LA CONSULTA SEMANAL

ABRIL 2001

CONSULTA

Endocrinol Metab Clin North Am 2000 Dec;29(4):683-705, V
Diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome.
Delaney MF, Zisman A, Kettyle WM
Endocrinology-Hypertension Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) are life-threatening acute metabolic complications of diabetes mellitus. Although there are some important differences, the pathophysiology, the presenting clinical challenge, and the treatment of these metabolic derangements are similar. Each of these complications can be seen in type 1 or type 2 diabetes, although DKA is usually seen in patients with type 1 diabetes and HHNS in patients with type 2 disease. The clinical management of these syndromes involves careful evaluation and correction of the metabolic and volume status of the patient, identification and treatment of precipitating and comorbid conditions, a smooth transition to a long-term treatment regimen, and a plan to prevent recurrence.
Publication Types:
  Review
  Review, tutorial


Endocrinol Metab Clin North Am 2000 Dec;29(4):657-82
Diabetic ketoacidosis in children.
White NH
Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA. white_n@kids.wustl.edu
Diabetic ketoacidosis is a serious condition that warrants immediate and aggressive intervention. Even with appropriate intervention, DKA is associated with significant morbidity and possible mortality in diabetic patients in the pediatric age group. With appreciation of its severity, proper understanding of the pathophysiology, and careful attention to the details of management and close monitoring, most cases will have a satisfactory outcome. Because treatment is costly and because the risk for morbidity remains even under the best of circumstances, prevention of DKA must be a major goal in the treatment of type 1 diabetes mellitus. Involvement and close follow-up by a multidisciplinary team of health care professionals with experience in dealing with diabetes in
children and adolescents is the best way to avoid DKA.
Publication Types:
  Review
  Review, tutorial


Am J Emerg Med 2000 Oct;18(6):658-60
Initial fluid management of diabetic ketoacidosis in children.
Rutledge J, Couch R
Department of Pediatrics, University of Alberta, Edmonton, Canada.
The purpose of this study was to review the emergency department management of children presenting in diabetic ketoacidosis (DKA) to determine if current  recommendations for fluid therapy are practiced. A 5-year retrospective chart review was conducted of all pediatric patients admitted with DKA to the University of Alberta Hospital. Presenting clinical and laboratory data, the initial fluid therapy, and insulin dose were analyzed. The therapy was also compared between sites of initial presentation (primary, secondary, or tertiary hospital). A total of 49 cases of DKA in 37 patients were reviewed. There were no significant clinical or biochemical differences between patients presenting at the three levels of hospital. Forty-one cases (84%) were given a saline bolus and the mean fluid volume given by 1 hour was 18.3 mL/kg. In the first hour 82% of patients presenting at a primary or secondary centre and 67% of those at the tertiary centre received more than 10 mL/kg. This excessive fluid therapy was also evident after 4 hours. Fluid management of children in DKA is excessive and not in keeping with current recommendations. Education of emergency physicians is needed to reduce fluid therapy and the risk of neurologic complications.


Crit Care Med 1999 Dec;27(12):2690-3
Does bicarbonate therapy improve the management of severe diabetic ketoacidosis?
Viallon A, Zeni F, Lafond P, Venet C, Tardy B, Page Y, Bertrand JC
Emergency and Intensive Care Units, Hopital Bellevue, Centre Hospitalo-Universitaire, Saint-Etienne, France.
OBJECTIVE: The use of bicarbonates in the treatment of severe diabetic ketoacidosis remains controversial, especially regarding the benefit/risk ratio. The aim of this study was to assess the efficacy of bicarbonate therapy during severe diabetic ketoacidosis (pH <7.10). DESIGN: Retrospective study. SETTING: The emergency unit of a teaching hospital. PATIENTS: The records of 39 patients consecutively admitted for severe diabetic ketoacidosis were analyzed (pH <7.10).The patients were divided into two groups: group 1 (n = 24; patients with bicarbonate treatment) and group 2 (n = 15; patients without bicarbonate treatment). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared two groups of patients presenting with severe diabetic ketoacidosis (pH values between 6.83 and 7.08) treated with or without bicarbonate. A group of 24 patients received 120+/-40 mmol sodium bicarbonate. The two groups were similar at admission with regard to clinical and biological parameters. No difference could be demonstrated between the two groups concerning the clinical parameters or the normalization time of biochemical parameters. If the number of patients with hypokalemia was comparable between the two groups, the potassium supply was significantly more important in group 1 compared with group 2 (366+/-74 mmol/L vs. 188+/-109 mmol/L, respectively; p < .001). CONCLUSIONS: Data from the literature and this study are not in favor of the use of bicarbonate in the treatment of diabetic ketoacidosis with pH values between 6.90 and 7.10.
Publication Types:
  Review
  Review, tutorial


Am Fam Physician 1999 Aug;60(2):455-64 [Texto completo]
Management of diabetic ketoacidosis.
Kitabchi AE, Wall BM
Department of Medicine, University of Tennessee, Memphis, College of Medicine, 38163, USA.
Diabetic ketoacidosis is an emergency medical condition that can be life-threatening if not treated properly. The incidence of this condition may be increasing, and a 1 to 2 percent mortality rate has stubbornly persisted since the 1970s. Diabetic ketoacidosis occurs most often in patients with type 1 diabetes (formerly called insulin-dependent diabetes mellitus); however, its occurrence in patients with type 2 diabetes (formerly called non-insulin-dependent diabetes mellitus), particularly obese black patients, is not as rare as was once thought. The management of patients with diabetic ketoacidosis includes obtaining a thorough but rapid history and performing a physical examination in an attempt to identify possible precipitating factors. The major treatment of this condition is initial rehydration (using isotonic saline) with subsequent potassium replacement and low-dose insulin therapy. The use of bicarbonate is not recommended in most patients. Cerebral edema, one of the most dire complications of diabetic ketoacidosis, occurs more commonly in children and adolescents than in adults. Continuous follow-up of patients using treatment algorithms and flow sheets can help to minimize adverse outcomes. Preventive measures include patient education and instructions for the patient to contact the physician early during an illness.
Publication Types:
  Review
  Review, tutorial


Diabetes Care 1999 May;22(5):700-5
Risk for metabolic control problems in minority youth with diabetes.
Delamater AM, Shaw KH, Applegate EB, Pratt IA, Eidson M, Lancelotta GX, Gonzalez-Mendoza L, Richton S
University of Miami School of Medicine, FL 33101, USA. adelamat@peds.med.miami.edu
OBJECTIVE: We examined and quantified the degree of risk for poor glycemic control and hospitalizations for diabetic ketoacidosis (DKA) among black, Hispanic, and white children and adolescents with diabetes. RESEARCH DESIGN AND METHODS: We examined ethnic differences in metabolic control among 68 black, 145 Hispanic, and 44 white children and adolescents with type 1 diabetes (mean age 12.9 [range 1-21] years), who were primarily of low socioeconomic status. Clinical and demographic data were obtained by medical chart review. Glycohemoglobins were standardized and compared across ethnic groups. Odds ratios among the ethnic groups for poor glycemic control and hospitalizations for DKA were also calculated. RESULTS: The ethnic groups were not different with respect to age, BMI, insulin dose, or hospitalizations for DKA, but black children were older at the time of diagnosis than Hispanics (P < 0.05) and were less likely to have private health insurance than white and Hispanic children (P < 0.001). Black youths had higher glycohemoglobin levels than white and Hispanic youths (P < 0.001 after controlling for age at diagnosis). Black youths were also at greatest risk for poor glycemic control (OR = 3.9, relative to whites; OR = 2.5, relative to Hispanics). CONCLUSIONS: These results underscore and quantify the increased risk for glycemic control problems of lower-income, black children with diabetes. In the absence of effective intervention, these youths are likely to be overrepresented in the health care system as a result of increased health complications related to diabetes.


Acta Paediatr Suppl 1999 Jan;88(427):14-24
Diabetic ketoacidosis.
Brink SJ
New England Diabetes and Endocrinology Center, Waltham, MA 02154-1136, USA.
Diabetic ketoacidosis (DKA) is a true pediatric and medical emergency. Diagnosis should be entertained and confirmed within 30 min of presentation. Any delay in making the diagnosis or instituting fluid and electrolyte correction is likely to increase morbidity and mortality. Slow and careful monitoring and correction of water, sodium and potassium levels should decrease DKA-associated problems with either continuous intravenous low-dose insulin or intramuscular insulin protocols designed to slowly bring the hyperglycemic and hyperosmotic state towards normal homeostasis. Special attention should be paid to potassium replenishment. Most patients do not require bicarbonate replacement. Cerebral edema, when it occurs, is associated with an approximately 50% morbidity and mortality; therefore, all attempts should be made at early recognition and prevention since treatment is less than ideal. Recurrent ketoacidosis is often related to omitted insulin and major psychosocial turmoil in the family, such as depression substance abuse, physical and/or sexual abuse. Prevention of recurrent DKA remains a major challenge for diabetologists and involves detailed assessment of family psychodynamics plus responsibility for home monitoring and insulin administration by a mature adult. Sick day guidelines should be taught and reviewed frequently in an effort to decrease ketoacidosis and metabolic decompensation during episodes of intercurrent illness.
Publication Types:
  Review
  Review, tutorial


Postgrad Med 1997 Apr;101(4):193-8, 203-4
Diabetic ketoacidosis. Why early detection and aggressive treatment are crucial.
Bell DS, Alele J
Department of Medicine, University of Alabama School of Medicine, Birmingham, USA.
Diabetic ketoacidosis is a preventable condition that usually has a satisfactory outcome. However, the potential for a poor outcome and even death demands early and aggressive treatment. Insulin administration, rehydration, and electrolyte replacement are the mainstays of treatment. A search for the underlying cause is also a priority if recurrences are to be avoided.
Publication Types:
  Review
  Review, tutorial


Postgrad Med 1996 Jun;99(6):143-52
Diabetic ketoacidosis and hyperosmolar nonketotic state: gaining control over extreme hyperglycemic complications.
Gonzalez-Campoy JM, Robertson RP
Division of Diabetes, Endocrinology and Metabolism, University of Minnesota Medical School, Minneapolis, MN 55455, USA. gonza017@gold.tc.umn.edu
Decompensated hyperglycemia is a frequent, severe complication of diabetes mellitus. Ketoacidosis usually occurs in patients with insulin-dependent (type I) diabetes, and insulin therapy is required to correct their hyperglycemic derangement. Hyperosmolar nonketotic state is more common in patients with non-insulin-dependent (type II) diabetes, who usually present with severe dehydration and hyperosmolar plasma. They respond readily to aggressive volume expansion, and insulin has a lesser role in management. Some patients exhibit a mixture of ketoacidosis and hyperosmolarity, which suggests that the two conditions may represent variants of decompensated hyperglycemia that differ only by the magnitude of dehydration and the severity of acidosis. All diabetic patients with hyperglycemic decompensation should return to their usual hypoglycemic programs as soon as possible and receive close follow-up after hospitalization.
Publication Types:
  Review
  Review, tutorial


Lancet 1995 Mar 25;345(8952):767-72
Diabetic ketoacidosis.
Lebovitz HE
Department of Medicine, State University of New York Health Science Center at
Brooklyn, 11203-2098.
Publication Types:
  Review
  Review, tutorial


Obstet Gynecol Clin North Am 1995 Mar;22(1):143-55
Management of diabetic ketoacidosis in the obstetric patient.
Chauhan SP, Perry KG Jr
Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Peoria, USA.
Because of the normal metabolic changes found in pregnancy, diabetics are at increased risk to develop ketoacidosis. Even though the incidence of DKA during pregnancy has declined in recent years, prompt recognition of the presenting signs and symptoms followed by appropriate treatment of the associated metabolic disturbances can be lifesaving to the mother and her unborn child. Therapy is directed toward aggressive fluid resuscitation, avoidance of hypokalemia, and reversal of the hyperglycemia and ketoacidosis. When the clinician is confronted with DKA in the obstetric patient, aggressive therapeutic measures should maximize maternal and fetal outcome.
Publication Types:
  Review
  Review, tutorial