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1.
Hyperlactatemia associated with diabetic ketoacidosis in pediatric intensive care unit.
Liu, J, Yan, H, Li, Y
BMC endocrine disorders. 2021;(1):110
Abstract
BACKGROUND Children with diabetic ketoacidosis often have elevated lactate. In this study, we investigated the clinical variables associated with hyperlactatemia in children with diabetic ketoacidosis. METHODS We designed a single-center retrospective descriptive study of children with diabetic ketoacidosis in a pediatric intensive care unit. RESULTS Of the 107 patients with diabetic ketoacidosis included in the analysis, 61 developed hyperlactatemia. Multivariate logistic regression analysis showed that heart rate (p = 0.003),diastolic blood pressure (p = 0.001) and stage of severity (p = 0.042) were independently associated with the development of hyperlactatemia in diabetic ketoacidosis. We found that lactate level was not significantly associated with length of hospital stay (p = 0.115) or the length of time to diabetic ketoacidosis resolution (p = 0.143). CONCLUSIONS Children with diabetic ketoacidosis presenting with severer stage, elevated heart rate and higher diastolic blood pressure may be prone to hyperlactatemia. Hyperlactatemia was not associated with length of time to DKA resolution and length of hospital stay.
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Effect of insulin therapy on IGF-1 level in children with new-onset type 1 diabetes mellitus: a comparison between DKA and non-DKA.
Shiva, S, Behbod, H, Ghergherechi, R
Journal of pediatric endocrinology & metabolism : JPEM. 2013;(9-10):883-6
Abstract
BACKGROUND AND OBJECTIVE The issue of insulin-like growth factor 1 (IGF-1) and diabetes in adults and type 2 diabetes has been well investigated. A few studies have investigated the serum IGF-1 level at the onset of type 1 diabetes mellitus (T1DM) in children. In the present study, we investigated the IGF-1 level of T1DM children before and after insulin therapy. SUBJECTS AND METHODS Between August 2011 and October 2012, 62 children with newly diagnosed T1DM were recruited. Serum IGF-1 levels were compared before and 1 month after insulin therapy between diabetic ketoacidosis (DKA) and non-DKA patients. RESULTS Thirty-one patients without DKA (18 girls and 13 boys, mean age 8.8 ± 3.01 years) and 31 patients with DKA (18 girls and 13 boys, mean age 8.3 ± 3.7 years) were studied. The mean IGF-1 in the DKA group was lower than that in the non-DKA group; however, this difference was not statistically significant (p=0.10). Serum IGF-1 levels increased significantly 1 month after insulin therapy in both the DKA (p<0.001) and non-DKA (p<0.001) groups. CONCLUSION Serum IGF-1 level is reduced in new-onset T1DM children. A significant increase in serum IGF-1 level can occur with insulin therapy in both DKA and non-DKA children.
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3.
Coagulation assessment in children with diabetic ketoacidosis.
Tran, TH, Al-Harfi, I, Harle, CC, Kahr, WH, Morrison, GC, Kornecki, A
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2013;(3):256-60
Abstract
OBJECTIVES To assess potential hypercoagulability during diabetic ketoacidosis in children. DESIGN A prospective, controlled pilot study. SETTING University-affiliated pediatric critical care unit and emergency department in a tertiary care children's hospital. PATIENTS Children (1-18 years) admitted with an episode of diabetic ketoacidosis and healthy children as controls. All patients with diabetic ketoacidosis managed according to a preestablished protocol. INTERVENTIONS Thromboelastography was performed using citrated whole-blood samples drawn at the time of admission and upon biochemical and clinical resolution of diabetic ketoacidosis. Citrated whole-blood samples drawn from healthy nondiabetic children acted as control samples. MEASUREMENTS AND MAIN RESULTS Fifteen patients (11.7 ± 4.1 years) in the diabetic ketoacidosis group and 20 patients (8.9 ± 4.5 years; p = 0.06) in the control group completed the study. Values for standard thromboelastography parameters (R and K time, α angle, maximum amplitude, coagulation index, and Ly30) in the diabetic ketoacidosis group, both on admission and resolution, were within the control range; thromboelastography profiles of diabetic ketoacidosis patients on admission were not significantly different from profiles obtained upon diabetic ketoacidosis resolution. The mean α-angle was significantly higher in known diabetic patients compared with newly diagnosed diabetics on admission; however, it still remained within the control normal range. CONCLUSIONS Thromboelastographic assay results do not reflect a hypercoagulable state in this group of children with diabetic ketoacidosis. Further investigation is required to examine the potential role of injured endothelium in the suspected hypercoagulability during diabetic ketoacidosis.
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Diabetic ketoacidosis at diagnosis influences complete remission after treatment with hematopoietic stem cell transplantation in adolescents with type 1 diabetes.
Gu, W, Hu, J, Wang, W, Li, L, Tang, W, Sun, S, Cui, W, Ye, L, Zhang, Y, Hong, J, et al
Diabetes care. 2012;(7):1413-9
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Abstract
OBJECTIVE To determine if autologous nonmyeloablative hematopoietic stem cell transplantation (AHSCT) was beneficial for type 1 diabetic adolescents with diabetic ketoacidosis (DKA) at diagnosis. RESEARCH DESIGN AND METHODS We enrolled 28 patients with type 1 diabetes, aged 14-30 years, in a prospective AHSCT phase II clinical trial. HSCs were harvested from the peripheral blood after pretreatment consisting of a combination of cyclophosphamide and antithymocyte globulin. Changes in the exogenous insulin requirement were observed and serum levels of HbA(1c), C-peptide, and anti-glutamic acid decarboxylase antibody were measured before and after the AHSCT. RESULTS After transplantation, complete remission (CR), defined as insulin independence, was observed in 15 of 28 patients (53.6%) over a mean period of 19.3 months during a follow-up ranging from 4 to 42 months. The non-DKA patients achieved a greater CR rate than the DKA patients (70.6% in non-DKA vs. 27.3% in DKA, P = 0.051). In the non-DKA group, the levels of fasting C-peptide, peak value during oral glucose tolerance test (C(max)), and area under C-peptide release curve during oral glucose tolerance test were enhanced significantly 1 month after transplantation and remained high during the 24-month follow-up (all P < 0.05). In the DKA group, significant elevation of fasting C-peptide levels and C(max) levels was observed only at 18 and 6 months, respectively. There was no mortality. CONCLUSIONS We have performed AHSCT in 28 patients with type 1 diabetes. The data show AHSCT to be an effective long-term treatment for insulin dependence that achieved a greater efficacy in patients without DKA at diagnosis.
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Diabetic ketoacidosis and memory dysfunction in children with type 1 diabetes.
Ghetti, S, Lee, JK, Sims, CE, Demaster, DM, Glaser, NS
The Journal of pediatrics. 2010;(1):109-14
Abstract
OBJECTIVE We tested the hypothesis that diabetic ketoacidosis (DKA) results in memory deficits typical of hypoxic/ischemic injury because recent studies suggest that cerebral metabolic changes similar to those observed in hypoxic/ischemic cerebral injury are observed in children with DKA, even without symptoms suggesting cerebral injury. STUDY DESIGN Thirty-three children with type 1 diabetes mellitus (T1DM) and a history of DKA and 29 children with T1DM without a history of DKA were enrolled from an academic hospital pediatric endocrinology clinic. These groups were comparable on demographic and disease-related variables. These groups' ability to recall events in association with specific details, the memory function most directly affected by mild hypoxia/ischemia, was compared on 2 tasks (ie, event-color associations and event-spatial position associations). RESULTS In multivariate analyses controlling for other critical variables, children with DKA history had significantly lower rates of accurate memory on both tasks (mean, 0.34 +/- 0.13 on the color task and 0.57 +/- 0.15 on the spatial task) than did children without DKA history (mean, 0.44 +/- 0.11 and 0.65 +/- 0.18, P < .01). CONCLUSIONS DKA disrupts memory function, underscoring the importance of DKA prevention when T1DM is known and prompt diagnosis of children with new onset of T1DM.
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Point-of-care test identifies diabetic ketoacidosis at triage.
Naunheim, R, Jang, TJ, Banet, G, Richmond, A, McGill, J
Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2006;(6):683-5
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a common, life-threatening complication of diabetes. The diagnosis of DKA relies on signs and symptoms, plus laboratory findings of blood glucose (BG) of > 250 mg/dL, an anion gap (AG) of > or = 15 mmol/L, and carbon dioxide (CO2) of < or = 18 mmol/L when other causes of acidosis are excluded. OBJECTIVES To compare the results of a point-of-care test for the ketone beta-hydroxybutyrate (beta-OHB) with standard measures for accuracy in predicting DKA. METHODS After providing informed consent, 160 patients who presented with BG of > 250 mg/dL underwent testing for beta-OHB with the Precision Xtra meter (Abbott Laboratories, North Chicago, IL) at triage in a large urban hospital emergency department. The diagnosis of DKA was made by clinicians by using standard clinical criteria without knowledge of the beta-OHB test. RESULTS A diagnosis of DKA was made in 57 of 160 subjects. The beta-OHB values correlated strongly with AG (r = 0.66, p < 0.001) and with CO2 (r = -0.69, p < 0.001), as well as with glucose (r = 0.31, p < 0.001). Cross-classification of DKA vs. beta-OHB yielded sensitivity of 98% (95% CI = 91% to 100%), specificity of 85% (95% CI = 78% to 91%), with a positive likelihood ratio of 6.7 (95% CI = 4.22 to 10.78), and negative likelihood ratio of 0.021 (95% CI = 0.003 to 0.144) at the manufacturer-suggested beta-OHB level of 1.5. CONCLUSIONS The point-of-care test for beta-OHB was as sensitive as more established indicators of DKA. It is more useful than glucose alone for the diagnosis of DKA and offers immediate diagnosis of patients at triage.
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Does potassium concentration measured on blood gas analysis agree with serum potassium in patients with diabetic ketoacidosis?
Fu, P, Douros, G, Kelly, AM
Emergency medicine Australasia : EMA. 2004;(4):280-3
Abstract
OBJECTIVE The aims of this study were to define the maximum clinically acceptable difference between potassium concentrations on different samples and to determine the degree of agreement between potassium concentration measured on blood gas analysis and serum for patients with diabetic ketoacidosis (DKA). METHODS This project comprised two sub studies. In the first, 15 emergency physicians, intensivists and endocrinologists were surveyed and asked to mark on a line with markings at 0.5 mmol/L intervals, the maximum clinically acceptable differences (both above and below the 'true' value) between potassium concentration measured on different samples. The maximum clinically acceptable difference was calculated as the median of responses. The second study was a retrospective agreement study. Patients with an ED diagnosis of DKA were identified from a computer database. They were eligible for inclusion if they had both blood gas analysis including potassium concentration and serum potassium concentration and pH was less than 7.3. Data collected included potassium concentration on serum and blood gas samples, pH, serum glucose concentration and time of sample collections. Data were analysed using bias plot and Spearman correlation analyses. RESULTS The maximum clinically acceptable difference was defined as 0.5 mmol/L for both over and underestimation of potassium concentration. Fifty patients were studied with a median pH of 7.17 and median serum glucose of 29.5 mmol/L. Difference in potassium concentration between samples ranged from -0.9-2.9 mmol/L. 80% of sample pairs had a difference within the maximum clinically acceptable difference defined previously. The magnitude of difference between samples correlated with serum glucose (P = 0.0033, coefficient 0.41) but not with pH. CONCLUSION This study suggests that potassium concentration derived from blood gas analysis may not be an acceptable substitute for serum potassium concentration in patients with diabetic ketoacidosis, particularly at higher serum glucose concentrations.
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A prospective study of the "two-bag system'' in diabetic ketoacidosis management.
Poirier, MP, Greer, D, Satin-Smith, M
Clinical pediatrics. 2004;(9):809-13
Abstract
The "two-bag'' system, an adaptation of the euglycemic clamp technique, consists of simultaneous administration of 2 intravenous (IV) fluid bags of differing dextrose concentrations. Individualized therapy is dictated by adjustment of the infusion rate of each bag. We sought to assess the benefits of the two-bag system in the initial acute emergency department management of children in diabetic ketoacidosis (DKA). Thirty-three children presenting to an urban pediatric emergency department in DKA were randomized into 2 groups: patients managed with the two-bag system and patients managed with the traditional "one-bag'' system. Other aspects of the management were standardized. Outcome measures included rate of decline in serum glucose, rate of bicarbonate correction, time on IV insulin therapy, and response time for IV fluid changes. Study period was defined as time on IV insulin therapy. There were no differences between the 2 groups in demographic parameters, initial baseline metabolic parameters, or total time on IV insulin therapy. There were no differences between the groups in average rates of serum glucose decline: two-bag 33.1 mg/dL/hr (s.e. 5.57, 95% CI 22.2, 44), one-bag 30.2 mg/dL/hr (s.e. 5.72, 95% CI 19, 41.4); average rate of serum bicarbonate correction: two-bag 1.19 mEq/L/hr, one-bag 1.27 mEq/L/hr; or the average number of IV fluid bags used: two-bag 4.1 bags, one-bag 3.2 bags. However, there was a difference between the groups in regard to elapsed total time to make changes in the IV fluids: two-bag 1 minute, one-bag 42 minutes, (p < 0.001). The "two-bag'' system enables a faster response time in making IV fluid therapy changes. This efficiency makes this system ideal for use in the emergency department.
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Treatment of diabetic ketoacidosis with subcutaneous insulin aspart.
Umpierrez, GE, Cuervo, R, Karabell, A, Latif, K, Freire, AX, Kitabchi, AE
Diabetes care. 2004;(8):1873-8
Abstract
OBJECTIVE In this prospective, randomized, open trial, we compared the efficacy and safety of aspart insulin given subcutaneously at different time intervals to a standard low-dose intravenous (IV) infusion protocol of regular insulin in patients with uncomplicated diabetic ketoacidosis (DKA). RESEARCH DESIGN AND METHODS A total of 45 consecutive patients admitted with DKA were randomly assigned to receive subcutaneous (SC) aspart insulin every hour (SC-1h, n = 15) or every 2 h (SC-2h, n = 15) or to receive IV infusion of regular insulin (n = 15). Response to medical therapy was evaluated by assessing the duration of treatment until resolution of hyperglycemia and ketoacidosis. Additional end points included total length of hospitalization, amount of insulin administration until resolution of hyperglycemia and ketoacidosis, and number of hypoglycemic events. RESULTS Admission biochemical parameters in patients treated with SC-1h (glucose: 44 +/- 21 mmol/l [means +/- SD], bicarbonate: 7.1 +/- 3 mmol/l, pH: 7.14 +/- 0.09) were similar to those treated with SC-2h (glucose: 42 +/- 21 mmol/l, bicarbonate: 7.6 +/- 4 mmol/l, pH: 7.15 +/- 0.12) and IV regular insulin (glucose: 40 +/- 13 mmol/l, bicarbonate 7.1 +/- 4 mmol/l, pH: 7.11 +/- 0.17). There were no statistical differences in the mean duration of treatment until correction of hyperglycemia (6.9 +/- 4, 6.1 +/- 4, and 7.1 +/- 5 h) or until resolution of ketoacidosis (10 +/- 3, 10.7 +/- 3, and 11 +/- 3 h) among patients treated with SC-1h and SC-2h or with IV insulin, respectively (NS). There was no mortality and no differences in the length of hospital stay, total amount of insulin administration until resolution of hyperglycemia or ketoacidosis, or the number of hypoglycemic events among treatment groups. CONCLUSIONS Our results indicate that the use of subcutaneous insulin aspart every 1 or 2 h represents a safe and effective alternative to the use of intravenous regular insulin in the management of patients with uncomplicated DKA.
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Differential effects of fasting and dehydration in the pathogenesis of diabetic ketoacidosis.
Burge, MR, Garcia, N, Qualls, CR, Schade, DS
Metabolism: clinical and experimental. 2001;(2):171-7
Abstract
Glycemia varies widely in patients with diabetic ketoacidosis (DKA), with plasma glucose concentrations between 10 to 50 mmol/L commonly encountered. The mechanism of this glycemic variability is uncertain. Our study examined the differential effects of fasting and dehydration on hyperglycemia induced by withdrawal of insulin in type 1 diabetes. To evaluate the respective roles of dehydration and fasting in the pathogenesis of DKA, 25 subjects with type 1 diabetes were studied during 5 hours of insulin withdrawal before (control) and after either 32 hours of fasting (n = 10) or dehydration of 4.1% +/- 2.0% of baseline body weight (n = 15). Samples were obtained every 30 minutes during insulin withdrawal for substrate and counterregulatory hormone levels and rates of glucose production and disposal. Fasting resulted in reduced plasma glucose concentrations compared with the control study, while dehydration resulted in increased plasma glucose concentrations compared with the control study (P < .001). Glucose production and disposal were decreased during the fasting study and increased during the dehydration study compared with the control study. Glucagon concentrations and rates of development of ketosis and metabolic acidosis were increased during both fasting and dehydration compared with control. These data suggest that fasting and dehydration have differential effects on glycemia during insulin deficiency, with dehydration favoring the development of hyperglycemia and fasting resulting in reduced glucose concentrations. This finding is probably attributable to the differing effect of these conditions on endogenous glucose production, as well as to differences in substrate availability and counterregulatory hormone concentrations. The severity of pre-existing fasting and dehydration likely explains much of the variability in plasma glucose concentrations observed in DKA.