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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 diabetic ketoacidosis (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 10 to 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 starting 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 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, and if there are persistent neurological deficits.

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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 incidence of DKA in the United States ranges from 4.6 to 8 episodes per 1000 ...

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