The management of diabetic ketoacidosis can be challenging in high-risk patients.Recent studies have reported a significant increase in diabetic ketoacidosis hospitalization rates.While managing this high-risk conditi...The management of diabetic ketoacidosis can be challenging in high-risk patients.Recent studies have reported a significant increase in diabetic ketoacidosis hospitalization rates.While managing this high-risk condition,patient factors and comorbidities should be given careful attention and consideration.Factors like pregnancy,renal disease,cardiac disease,older age,and use of sodium-glucose cotransporter-2 inhibitors all impact the treatment approach,and tailored management strategies are required.Particularly in children,specialized treatment and care during a diabetic ketoacidosis episode is necessary due to its long-term neurological consequences.However,guidelines often lack adequate recommendations about the approach to manage complex patients with specific conditions and comorbidities.Furthermore,there are still controversies around certain aspects of diabetic ketoacidosis management,and additional investigations are needed to determine the best management options.We aim to address these special conditions and provide an approach to manage complex patients with specific conditions and co-morbidities.展开更多
This study reports a case of a 63-year-old female patient who developed euglycemic diabetic ketoacidosis(euDKA)within 24 h adding Empagliflozin.Upon admission,the patient's fasting blood glucose was 14.7 mmol/L an...This study reports a case of a 63-year-old female patient who developed euglycemic diabetic ketoacidosis(euDKA)within 24 h adding Empagliflozin.Upon admission,the patient's fasting blood glucose was 14.7 mmol/L and glycated hemoglobin(HbA1c)was 7.9%.She had been using insulin combined with repaglinide for long-term blood glucose control.On the next day after initiating Empagliflozin,persistent positive urine ketones were detected,with blood glucose fluctuating between 7.8-14.7 mmol/L.Serum bicarbonate was normal(32.0 mmol/L),and there were no typical symptoms of acidosis.After discontinuing Empagliflozin,receiving intravenous fluid rehydration,and low-dose insulin therapy,urine ketones gradually turned negative.This case suggests that in clinical practice,it is necessary to achieve a precise balance between cardiovascular benefits and metabolic risks,adhering to the principle of individualized medication.展开更多
BACKGROUND Type 1 diabetes is an autoimmune disease leading to insulin deficiency,and it is mainly diagnosed in young adults.One of the major acute complications of type 1 diabetes is diabetic ketoacidosis(DKA),which ...BACKGROUND Type 1 diabetes is an autoimmune disease leading to insulin deficiency,and it is mainly diagnosed in young adults.One of the major acute complications of type 1 diabetes is diabetic ketoacidosis(DKA),which is a metabolic emergency that can be triggered by stress,infection,or poor blood glucose control.The association of DKA with conditions such as acute pancreatitis and malaria is rare and therefore represents a major diagnostic and therapeutic challenge.CASE SUMMARY A 20-year-old female was admitted to the emergency room for abdominal pelvic pain,fever,asthenia,polyuria,and polydipsia with a progressive deterioration of her state of consciousness.At admission,she was in a mild coma(Glasgow score:9),had a fever of 38.5°C,and had hyperglycemia(6 g/dL).The tests revealed severe DKA,hypertriglyceridemia,hyperamylasemia,and hyperlipasemia as well as malaria parasite density.The computed tomography scan confirmed acute stage E pancreatitis.The diagnosis was that of inaugural ketoacidosis of type 1 diabetes unbalanced by pancreatitis and malaria.Treatment included insulin therapy,rehydration,and antimalarial and analgesic treatment.After 10 days,the outcome was favorable with a normalization of the blood sugar,and an endocrine follow-up was recommend.CONCLUSION Rapid and multidisciplinary management of DKA,pancreatitis,and malaria led to a favorable and stable prognosis.展开更多
BACKGROUND Gastroparesis may repeatedly induce diabetic ketoacidosis(DKA),and the differential diagnosis of these diseases is challenging because of similar gastrointestinal symptoms.If DKA is accompanied by gastropar...BACKGROUND Gastroparesis may repeatedly induce diabetic ketoacidosis(DKA),and the differential diagnosis of these diseases is challenging because of similar gastrointestinal symptoms.If DKA is accompanied by gastroparesis,patients present with persistent gastrointestinal symptoms without relief and may even experience recurrent DKA.Misdiagnosis results in poor treatment outcomes and prognosis.We hypothesized that biomarkers or screening tools can be identified by comparing the clinical data between DKA alone and DKA+gastroparesis to facilitate early screening.AIM To achieve early detection and diagnosis of DKA+gastroparesis to enable early treatment aimed at relieving gastrointestinal symptoms and preventing reinduction of DKA.METHODS We conducted a case-control study in which 15 patients hospitalized for DKA at the Endocrinology Department of Peking Union Medical College Hospital and diagnosed with DKA and gastroparesis between December 1999 and January 2023(DKA+gastroparesis group)were included.Then,we selected 60 DKA patients without DKA as a control group(DKA alone group)based on gender,age,disease course,and diabetes subtype in a 1:4 matching ratio.Clinical manifestations and physical and laboratory examination results were statistically compared between the groups.RESULTS The DKA+gastroparesis group was composed of nine males and six females,with a mean age of 35±11 years,while the DKA alone group included 34 males and 26 females,with a mean age of 34±17 years.In the DKA+gastroparesis group,urine ketone levels normalized,while gastrointestinal symptoms persisted despite treatment,and the tests indicated lower glycosylated hemoglobin levels(HbA1c;7.07%vs 11.51%,P<0.01),largest amplitude of glycemic excursions(5.86 vs 17.41,P<0.01),standard deviation of blood glucose(SDBG;2.69 vs 5.83,P<0.01),and coefficient of blood glucose variation(0.31 vs 0.55,P=0.014)compared with the DKA alone group.Probable gastroparesis was considered at HbA1c<8.55%.Besides,the patients in the DKA+gastroparesis group had lower body mass index(19.28 kg/m^(2) vs 23.86 kg/m^(2),P=0.02)and higher high density lipoprotein cholesterol level(2.34 mmol/L vs 1.05 mmol/L,P=0.019)compared to the DKA alone group,but no difference was observed in the remaining lipid profiles between the two groups.CONCLUSION Gastroparesis should be considered in DKA patients who fail to have improved gastrointestinal symptoms after ketone elimination and acidosis correction,particularly when the HbA1c level is<8.55%.展开更多
BACKGROUND Sodium-glucose cotransporter-2(SGLT-2)inhibitors improve cardiovascular and renal outcomes in diabetes but may induce euglycemic diabetic ketoacidosis(euDKA)via insulin-independent mechanisms.Post-pancreati...BACKGROUND Sodium-glucose cotransporter-2(SGLT-2)inhibitors improve cardiovascular and renal outcomes in diabetes but may induce euglycemic diabetic ketoacidosis(euDKA)via insulin-independent mechanisms.Post-pancreatitis diabetes mellitus(PPDM)patients with impairedβ-cell function face undefined risks with these agents.CASE SUMMARY A 29-year-old man with PPDM developed euDKA 1 week after initiating etogliflozin(5 mg/day).On admission,laboratory tests revealed blood ketones>4.5 mmol/L,pH 7.1,and glucose 10.78 mmol/L.Discontinuation of SGLT-2 inhibitor,insulin pump therapy(basal 12 U/day,premeal bolus 4 U),aggressive hydration(6000 mL first 2 days),and nutritional support normalized ketosis and acidosis within 24 hours.CONCLUSION Caution is warranted with SGLT-2 inhibitors in PPDM.Insulin therapy is preferred to prevent euDKA.展开更多
BACKGROUND Diabetic ketoacidosis(DKA)remains a serious and potentially preventable complication among children with type 1 diabetes mellitus(T1DM),particularly in Saudi Arabia.Psychological constructs such as perceive...BACKGROUND Diabetic ketoacidosis(DKA)remains a serious and potentially preventable complication among children with type 1 diabetes mellitus(T1DM),particularly in Saudi Arabia.Psychological constructs such as perceived severity and susceptibility influence health behaviour,yet their role in pediatric diabetes management remains underexplored.AIM To examine psychological predictors of DKA in children with T1DM using the health belief model,and to assess the role of caregiver-perceived understanding in influencing adherence and DKA occurrence.METHODS A case-control study was conducted at Prince Sultan Military Medical City in Riyadh,Saudi Arabia,involving 191 caregivers of children with T1DM(96 cases with a history of DKA and 95 controls without).Validated questionnaires measured perceived severity,susceptibility,understanding,and adherence.Statistical analyses included independent t-tests,Pearson and Spearman correlations,and multiple regression.RESULTS Perceived understanding was the strongest predictor of adherence(β=1.03,P<0.001)and was inversely associated with DKA occurrence(P<0.001).Children without a DKA history had significantly higher levels of perceived understanding and adherence.Perceived severity had a moderate positive association with adherence,while perceived susceptibility showed a weak negative correlation.CONCLUSION Caregiver-perceived understanding plays a critical role in adherence and DKA prevention.These findings support expanding the health belief model to include perceived understanding as a distinct construct and highlight the importance of integrating comprehension-focused strategies into pediatric diabetes education.展开更多
Introduction: Diabetic ketoacidosis (DKA) is the most common metabolic complication of diabetes. Although historically reported in children, it is increasingly observed in adults. Short-term outcomes and prognosis var...Introduction: Diabetic ketoacidosis (DKA) is the most common metabolic complication of diabetes. Although historically reported in children, it is increasingly observed in adults. Short-term outcomes and prognosis vary widely across healthcare settings. Therefore, we aimed to determine the prevalence, diagnostic characteristics, and outcomes of newly diagnosed diabetic ketoacidosis in a hospital setting in Dakar. Methodology: We conducted a descriptive and analytical cross-sectional study from January 1, 2020, to January 31, 2021, in the Endocrinology-Metabolism Department of the Pikine National Hospital Center. All diabetic patients hospitalized for newly diagnosed diabetic ketoacidosis during this period were included. Results: A total of 54 patients were enrolled in the study. The prevalence of newly diagnosed DKA in the facility was 17.1%. The mean age was 38.54 years, with a male predominance and a sex ratio of 1.16. Thirty-five patients had a family history of diabetes. Upon admission, 14.9% of patients had altered consciousness, and 92.4% exhibited cardinal symptoms, with an average duration of 14.2 days. Kussmaul breathing and gastrointestinal symptoms were observed in 13% and 33% of cases, respectively. The mean capillary blood glucose level at admission was 3.43 g/L. Infection was identified as the precipitating factor in half of the cases, while no triggering factor was found in the remaining cases. The mean BMI was 25.27 kg/m², and the average glycated hemoglobin (HbA1c) level was 12.2%. We recorded the diabetes classification for all patients. Nine had type 1 diabetes, twelve had type 1b diabetes, thirty-one had type 2 diabetes, and two had diabetes secondary to corticosteroid therapy. All patients received continuous intravenous insulin therapy via a syringe pump. The mean time to ketosis resolution was 34.6 hours. The average total dose of regular insulin administered was 442.3 IU. The mean duration of hospitalization was 7.6 days. One patient died, and fifty-one were discharged while continuing insulin therapy, with an average dose of 53 IU. Conclusion: The prevalence of newly diagnosed DKA remains high. With proper management, the prognosis is generally favorable. Diabetes classification is crucial, as it determines subsequent treatment strategies.展开更多
Euglycemic diabetic ketoacidosis(DKA)is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose(less than 11 mmol/L).The absence of hyperglycemia is a conundrum f...Euglycemic diabetic ketoacidosis(DKA)is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose(less than 11 mmol/L).The absence of hyperglycemia is a conundrum for physicians in the emergency department and intensive care units;it may delay diagnosis and treatment causing worse outcomes.Euglycemic DKA is an uncommon diagnosis but can occur in patients with type 1 or type 2 diabetes mellitus.With the addition of sodium/glucose cotransporter-2 inhibitors in diabetes mellitus management,euglycemic DKA incidence has increased.The other causes of euglycemic DKA include pregnancy,fasting,bariatric surgery,gastroparesis,insulin pump failure,cocaine intoxication,chronic liver disease and glycogen storage disease.The pathophysiology of euglycemic DKA involves a relative or absolute carbohydrate deficit,milder degree of insulin deficiency or resistance and increased glucagon/insulin ratio.Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones.The diagnostic workup includes arterial blood gas for metabolic acidosis,serum ketones and exclusion of other causes of high anion gap metabolic acidosis.Euglycemic DKA treatment is on the same principles as for DKA with correction of dehydration,electrolytes deficit and insulin replacement.The dextrosecontaining fluids should accompany intravenous insulin to correct metabolic acidosis,ketonemia and to avoid hypoglycemia.展开更多
BACKGROUND Diabetic ketoacidosis(DKA)manifests as hyperglycemia,metabolic acidosis,and ketosis.However,euglycemic DKA(eu-DKA)conceals severe DKA with glucose levels below 200 mg/dL.Sodium-glucose cotransporter-2(SGLT2...BACKGROUND Diabetic ketoacidosis(DKA)manifests as hyperglycemia,metabolic acidosis,and ketosis.However,euglycemic DKA(eu-DKA)conceals severe DKA with glucose levels below 200 mg/dL.Sodium-glucose cotransporter-2(SGLT2)inhibitors can induce eu-DKA in diabetic patients.Notably,coronavirus disease 2019(COVID-19)-infected individuals with diabetes using SGLT2 inhibitors face an augmented risk of eu-DKA due to the direct toxic impact of the virus on pancreatic islets.This study aims to comprehensively investigate the association between SGLT2 inhibitors and eu-DKA in COVID-19 patients through meticulous case report analysis.Additionally,we endeavor to examine the outcomes and treatment approaches for COVID-19-infected diabetics receiving SGLT2 inhibitors,providing indispensable insights for healthcare professionals managing this specific patient population.AIM To investigate the connection between SGLT2 inhibitors and euglycemic DKA in COVID-19 patients through a meticulous analysis of case reports.METHODS We conducted an exhaustive search across prominent electronic databases,including PubMed,SCOPUS,Web of Science,and Google Scholar.This search encompassed the period from December 2019 to May 2022,incorporating published studies and pre-prints.The search terms employed encompassed“SGLT2 inhibitors”,“euglycemic DKA”,“COVID-19”,and related variations.By incorporating these diverse sources,our objective was to ensure a thorough exploration of the existing literature on this subject,thereby augmenting the validity and robustness of our findings.RESULTS Our search yielded a total of seven case reports and one case series,collectively comprising a cohort of twelve patients.These reports detailed instances of eu-DKA in individuals with COVID-19.Crucially,all twelve patients were utilizing SGLT2 as their primary anti-diabetic medication.Upon admission,all oral medications were promptly discontinued,and the patients were initiated on intravenous insulin therapy to effectively manage the DKA.Encouragingly,eleven patients demonstrated a favorable outcome,while regrettably,one patient succumbed to the condition.Subsequently,SGLT2 were discontinued for all patients upon their discharge from the hospital.These findings provide valuable insights into the clinical management and outcomes of eu-DKA cases associated with COVID-19 and SGLT2,underscoring the critical importance of prompt intervention and vigilant medication adjustments.CONCLUSION Our study sheds light on the possibility of diabetic patients developing both drug-related and unrelated DKA,as well as encountering adverse outcomes in the context of COVID-19,despite maintaining satisfactory glycemic control.The relationship between glycemic control and clinical outcomes in COVID-19 remains ambiguous.Consequently,this systematic review proposes that COVID-19-infected diabetic patients using SGLT2 should contemplate alternative treatment protocols until their recovery from the disease.展开更多
Objective: This study aims to analyze the causes of postoperative transition from euglycemic diabetic ketoacidosis (EDKA) to diabetic ketoacidosis (DKA), summarize clinical nursing experiences, enhance the recognition...Objective: This study aims to analyze the causes of postoperative transition from euglycemic diabetic ketoacidosis (EDKA) to diabetic ketoacidosis (DKA), summarize clinical nursing experiences, enhance the recognition and management of such complications, and improve patient prognosis. Methods: A detailed case analysis was conducted on a patient who developed EDKA early after breast cancer surgery, which subsequently transitioned to DKA. A multidisciplinary team (MDT) consultation was employed to formulate a personalized nursing plan. Specific methods included comprehensive clinical data collection, monitoring of blood glucose, urine ketones, and blood ketone levels;implementing dynamic insulin adjustment strategies;providing dietary education and psychological support;and guiding dietary adjustments through nutritional consultations. Results: Through personalized observation, blood glucose management, dietary management, psychological care, and wound care, the patient’s blood and urine ketone levels returned to normal, the flap healed well, and blood glucose was maintained within the normal range. The patient is currently undergoing postoperative adjuvant chemotherapy. Conclusion: For postoperative patients with unexplained nausea, vomiting, and dehydration, regardless of diabetes history, timely testing of blood glucose, blood ketones, blood urea nitrogen, creatinine, electrolytes, and blood gas analysis can facilitate early detection of EDKA. Additionally, personalized management of blood glucose, diet, psychological care, and wound care is crucial for the prevention and treatment of EDKA.展开更多
The incidence of type 1 diabetes(T1D) among youth is steadily increasing across the world. Up to a third of pediatric patients with T1 D present with diabetic ketoacidosis, a diagnosis that continues to be the leading...The incidence of type 1 diabetes(T1D) among youth is steadily increasing across the world. Up to a third of pediatric patients with T1 D present with diabetic ketoacidosis, a diagnosis that continues to be the leading cause of death in this population. Cerebral edema is the most common rare complication of diabetic ketoacidosis in children. Accordingly, treatment and outcome measures of cerebral edema are vastly researched and the pathophysiology is recently the subject of much debate. Nevertheless, cerebral edema is not the onlysequela of diabetic ketoacidosis that warrants close monitoring. The medical literature details various other complications in children with diabetic ketoacidosis, including hypercoagulability leading to stroke and deep vein thrombosis, rhabdomyolysis, pulmonary and gastrointestinal complications, and long-term memory dysfunction. We review the pathophysiology, reported cases, management, and outcomes of each of these rare complications in children. As the incidence of T1 D continues to rise, practitioners will care for an increasing number of pediatric patients with diabetic ketoacidosis and should be aware of the various systems that may be affected in both the acute and chronic setting.展开更多
Diabetes affects approximately 30 million persons in the United States. Diabetes ketoacidosis is one of the most serious and acute complications of diabetes. At the time of presentation and during treatment of diabeti...Diabetes affects approximately 30 million persons in the United States. Diabetes ketoacidosis is one of the most serious and acute complications of diabetes. At the time of presentation and during treatment of diabetic ketoacidosis(DKA), several metabolic and electrolyte derangements can ultimately result in respiratory compromise. Most commonly, hypokalemia, hypomagnesemia and hypophosphatemia can eventually lead to respiratory muscles failure.Furthermore, tachypnea, hyperpnea and more severely, Kussmaul breathing pattern can develop. Also, hydrostatic and non-hydrostatic pulmonary edema can occur secondary to volume shifts into the extracellular space and secondary to increased permeability of the pulmonary capillaries. The presence of respiratory failure in patients with DKA is associated with higher morbidity and mortality. Being familiar with the causes of respiratory compromise in DKA, and how to treat them, may represent better outcomes for patients with DKA.展开更多
Diabetic ketoacidosis(DKA) is a complication seen in patients with both type 1 and type 2 diabetes. Due to its large, growing economic impact with associated morbidity, closer look at proper management is im-portant. ...Diabetic ketoacidosis(DKA) is a complication seen in patients with both type 1 and type 2 diabetes. Due to its large, growing economic impact with associated morbidity, closer look at proper management is im-portant. Factors involved in appropriate management involves fluid resuscitation, insulin regimen, and elec-trolyte replacement including types of fluid and insulin treatment. The caveat with generalized protocol is application to special populations such as renal or heart failure patients the sequelae of complications due to pathophysiology of the disease processes. This leads to complications and longer length of stay in the hospital, therefore, possibly increased cost and resource utilization during the hospitalization. This review takes a closer look at current guidelines of DKA management and resource utilization, the drawbacks of current management protocols and the cost associated with it. Therefore, a need for amendment to existing protocol or initiation of a newer guideline that properly manages DKA should incorporate special populations and appropriate regimen of fluid resuscitation, insulin therapy and electrolyte management.展开更多
Respiratory failure complicating the course of diabetic ketoacidosis(DKA)is a source of increased morbidity and mortality.Detection of respiratory failure in DKA requires focused clinical monitoring,careful interpreta...Respiratory failure complicating the course of diabetic ketoacidosis(DKA)is a source of increased morbidity and mortality.Detection of respiratory failure in DKA requires focused clinical monitoring,careful interpretation of arterial blood gases,and investigation for conditions that can affect adversely the respiration.Conditions that compromise respiratory function caused by DKA can be detected at presentation but are usually more prevalent during treatment.These conditions include deficits of potassium,magnesium and phosphate and hydrostatic or non-hydrostatic pulmonary edema.Conditions not caused by DKA that can worsen respiratory function under the added stress of DKA include infections of the respiratory system,pre-existing respiratory or neuromuscular disease and miscellaneous other conditions.Prompt recognition and management of the conditions that can lead to respiratory failure in DKA may prevent respiratory failure and improve mortality from DKA.展开更多
Acute esophageal necrosis,also known as "black esophagus syndrome",is a rare acute esophageal disease that is often associated with vomiting and upper gastrointestinal haemorrhage.At present,little is known ...Acute esophageal necrosis,also known as "black esophagus syndrome",is a rare acute esophageal disease that is often associated with vomiting and upper gastrointestinal haemorrhage.At present,little is known regarding the pathogenesis of this disease.We present the case of a 50-year-old white male patient with diabetic ketoacidosis suffering from acute esophageal necrosis with nausea and vomiting but without any clinical signs of upper gastrointestinal bleeding.展开更多
BACKGROUND Diabetic ketoacidosis(DKA)is a serious complication of type 1 diabetes mellitus(T1DM).Very rarely does DKA lead to cerebral edema,and it is even rarer for it to result in cerebral infarction.Bilateral inter...BACKGROUND Diabetic ketoacidosis(DKA)is a serious complication of type 1 diabetes mellitus(T1DM).Very rarely does DKA lead to cerebral edema,and it is even rarer for it to result in cerebral infarction.Bilateral internal carotid artery occlusion(BICAO)is also rare and can cause fatal stroke.Moreover,case reports about acute cerebral infarction throughout both internal carotid arteries with simultaneous BICAO are very scarce.In this study,we present a patient with BICAO,T1DM,hypertension,and hyperlipidemia,who had a catastrophic bilateral cerebral infarction after a DKA episode.We briefly introduce BICAO and the mechanisms by which DKA results in cerebral infarction.CASE SUMMARY A 41-year-old woman presented with ischemic stroke that took place 3 mo prior over the left corona radiata,bilateral frontal lobe,and parietal lobe with right hemiplegia and Broca’s aphasia.She had a history of hypertension for 5 years,hyperlipidemia for 4 years,hyperthyroidism for 3 years,and T1DM for 31 years.The first brain magnetic resonance imaging not only revealed the aforementioned ischemic lesions but also bilateral internal carotid artery occlusion.She was admitted to our ward for rehabilitation due to prior stroke sequalae.DKA took place on hospital day 2.On hospital day 6,she had a new massive infarction over the bilateral anterior cerebral artery and middle cerebral artery territory.After weeks of aggressive treatment,she remained in a coma and on mechanical ventilation due to respiratory failure.After discussion with her family,compassionate extubation was performed on hospital day 29 and she died.CONCLUSION DKA can lead to cerebral infarction due to several mechanisms.In people with existing BICAO and several stroke risk factors such as hypertension, T1DM,hyperlipidemia, DKA has the potential to cause more serious ischemic strokes.展开更多
BACKGROUND Sodium-glucose cotransporter-2 inhibitors(SGLT2i)are commonly prescribed to manage patients with diabetes mellitus.These agents may rarely lead to the development of euglycemic diabetic ketoacidosis(EDKA),w...BACKGROUND Sodium-glucose cotransporter-2 inhibitors(SGLT2i)are commonly prescribed to manage patients with diabetes mellitus.These agents may rarely lead to the development of euglycemic diabetic ketoacidosis(EDKA),which may complicate the disease course of these patients.AIM To analyze the demographic profile,predisposing factors,symptomology,clinical interventions and outcomes of patients presenting with EDKA secondary to SGLT2i use by reviewing the published case reports and series.METHODS We performed a systematic search of PubMed,Science Direct,Google Scholar and Reference Citation Analysis databases using the terms“canagliflozin”OR“empagliflozin”OR“dapagliflozin”OR“SGLT2 inhibitors”OR“Sodium-glucose cotransporter-2”AND“euglycemia”OR“euglycemic diabetic ketoacidosis”OR“metabolic acidosis”.The inclusion criteria were:(1)Case reports or case series with individual patient details;and(2)Reported EDKA secondary to SGLT2i.Furthermore,the data were filtered from the literature published in the English language and on adults(>18 years).We excluded:(1)Conference abstracts;and(2)Case reports or series which did not have individual biochemical data.All the case reports and case series were evaluated.The data extracted included patient demographics,clinical symptomatology,clinical interventions,intensive care unit course,need for organ support and outcomes.RESULTS Overall,108 case reports and 17 cases series with 169 unique patients that met all the inclusion criteria were included.The majority of patients were females(54.4%,n=92),and the commonly reported symptoms were gastrointestinal(nausea/vomiting 65.1%,abdominal pain 37.3%)and respiratory(breathlessness 30.8%).One hundred and forty-nine(88.2%)patients had underlying type II diabetes,and the most commonly involved SGLT-2 inhibitor reported was empagliflozin(46.8%).A triggering factor was reported in most patients(78.7%),the commonest being acute severe infection(37.9%),which included patients with sepsis,coronavirus disease 2019,other viral illnesses,and acute pancreatitis.61.5%were reported to require intensive unit care,but only a minority of patients required organ support in the form of invasive mechanical ventilation(13%),vasopressors(6.5%)or renal replacement therapy(5.9%).The overall mortality rate was only 2.4%.CONCLUSION Patients on SGLT2i may rarely develop EDKA,especially in the presence of certain predisposing factors,including severe acute infections and following major surgery.The signs and symptoms of EDKA may be similar to that of DKA but with normal blood sugar levels,which may make the diagnosis challenging.Outcomes of EDKA are good if recognized early and corrective actions are taken.Hence,physicians managing such patients must be aware of this potential complication and must educate their patients accordingly to ensure early diagnosis and management.展开更多
Diabetic ketoacidosis(DKA) is a severe and toocommon complication of uncontrolled diabetes mellitus. Acidosis is one of the fundamental disruptions stemming from the disease process, the complications of which are pot...Diabetic ketoacidosis(DKA) is a severe and toocommon complication of uncontrolled diabetes mellitus. Acidosis is one of the fundamental disruptions stemming from the disease process, the complications of which are potentially lethal. Hydration and insulin administration have been the cornerstones of DKA therapy; however, adjunctive treatments such as the use of sodium bicarbonate and protocols that include serial monitoring with blood gas analysis have been much more controversial. There is substantial literature available regarding the use of exogenous sodium bicarbonate in mild to moderately severe acidosis; the bulk of the data argue against significant benefit in important clinical outcomes and suggest possible adverse effects with the use of bicarbonate. However, there is scant data to support or refute the role of bicarbonate therapy in very severe acidosis. Arterial blood gas(ABG) assessment is an element of some treatment protocols, including society guidelines, for DKA. We review the evidence supporting these recommendations. In addition, we review the data supporting some less cumbersome tests, including venous blood gas assessment and routine chemistries. It remains unclear that measurement of blood gas pH, via arterial or venous sampling, impacts management of the patient substantially enough to warrant the testing, especially if sodium bicarbonate administration is not being considered. There are special circumstances when serial ABG monitoring and/or sodium bicarbonate infusion are necessary, which we also review. Additional studies are needed to determine the utility of these interventions in patients with severe DKA and pH less than 7.0.展开更多
Diabetic ketoacidosis(DKA)and hyperosmolar hyperglycemia state(HHS)are two life-threatening metabolic complications of diabetes that significantly increase mortality and morbidity.Despite major advances,reaching a uni...Diabetic ketoacidosis(DKA)and hyperosmolar hyperglycemia state(HHS)are two life-threatening metabolic complications of diabetes that significantly increase mortality and morbidity.Despite major advances,reaching a uniform consensus regarding the diagnostic criteria and treatment of both conditions has been challenging.A significant overlap between these two extremes of the hyperglycemic crisis spectrum poses an additional hurdle.It has well been noted that a complete biochemical and clinical patient evaluation with timely diagnosis and treatment is vital for symptom resolution.Worldwide,there is a lack of large-scale studies that help define how hyperglycemic crises should be managed.This article will provide a comprehensive review of the pathophysiology,diagnosis,and management of DKA-HHS overlap.展开更多
Diabetic ketoacidosis(DKA)is defined as an acute metabolic disorder,which is characterized by an increased presence of circulating ketones,and the development of ketoacidosis in the presence of hyperglycemia.This synd...Diabetic ketoacidosis(DKA)is defined as an acute metabolic disorder,which is characterized by an increased presence of circulating ketones,and the development of ketoacidosis in the presence of hyperglycemia.This syndrome occurs as a result of insulin deficiency.Patients can be dramatically ill,however,with aggressive treatment,most patients recover rapidly.Despite being a low-risk condition,the development of acidosis,is one of the admission criteria to the intensive care unit(ICU)for these patients,in order to provide close monitoring,and recognize complications that could result from the use of aggressive therapy,such as continuous infusions if insulin.In some institutions,DKA is treated in the emergency department and general medical/surgical wards to avoid ICU overcrowding.展开更多
文摘The management of diabetic ketoacidosis can be challenging in high-risk patients.Recent studies have reported a significant increase in diabetic ketoacidosis hospitalization rates.While managing this high-risk condition,patient factors and comorbidities should be given careful attention and consideration.Factors like pregnancy,renal disease,cardiac disease,older age,and use of sodium-glucose cotransporter-2 inhibitors all impact the treatment approach,and tailored management strategies are required.Particularly in children,specialized treatment and care during a diabetic ketoacidosis episode is necessary due to its long-term neurological consequences.However,guidelines often lack adequate recommendations about the approach to manage complex patients with specific conditions and comorbidities.Furthermore,there are still controversies around certain aspects of diabetic ketoacidosis management,and additional investigations are needed to determine the best management options.We aim to address these special conditions and provide an approach to manage complex patients with specific conditions and co-morbidities.
文摘This study reports a case of a 63-year-old female patient who developed euglycemic diabetic ketoacidosis(euDKA)within 24 h adding Empagliflozin.Upon admission,the patient's fasting blood glucose was 14.7 mmol/L and glycated hemoglobin(HbA1c)was 7.9%.She had been using insulin combined with repaglinide for long-term blood glucose control.On the next day after initiating Empagliflozin,persistent positive urine ketones were detected,with blood glucose fluctuating between 7.8-14.7 mmol/L.Serum bicarbonate was normal(32.0 mmol/L),and there were no typical symptoms of acidosis.After discontinuing Empagliflozin,receiving intravenous fluid rehydration,and low-dose insulin therapy,urine ketones gradually turned negative.This case suggests that in clinical practice,it is necessary to achieve a precise balance between cardiovascular benefits and metabolic risks,adhering to the principle of individualized medication.
文摘BACKGROUND Type 1 diabetes is an autoimmune disease leading to insulin deficiency,and it is mainly diagnosed in young adults.One of the major acute complications of type 1 diabetes is diabetic ketoacidosis(DKA),which is a metabolic emergency that can be triggered by stress,infection,or poor blood glucose control.The association of DKA with conditions such as acute pancreatitis and malaria is rare and therefore represents a major diagnostic and therapeutic challenge.CASE SUMMARY A 20-year-old female was admitted to the emergency room for abdominal pelvic pain,fever,asthenia,polyuria,and polydipsia with a progressive deterioration of her state of consciousness.At admission,she was in a mild coma(Glasgow score:9),had a fever of 38.5°C,and had hyperglycemia(6 g/dL).The tests revealed severe DKA,hypertriglyceridemia,hyperamylasemia,and hyperlipasemia as well as malaria parasite density.The computed tomography scan confirmed acute stage E pancreatitis.The diagnosis was that of inaugural ketoacidosis of type 1 diabetes unbalanced by pancreatitis and malaria.Treatment included insulin therapy,rehydration,and antimalarial and analgesic treatment.After 10 days,the outcome was favorable with a normalization of the blood sugar,and an endocrine follow-up was recommend.CONCLUSION Rapid and multidisciplinary management of DKA,pancreatitis,and malaria led to a favorable and stable prognosis.
基金Supported by National High Level Hospital Clinical Research Funding,No.2022-PUMCH-B-015the Chinese Academy of Medical Sciences(CAMS)Innovation Fund for Medical Sciences,No.2021-I2M-C&T-B-003.
文摘BACKGROUND Gastroparesis may repeatedly induce diabetic ketoacidosis(DKA),and the differential diagnosis of these diseases is challenging because of similar gastrointestinal symptoms.If DKA is accompanied by gastroparesis,patients present with persistent gastrointestinal symptoms without relief and may even experience recurrent DKA.Misdiagnosis results in poor treatment outcomes and prognosis.We hypothesized that biomarkers or screening tools can be identified by comparing the clinical data between DKA alone and DKA+gastroparesis to facilitate early screening.AIM To achieve early detection and diagnosis of DKA+gastroparesis to enable early treatment aimed at relieving gastrointestinal symptoms and preventing reinduction of DKA.METHODS We conducted a case-control study in which 15 patients hospitalized for DKA at the Endocrinology Department of Peking Union Medical College Hospital and diagnosed with DKA and gastroparesis between December 1999 and January 2023(DKA+gastroparesis group)were included.Then,we selected 60 DKA patients without DKA as a control group(DKA alone group)based on gender,age,disease course,and diabetes subtype in a 1:4 matching ratio.Clinical manifestations and physical and laboratory examination results were statistically compared between the groups.RESULTS The DKA+gastroparesis group was composed of nine males and six females,with a mean age of 35±11 years,while the DKA alone group included 34 males and 26 females,with a mean age of 34±17 years.In the DKA+gastroparesis group,urine ketone levels normalized,while gastrointestinal symptoms persisted despite treatment,and the tests indicated lower glycosylated hemoglobin levels(HbA1c;7.07%vs 11.51%,P<0.01),largest amplitude of glycemic excursions(5.86 vs 17.41,P<0.01),standard deviation of blood glucose(SDBG;2.69 vs 5.83,P<0.01),and coefficient of blood glucose variation(0.31 vs 0.55,P=0.014)compared with the DKA alone group.Probable gastroparesis was considered at HbA1c<8.55%.Besides,the patients in the DKA+gastroparesis group had lower body mass index(19.28 kg/m^(2) vs 23.86 kg/m^(2),P=0.02)and higher high density lipoprotein cholesterol level(2.34 mmol/L vs 1.05 mmol/L,P=0.019)compared to the DKA alone group,but no difference was observed in the remaining lipid profiles between the two groups.CONCLUSION Gastroparesis should be considered in DKA patients who fail to have improved gastrointestinal symptoms after ketone elimination and acidosis correction,particularly when the HbA1c level is<8.55%.
文摘BACKGROUND Sodium-glucose cotransporter-2(SGLT-2)inhibitors improve cardiovascular and renal outcomes in diabetes but may induce euglycemic diabetic ketoacidosis(euDKA)via insulin-independent mechanisms.Post-pancreatitis diabetes mellitus(PPDM)patients with impairedβ-cell function face undefined risks with these agents.CASE SUMMARY A 29-year-old man with PPDM developed euDKA 1 week after initiating etogliflozin(5 mg/day).On admission,laboratory tests revealed blood ketones>4.5 mmol/L,pH 7.1,and glucose 10.78 mmol/L.Discontinuation of SGLT-2 inhibitor,insulin pump therapy(basal 12 U/day,premeal bolus 4 U),aggressive hydration(6000 mL first 2 days),and nutritional support normalized ketosis and acidosis within 24 hours.CONCLUSION Caution is warranted with SGLT-2 inhibitors in PPDM.Insulin therapy is preferred to prevent euDKA.
基金Supported by the Ongoing Research Funding Program at King Saud University,Riyadh,Saudi Arabia,No.ORF-2025-1315.
文摘BACKGROUND Diabetic ketoacidosis(DKA)remains a serious and potentially preventable complication among children with type 1 diabetes mellitus(T1DM),particularly in Saudi Arabia.Psychological constructs such as perceived severity and susceptibility influence health behaviour,yet their role in pediatric diabetes management remains underexplored.AIM To examine psychological predictors of DKA in children with T1DM using the health belief model,and to assess the role of caregiver-perceived understanding in influencing adherence and DKA occurrence.METHODS A case-control study was conducted at Prince Sultan Military Medical City in Riyadh,Saudi Arabia,involving 191 caregivers of children with T1DM(96 cases with a history of DKA and 95 controls without).Validated questionnaires measured perceived severity,susceptibility,understanding,and adherence.Statistical analyses included independent t-tests,Pearson and Spearman correlations,and multiple regression.RESULTS Perceived understanding was the strongest predictor of adherence(β=1.03,P<0.001)and was inversely associated with DKA occurrence(P<0.001).Children without a DKA history had significantly higher levels of perceived understanding and adherence.Perceived severity had a moderate positive association with adherence,while perceived susceptibility showed a weak negative correlation.CONCLUSION Caregiver-perceived understanding plays a critical role in adherence and DKA prevention.These findings support expanding the health belief model to include perceived understanding as a distinct construct and highlight the importance of integrating comprehension-focused strategies into pediatric diabetes education.
文摘Introduction: Diabetic ketoacidosis (DKA) is the most common metabolic complication of diabetes. Although historically reported in children, it is increasingly observed in adults. Short-term outcomes and prognosis vary widely across healthcare settings. Therefore, we aimed to determine the prevalence, diagnostic characteristics, and outcomes of newly diagnosed diabetic ketoacidosis in a hospital setting in Dakar. Methodology: We conducted a descriptive and analytical cross-sectional study from January 1, 2020, to January 31, 2021, in the Endocrinology-Metabolism Department of the Pikine National Hospital Center. All diabetic patients hospitalized for newly diagnosed diabetic ketoacidosis during this period were included. Results: A total of 54 patients were enrolled in the study. The prevalence of newly diagnosed DKA in the facility was 17.1%. The mean age was 38.54 years, with a male predominance and a sex ratio of 1.16. Thirty-five patients had a family history of diabetes. Upon admission, 14.9% of patients had altered consciousness, and 92.4% exhibited cardinal symptoms, with an average duration of 14.2 days. Kussmaul breathing and gastrointestinal symptoms were observed in 13% and 33% of cases, respectively. The mean capillary blood glucose level at admission was 3.43 g/L. Infection was identified as the precipitating factor in half of the cases, while no triggering factor was found in the remaining cases. The mean BMI was 25.27 kg/m², and the average glycated hemoglobin (HbA1c) level was 12.2%. We recorded the diabetes classification for all patients. Nine had type 1 diabetes, twelve had type 1b diabetes, thirty-one had type 2 diabetes, and two had diabetes secondary to corticosteroid therapy. All patients received continuous intravenous insulin therapy via a syringe pump. The mean time to ketosis resolution was 34.6 hours. The average total dose of regular insulin administered was 442.3 IU. The mean duration of hospitalization was 7.6 days. One patient died, and fifty-one were discharged while continuing insulin therapy, with an average dose of 53 IU. Conclusion: The prevalence of newly diagnosed DKA remains high. With proper management, the prognosis is generally favorable. Diabetes classification is crucial, as it determines subsequent treatment strategies.
文摘Euglycemic diabetic ketoacidosis(DKA)is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose(less than 11 mmol/L).The absence of hyperglycemia is a conundrum for physicians in the emergency department and intensive care units;it may delay diagnosis and treatment causing worse outcomes.Euglycemic DKA is an uncommon diagnosis but can occur in patients with type 1 or type 2 diabetes mellitus.With the addition of sodium/glucose cotransporter-2 inhibitors in diabetes mellitus management,euglycemic DKA incidence has increased.The other causes of euglycemic DKA include pregnancy,fasting,bariatric surgery,gastroparesis,insulin pump failure,cocaine intoxication,chronic liver disease and glycogen storage disease.The pathophysiology of euglycemic DKA involves a relative or absolute carbohydrate deficit,milder degree of insulin deficiency or resistance and increased glucagon/insulin ratio.Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones.The diagnostic workup includes arterial blood gas for metabolic acidosis,serum ketones and exclusion of other causes of high anion gap metabolic acidosis.Euglycemic DKA treatment is on the same principles as for DKA with correction of dehydration,electrolytes deficit and insulin replacement.The dextrosecontaining fluids should accompany intravenous insulin to correct metabolic acidosis,ketonemia and to avoid hypoglycemia.
文摘BACKGROUND Diabetic ketoacidosis(DKA)manifests as hyperglycemia,metabolic acidosis,and ketosis.However,euglycemic DKA(eu-DKA)conceals severe DKA with glucose levels below 200 mg/dL.Sodium-glucose cotransporter-2(SGLT2)inhibitors can induce eu-DKA in diabetic patients.Notably,coronavirus disease 2019(COVID-19)-infected individuals with diabetes using SGLT2 inhibitors face an augmented risk of eu-DKA due to the direct toxic impact of the virus on pancreatic islets.This study aims to comprehensively investigate the association between SGLT2 inhibitors and eu-DKA in COVID-19 patients through meticulous case report analysis.Additionally,we endeavor to examine the outcomes and treatment approaches for COVID-19-infected diabetics receiving SGLT2 inhibitors,providing indispensable insights for healthcare professionals managing this specific patient population.AIM To investigate the connection between SGLT2 inhibitors and euglycemic DKA in COVID-19 patients through a meticulous analysis of case reports.METHODS We conducted an exhaustive search across prominent electronic databases,including PubMed,SCOPUS,Web of Science,and Google Scholar.This search encompassed the period from December 2019 to May 2022,incorporating published studies and pre-prints.The search terms employed encompassed“SGLT2 inhibitors”,“euglycemic DKA”,“COVID-19”,and related variations.By incorporating these diverse sources,our objective was to ensure a thorough exploration of the existing literature on this subject,thereby augmenting the validity and robustness of our findings.RESULTS Our search yielded a total of seven case reports and one case series,collectively comprising a cohort of twelve patients.These reports detailed instances of eu-DKA in individuals with COVID-19.Crucially,all twelve patients were utilizing SGLT2 as their primary anti-diabetic medication.Upon admission,all oral medications were promptly discontinued,and the patients were initiated on intravenous insulin therapy to effectively manage the DKA.Encouragingly,eleven patients demonstrated a favorable outcome,while regrettably,one patient succumbed to the condition.Subsequently,SGLT2 were discontinued for all patients upon their discharge from the hospital.These findings provide valuable insights into the clinical management and outcomes of eu-DKA cases associated with COVID-19 and SGLT2,underscoring the critical importance of prompt intervention and vigilant medication adjustments.CONCLUSION Our study sheds light on the possibility of diabetic patients developing both drug-related and unrelated DKA,as well as encountering adverse outcomes in the context of COVID-19,despite maintaining satisfactory glycemic control.The relationship between glycemic control and clinical outcomes in COVID-19 remains ambiguous.Consequently,this systematic review proposes that COVID-19-infected diabetic patients using SGLT2 should contemplate alternative treatment protocols until their recovery from the disease.
文摘Objective: This study aims to analyze the causes of postoperative transition from euglycemic diabetic ketoacidosis (EDKA) to diabetic ketoacidosis (DKA), summarize clinical nursing experiences, enhance the recognition and management of such complications, and improve patient prognosis. Methods: A detailed case analysis was conducted on a patient who developed EDKA early after breast cancer surgery, which subsequently transitioned to DKA. A multidisciplinary team (MDT) consultation was employed to formulate a personalized nursing plan. Specific methods included comprehensive clinical data collection, monitoring of blood glucose, urine ketones, and blood ketone levels;implementing dynamic insulin adjustment strategies;providing dietary education and psychological support;and guiding dietary adjustments through nutritional consultations. Results: Through personalized observation, blood glucose management, dietary management, psychological care, and wound care, the patient’s blood and urine ketone levels returned to normal, the flap healed well, and blood glucose was maintained within the normal range. The patient is currently undergoing postoperative adjuvant chemotherapy. Conclusion: For postoperative patients with unexplained nausea, vomiting, and dehydration, regardless of diabetes history, timely testing of blood glucose, blood ketones, blood urea nitrogen, creatinine, electrolytes, and blood gas analysis can facilitate early detection of EDKA. Additionally, personalized management of blood glucose, diet, psychological care, and wound care is crucial for the prevention and treatment of EDKA.
文摘The incidence of type 1 diabetes(T1D) among youth is steadily increasing across the world. Up to a third of pediatric patients with T1 D present with diabetic ketoacidosis, a diagnosis that continues to be the leading cause of death in this population. Cerebral edema is the most common rare complication of diabetic ketoacidosis in children. Accordingly, treatment and outcome measures of cerebral edema are vastly researched and the pathophysiology is recently the subject of much debate. Nevertheless, cerebral edema is not the onlysequela of diabetic ketoacidosis that warrants close monitoring. The medical literature details various other complications in children with diabetic ketoacidosis, including hypercoagulability leading to stroke and deep vein thrombosis, rhabdomyolysis, pulmonary and gastrointestinal complications, and long-term memory dysfunction. We review the pathophysiology, reported cases, management, and outcomes of each of these rare complications in children. As the incidence of T1 D continues to rise, practitioners will care for an increasing number of pediatric patients with diabetic ketoacidosis and should be aware of the various systems that may be affected in both the acute and chronic setting.
文摘Diabetes affects approximately 30 million persons in the United States. Diabetes ketoacidosis is one of the most serious and acute complications of diabetes. At the time of presentation and during treatment of diabetic ketoacidosis(DKA), several metabolic and electrolyte derangements can ultimately result in respiratory compromise. Most commonly, hypokalemia, hypomagnesemia and hypophosphatemia can eventually lead to respiratory muscles failure.Furthermore, tachypnea, hyperpnea and more severely, Kussmaul breathing pattern can develop. Also, hydrostatic and non-hydrostatic pulmonary edema can occur secondary to volume shifts into the extracellular space and secondary to increased permeability of the pulmonary capillaries. The presence of respiratory failure in patients with DKA is associated with higher morbidity and mortality. Being familiar with the causes of respiratory compromise in DKA, and how to treat them, may represent better outcomes for patients with DKA.
文摘Diabetic ketoacidosis(DKA) is a complication seen in patients with both type 1 and type 2 diabetes. Due to its large, growing economic impact with associated morbidity, closer look at proper management is im-portant. Factors involved in appropriate management involves fluid resuscitation, insulin regimen, and elec-trolyte replacement including types of fluid and insulin treatment. The caveat with generalized protocol is application to special populations such as renal or heart failure patients the sequelae of complications due to pathophysiology of the disease processes. This leads to complications and longer length of stay in the hospital, therefore, possibly increased cost and resource utilization during the hospitalization. This review takes a closer look at current guidelines of DKA management and resource utilization, the drawbacks of current management protocols and the cost associated with it. Therefore, a need for amendment to existing protocol or initiation of a newer guideline that properly manages DKA should incorporate special populations and appropriate regimen of fluid resuscitation, insulin therapy and electrolyte management.
文摘Respiratory failure complicating the course of diabetic ketoacidosis(DKA)is a source of increased morbidity and mortality.Detection of respiratory failure in DKA requires focused clinical monitoring,careful interpretation of arterial blood gases,and investigation for conditions that can affect adversely the respiration.Conditions that compromise respiratory function caused by DKA can be detected at presentation but are usually more prevalent during treatment.These conditions include deficits of potassium,magnesium and phosphate and hydrostatic or non-hydrostatic pulmonary edema.Conditions not caused by DKA that can worsen respiratory function under the added stress of DKA include infections of the respiratory system,pre-existing respiratory or neuromuscular disease and miscellaneous other conditions.Prompt recognition and management of the conditions that can lead to respiratory failure in DKA may prevent respiratory failure and improve mortality from DKA.
文摘Acute esophageal necrosis,also known as "black esophagus syndrome",is a rare acute esophageal disease that is often associated with vomiting and upper gastrointestinal haemorrhage.At present,little is known regarding the pathogenesis of this disease.We present the case of a 50-year-old white male patient with diabetic ketoacidosis suffering from acute esophageal necrosis with nausea and vomiting but without any clinical signs of upper gastrointestinal bleeding.
文摘BACKGROUND Diabetic ketoacidosis(DKA)is a serious complication of type 1 diabetes mellitus(T1DM).Very rarely does DKA lead to cerebral edema,and it is even rarer for it to result in cerebral infarction.Bilateral internal carotid artery occlusion(BICAO)is also rare and can cause fatal stroke.Moreover,case reports about acute cerebral infarction throughout both internal carotid arteries with simultaneous BICAO are very scarce.In this study,we present a patient with BICAO,T1DM,hypertension,and hyperlipidemia,who had a catastrophic bilateral cerebral infarction after a DKA episode.We briefly introduce BICAO and the mechanisms by which DKA results in cerebral infarction.CASE SUMMARY A 41-year-old woman presented with ischemic stroke that took place 3 mo prior over the left corona radiata,bilateral frontal lobe,and parietal lobe with right hemiplegia and Broca’s aphasia.She had a history of hypertension for 5 years,hyperlipidemia for 4 years,hyperthyroidism for 3 years,and T1DM for 31 years.The first brain magnetic resonance imaging not only revealed the aforementioned ischemic lesions but also bilateral internal carotid artery occlusion.She was admitted to our ward for rehabilitation due to prior stroke sequalae.DKA took place on hospital day 2.On hospital day 6,she had a new massive infarction over the bilateral anterior cerebral artery and middle cerebral artery territory.After weeks of aggressive treatment,she remained in a coma and on mechanical ventilation due to respiratory failure.After discussion with her family,compassionate extubation was performed on hospital day 29 and she died.CONCLUSION DKA can lead to cerebral infarction due to several mechanisms.In people with existing BICAO and several stroke risk factors such as hypertension, T1DM,hyperlipidemia, DKA has the potential to cause more serious ischemic strokes.
文摘BACKGROUND Sodium-glucose cotransporter-2 inhibitors(SGLT2i)are commonly prescribed to manage patients with diabetes mellitus.These agents may rarely lead to the development of euglycemic diabetic ketoacidosis(EDKA),which may complicate the disease course of these patients.AIM To analyze the demographic profile,predisposing factors,symptomology,clinical interventions and outcomes of patients presenting with EDKA secondary to SGLT2i use by reviewing the published case reports and series.METHODS We performed a systematic search of PubMed,Science Direct,Google Scholar and Reference Citation Analysis databases using the terms“canagliflozin”OR“empagliflozin”OR“dapagliflozin”OR“SGLT2 inhibitors”OR“Sodium-glucose cotransporter-2”AND“euglycemia”OR“euglycemic diabetic ketoacidosis”OR“metabolic acidosis”.The inclusion criteria were:(1)Case reports or case series with individual patient details;and(2)Reported EDKA secondary to SGLT2i.Furthermore,the data were filtered from the literature published in the English language and on adults(>18 years).We excluded:(1)Conference abstracts;and(2)Case reports or series which did not have individual biochemical data.All the case reports and case series were evaluated.The data extracted included patient demographics,clinical symptomatology,clinical interventions,intensive care unit course,need for organ support and outcomes.RESULTS Overall,108 case reports and 17 cases series with 169 unique patients that met all the inclusion criteria were included.The majority of patients were females(54.4%,n=92),and the commonly reported symptoms were gastrointestinal(nausea/vomiting 65.1%,abdominal pain 37.3%)and respiratory(breathlessness 30.8%).One hundred and forty-nine(88.2%)patients had underlying type II diabetes,and the most commonly involved SGLT-2 inhibitor reported was empagliflozin(46.8%).A triggering factor was reported in most patients(78.7%),the commonest being acute severe infection(37.9%),which included patients with sepsis,coronavirus disease 2019,other viral illnesses,and acute pancreatitis.61.5%were reported to require intensive unit care,but only a minority of patients required organ support in the form of invasive mechanical ventilation(13%),vasopressors(6.5%)or renal replacement therapy(5.9%).The overall mortality rate was only 2.4%.CONCLUSION Patients on SGLT2i may rarely develop EDKA,especially in the presence of certain predisposing factors,including severe acute infections and following major surgery.The signs and symptoms of EDKA may be similar to that of DKA but with normal blood sugar levels,which may make the diagnosis challenging.Outcomes of EDKA are good if recognized early and corrective actions are taken.Hence,physicians managing such patients must be aware of this potential complication and must educate their patients accordingly to ensure early diagnosis and management.
文摘Diabetic ketoacidosis(DKA) is a severe and toocommon complication of uncontrolled diabetes mellitus. Acidosis is one of the fundamental disruptions stemming from the disease process, the complications of which are potentially lethal. Hydration and insulin administration have been the cornerstones of DKA therapy; however, adjunctive treatments such as the use of sodium bicarbonate and protocols that include serial monitoring with blood gas analysis have been much more controversial. There is substantial literature available regarding the use of exogenous sodium bicarbonate in mild to moderately severe acidosis; the bulk of the data argue against significant benefit in important clinical outcomes and suggest possible adverse effects with the use of bicarbonate. However, there is scant data to support or refute the role of bicarbonate therapy in very severe acidosis. Arterial blood gas(ABG) assessment is an element of some treatment protocols, including society guidelines, for DKA. We review the evidence supporting these recommendations. In addition, we review the data supporting some less cumbersome tests, including venous blood gas assessment and routine chemistries. It remains unclear that measurement of blood gas pH, via arterial or venous sampling, impacts management of the patient substantially enough to warrant the testing, especially if sodium bicarbonate administration is not being considered. There are special circumstances when serial ABG monitoring and/or sodium bicarbonate infusion are necessary, which we also review. Additional studies are needed to determine the utility of these interventions in patients with severe DKA and pH less than 7.0.
文摘Diabetic ketoacidosis(DKA)and hyperosmolar hyperglycemia state(HHS)are two life-threatening metabolic complications of diabetes that significantly increase mortality and morbidity.Despite major advances,reaching a uniform consensus regarding the diagnostic criteria and treatment of both conditions has been challenging.A significant overlap between these two extremes of the hyperglycemic crisis spectrum poses an additional hurdle.It has well been noted that a complete biochemical and clinical patient evaluation with timely diagnosis and treatment is vital for symptom resolution.Worldwide,there is a lack of large-scale studies that help define how hyperglycemic crises should be managed.This article will provide a comprehensive review of the pathophysiology,diagnosis,and management of DKA-HHS overlap.
文摘Diabetic ketoacidosis(DKA)is defined as an acute metabolic disorder,which is characterized by an increased presence of circulating ketones,and the development of ketoacidosis in the presence of hyperglycemia.This syndrome occurs as a result of insulin deficiency.Patients can be dramatically ill,however,with aggressive treatment,most patients recover rapidly.Despite being a low-risk condition,the development of acidosis,is one of the admission criteria to the intensive care unit(ICU)for these patients,in order to provide close monitoring,and recognize complications that could result from the use of aggressive therapy,such as continuous infusions if insulin.In some institutions,DKA is treated in the emergency department and general medical/surgical wards to avoid ICU overcrowding.
