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High-Yield Facts

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  • Diabetic ketoacidosis (DKA) is a complex endocrine condition caused by an absolute or relative lack of insulin. It is characterized by hyperglycemia, dehydration, ketosis, and metabolic acidosis.

  • DKA is often insidious in onset with slow progression of the illness.

  • Definition of DKA by biochemical criteria includes the following:

    • Hyperglycemia: Blood glucose >200 mg/dL

    • Venous pH <7.3 or bicarbonate <15 mmol/L

    • Ketonemia and ketonuria

  • In type 2 diabetes mellitus, hyperglycemic hyperosmolar state (HHS) can occur and is defined by the following:

    • Plasma glucose concentration >600 mg/dL

    • Arterial pH >7.30

    • Serum bicarbonate >15 mmol/L

    • Small ketonuria and absent or mild ketonemia

    • Serum osmolarity ≥320 mOsm/kg

    • Stupor or coma

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Treatment of DKA consists of rapid assessment, replacement of the patient's fluid and electrolyte deficit, and reversal of the central pathophysiologic process by the administration of insulin.

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The initial fluid resuscitation is with normal saline at a dose of 20 mL/kg over 1 to 2 hours. After the initial bolus, the patient's cardiovascular status is reevaluated and a second bolus may be administered.

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An initial bolus of insulin is unnecessary and can increase the risk for cerebral edema. The insulin infusion dose is 0.1 U/kg/h and this should continue till resolution of DKA (pH >7.3, bicarbonate >15 mmol/L).

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Potassium replacement therapy is started once normal or low serum potassium is ensured and urine output is established. The usual dose of potassium is twice-daily maintenance or 3 to 4 mEq/kg per 24 hours provided as 40 mEq/L in the IV fluids, with half as potassium chloride or potassium acetate and half as potassium phosphate.

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Cerebral edema occurs in 0.5% to 0.9% of DKA patients and the mortality rate is 21% to 24%. The predisposing factors are younger age, new onset diabetes, and longer duration of symptoms.

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Newborns and young infants with hypoglycemia may be asymptomatic or may manifest nonspecific symptoms. Older children exhibit more classic symptoms of hypoglycemia, including sweating, tachycardia, tremor, anxiety, tachypnea, and weakness.

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Treatment of Hypoglycemia
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  • In newborns, give 10% dextrose 2 mL/kg (0.2 g/kg) as a bolus, followed by infusion at 6 to 9 mg/kg/min

  • In children, give 10% dextrose at 5 mL/kg (0.5 g/kg) as a bolus, followed by continuous infusion at 6 to 9 mg/kg/min

  • If an IV line is not possible, then give glucagon 0.03 mg/kg (maximum dose 1 mg) subcutaneously

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Admission of the hypoglycemic patient is indicated when there is no obvious cause, toxic ingestion as with oral hypoglycemic agents is suspected, administration of long-acting insulin was the cause, or if there are persistent neurological deficits.

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Diabetic Ketoacidosis

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DKA is a complex endocrine condition caused by an absolute or relative lack of insulin. It is characterized by hyperglycemia, dehydration, ketosis, and metabolic acidosis.

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Epidemiology
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The annual ...

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