomes that should be measured during diabetic ketoacidosis management is crucial. However, data associated to this was limited in Ethiopia. Methods. A cross-sectional study was conducted among children with diabetic keto acidosis between 2016 and 2021.Data were stored in Epi-data version 4.6 and exported into STATA 14.0 software for analysis. The association between independent variables and length of hospital stay was assessed using binary logistic regression. Finally, variables with P-value <.05 were considered statistically significant. Result. Median length of hospital stay was 8 ± 6.2 days. Majority of patients (97.5%) improved and discharged. Factors that affected longer hospital stay were Residence(aOR = 4.31;95% CI = 1.25-14.80),family history of diabetes (aOR = 0.12; 95% CI = 0.02-0.64), glycemia at admission (aOR = 1.01; 95% CI = 1.00-1.02),insulin skipping (aOR = 0.08; 95% CI = 0.01-0.98), abdominal pain (aOR = 4.28; 95% CI = 1.11-15.52) and time in which the patient get out of diabetic ketoacidosis(aOR = 6.39; 95% CI = 1.09-37.50). Conclusion. Majority of patients showed improvement and discharged to homes after a long hospital stay. Majority of patients resolved from diabetic ketoacidosis between 24 and 48 hours.

Management of diabetic ketoacidosis in internal medicine: insulin protocols, electrolyte balance, and clinical outcomes

Diabetic ketoacidosis (DKA) is a critical complication of diabetes mellitus (DM), characterized by hyper-glycemia, acidosis, and ketosis. It poses a substantial risk of morbidity and mortality, especially in type 1 DM patients. DKA can be triggered by various factors, including insulin deficiency, infections, alcohol abuse, and other medical conditions. Hospital admissions for DKA are increasing, with mortality rates of up to 5-9%, often linked to severe underlying illnesses and complications such as myocardial infarction and stroke. Effective DKA management involves rehydration, correction of electrolyte imbalances, insulin administration, and addressing precipitating factors. Fluid resuscitation with isotonic saline is vital to restore hydration, and continuous intravenous insulin infusion is the preferred method to control blood glucose and suppress ketone production. Electrolyte imbalances, particularly potassium, sodium, phosphate, and magnesium, require careful monitoring and correction. Clinical outcomes in DKA management include resolving acidosis, normalizing blood glucose, and restoring electrolyte balance, all while achieving and maintaining clinical stability. Complications like cerebral edema and acute respiratory distress syndrome can significantly impact the prognosis. Long-term considerations encompass diabetes management, patient education, and follow-up care.

Management of Critically Ill Patients with Severe Diabetic Ketoacidosis and Acute Renal Failure: A Case Report

Background: Diabetic ketoacidosis (DKA) is one of the hyperglycemic crises related to diabetes. The main problem in DKA is ketogenesis, a metabolic process that increases the production and decreases the utilization of ketones. DKA is characterized by a biochemical triad such as hyperglycemia, ketonemia, and high anion gap metabolic acidosis. Management of DKA needs to be carried out appropriately and immediately because it may lead to diabetic coma and death.&#x0D; Case presentation: A 38-year-old woman had decreased consciousness due to metabolic encephalopathy as a complication of severe DKA. The metabolic derangement shows an overlapping high anion gap metabolic acidosis and non-anion gap metabolic acidosis. This case is complicated by acute renal failure. The patient also had been in a hypovolemic state, causing pre-renal acute kidney injury. We treat the patient using a balanced solution to correct hypovolemia. Sonography of the vena cava and blood lactate levels are used to guide fluid resuscitation. We intubate and control the patient's breathing to reduce the metabolic demand. We titrate the insulin infusion until the ketogenesis process is abolished. Antibiotics are given based on sputum culture.&#x0D; Conclusion: Acute renal failure (ARF) is a rare but potentially fatal complication of diabetic ketoacidosis (DKA). Early recognition and aggressive treatment of ARF during DKA may improve the prognosis of these patients.

The impact of pediatric intensivists on the management of pediatric diabetic ketoacidosis in pediatric intensive care units

IntroductionThe impact of pediatric intensivists on managing pediatric patients with diabetic ketoacidosis (DKA) remains unknown. This study aimed to evaluate the impact of pediatric intensivists on outcomes in pediatric intensive care units (PICUs).MethodsThis was a two-institution retrospective study of patients with DKA admitted to the PICU between 2012 and 2023. Pediatric patients (< 19 years of age) were included if they met the moderate to severe DKA criteria on PICU admission. The patients were subsequently divided into two groups based on the presence or absence of a pediatric intensivist. The primary outcome was the PICU length of stay (LOS). Secondary outcomes were adverse events during DKA treatment, hospital LOS, and mortality.ResultsFifty-two patients admitted to the PICU with a median age of 13.00 years (range, 0–18 years) were included; 32 (61.54%) were female. Patients managed by pediatric intensivists had significantly shorter PICU LOS (2.52 vs. 3.69 days, p < 0.05). Also, adverse events during DKA treatment were significantly decreased in the high-intensity group compared to the low-intensity group (12.50% vs. 50.00%, p < 0.05).ConclusionsHigh-intensity ICU staffing was associated with shorter PICU LOS and lower adverse events in pediatric patients with DKA. Our results suggest that dedicated pediatric intensivists can improve outcomes of critically ill pediatric patients with DKA.

Management of diabetic ketoacidosis in 0 to 16 years presenting to the Southern Health and Social Care Trust between January 2020 and September 2022

Management of diabetic ketoacidosis in 0 to 16 years presenting to the Southern Health and Social Care Trust between January 2020 and September 2022