Fluid and electrolyte management in Diabetic Ketoacidosis and Hyperosmolar Hyperglycaemic state in the emergency department Introduction Diabetes Mellitus is a growing issue for health care providers internationally. The World Health organization estimated in 2013 there were 347 Million diabetics worldwide, predicting that Diabetes will be the 7th leading cause of death by 2030 (WHO, 2013). In both type 1 and type 2 diabetes Mellitus, factors such as poor compliance with diet and medication, infection, acute medical or surgical illness or trauma can lead to poor glycaemic control, precipitating a hyperglycaemic emergency such as Diabetic Ketoacidosis (DKA) (Scobie & Samaras, 2009). In Type 2 Diabetes, another equally dangerous complication can occur called Hyperosmolar, hyperglycaemic state (HHS) (Dunning, 2009). Both DKA and HHS are characterized by dehydration resulting from osmotic diuresis (Kisiel & Marsons 2009), often compounded by the patient already being in a dehydrated state due to the underlying cause (Del Garcia-Pascual & Kidby, 2012). It is therefore imperative that when a patient presents to an emergency department, rehydration and electrolyte replacement forms an integral component of treatment. Monash Health has developed protocols to treat DKA and HHS, a large part of which focus on rehydration and electrolyte management. This review will discuss the mechanisms of Dehydration in DKA and HHS, the importance of an effective rehydration and electrolyte management in both conditions; examine the differences between DKA and HHS in terms of onset, volume deficit and electrolyte changes, and compare best practice recommendations with the policies currently adopted by Monash Health. What are DKA and HHS? DKA an... ... middle of paper ... ...=eds-live Pamaiahgari, P. (2014). Diabetic Ketoacidosis and Hyperglycaemic Hyperosmolar Nonketotic Syndrome: Clinician Information. The Joanna Briggs Institute. Retrieved from: http://www.Joannabriggs.org Raghaven, V. A. (2014). Diabetic Ketoacidosis treatment and management. Medscape references, Drugs diseases and procedures. Retrieved from: http://emedicine.medscape.com/article/118361-treatment#aw2aab6b6b2 Scobie, I., & Samaras, K. (2009) Fast Facts: Diabetes Mellitus (3rd Ed.) Retrieved from: http://monash.worldcat.org/title/fast-facts-diabetes-mellitus/oclc/797833912&referer=brief_results Venkatraman, R., & Singhi,S. C. (2006) Hyperglycemic Hyperosmolar Nonketotic Syndrome. Indian Journal of Paediactrics (Vol 73), 55-60. DOI: 10.1007 BF02758261 WHO (2013) Diabetes Fact sheet No. 312. Retrieved from http://www.who.int/mediacentre/factsheets/fs312/en/
Vital to maintenance of homeostasis is the regulation of plasma osmolality. The Renin-Angiotensin-Aldosterone system, which works to regulate blood pressure, plays a crucial role in fluid balance. When dehydration occurs, blood osmolality increases, which stimulates the release of antidiuretic hormone (ADH), ultimately leading to increased water reabsorption. This leads to more concentrated urine, and less concentrated plasma. Low plasma osmolality works in the opposite fashion: ADH release is inhibited, water reabsorption decreases, and urine is less concentrated. The added electrolytes and carbohydrates in Gatorade would facilitate greater fluid retention through stimulation of renin and vasopressin, increasing urinary sodium reabsorption (3). Studies of both urine volume and plasma volume changes are eff...
3: Briscoe VJ, Davis SN (2006) Hypoglycaemia in Type 1 and 2 Diabetes: Physiology, pathophysiology and management. Clinical Diabetes, 24 (3), 115-121
During the year 1889, two researchers, Joseph Von Mering and Oskar Minkowski, discovered the disease that is known today as diabetes. Diabetes is a disease in which the insulin levels (a hormone produced in unique cells called the islets of Langerhans found in the pancreas) in the bloodstream are irregular and therefore affect the way the body uses sugars, as well as other nutrients. Up until the 1920’s, it was known that being diagnosed with diabetes was a death sentence which usually affected “children and adults under 30.” Those who were diagnosed were usually very hungry and thirsty, which are two of the symptoms associated with diabetes. However, no matter how much they ate, their bodies wouldn’t be able to use the nutrients due to the lack of insulin.
Rao, Goutham. "Childhood Obesity and Type 2 Diabetes Mellitus". Official Journal of the American Academy of Pediatrics.( 2005): 473-480. Print.
Peppa M, Uribarri J, and Vlassara H. Glucose, Advanced Glycation End Products, and Diabetes Complications: What Is New and What Works. Clinical Diabetes October 2003 vol. 21 no. 4 186-187.
Frequent urination results from the body trying to excrete the excess glucose and thirst follows as dehydration sets in. Hunger, fatigue, mental fogginess, irritability, and mood changes result from a deficiency in ATP as the body cannot produce enough purely through fat metabolism via ketones. Acetone breath quickly follows as the body starts to upregulate fat metabolism in an attempt to use ketones for ATP production. This metabolic pathway creates various ketones, but one ketone acetone, is toxic and is excreted via the lungs. It can be detected as a “fruity” odor in the breath. This upregulation of fat metabolism creates a crisis known as diabetic ketoacidosis which can lead to a coma or even death (Harvey, 2012). Another life threatening acute symptom which is not as common in type 1 as type 2 diabetes is hyperglycemic hyperosmolar nonketonic syndrome or HHNS which can result in serious consequences such as a coma or even death. It is caused by increasing blood sugar and dehydration without the presence of ketones (Harvey, 2012). It can be caused by severe infection, severe illness, and medications that reduce glucose tolerance and increase fluid loss (Harvey, 2012). The various acute symptoms of type 1 diabetes are just as deadly as the long term effects of poor blood sugar
Diabetes is a disease in which a person’s body in unable to make or utilize insulin properly which affects blood sugar levels. Insulin is a hormone that is produced in the pancreas, which helps to regulate glucose (sugar) levels, break down carbohydrates and fats, and is essential to produce the body’s energy. The CDC (2013) offers reliable insight, summarized here, into the different types of diabetes, some causes, and health complications that may arise from the disease.
The first evidence of diabetes was found on an early Egyptian manuscript from 1500 BCE, however; it is only in the last 200 years that we understand what is happening at the cellular level in a diabetic individual (Polansky, 2012). We now know that diabetes is a complex disorder of genetic, chemical, and lifestyle factors that contribute to the body’s inability to utilize glucose for energy and cellular functions (ADA, 2013).
Diabetes is one of the leading chronic causes of deaths in children and adolescent’s in the United States. Diabetes mellitus is a group of diseases that is characterized by high levels of glucose in the bloodstream resulting from defects in insulin production, insulin action or even both (Overview, 1). Diabetes is a serious health issue and can be associated with premature death or serious complications. Timely diagnosed treatment of diabetes can delay or prevent any onset of long-term complications, such as damage to blood vessels, kidneys, gums, skin, teeth, and many other complications (Overview, 1). Diabetes can be difficult to deal with during the time of adolescence. People with diabetes or those who have family members with diabetes should be very well informed (Cho, 1).
Type 1 diabetes has a genetic onset that often occurs in adolescence (Porth, 2005). It is an autoimmune disease in which the insulin-producing beta cells within the liver are destroyed (Dorman, 1993). This causes a deficiency in insulin secretion, which ultimately leads to high blood glucose levels, also referred to as hyperglycemia (Guthrie & Guthrie, 2004). The mechanism for insulin deficiency leading to hyperglycemia is described in more detail in the following section and in Figure 1.
Neu, A; Hofer, S.E., MD; Karges, Beate; Oeverink, Rudolf; Rosenbauer, J; Holl, R.W., MD. (Sept. 2009). Ketoacidosis at Diabetes Onset Is Still Frequent in Children and Adolescents: A multicenter analysis of 14,664 patients from 106 institutions. Diabetes Care, 32(9) 1647-8. Scholarly Journals. Retrieved from ProQuest Research Library.
Diabetes is a chronic disorder of metabolism characterized by a partial or complete deficiency of the hormone insulin. With this, there are metabolic adjustments that occur everywhere in the body. Specific to this child is Type One Diabetes. This is characterized by demolition of the pancreatic beta cells, which produce insulin. Because of this, it leads to complete insulin deficiency. Within Type One diabetes, there are two different forms. First there is immune-mediated deficiency, which typically results from an autoimmune destruction of the beta cells. The second type is called idiopathic type one, in which the cause is unknown. (Wong, Hockenberry, Wilson, 2015)
Retrieved from http://www.ninds.nih.gov/disorders/diabetic/diabetic.htm.
Diabetic Ketoacidosis (DKA) is a serious disease with complications that may have fatal results in some cases. DKA is defined as an insulin deficiency that occurs when glucose fails to enter insulin into muscles such as: liver and adipose tissue. When there is an accumulation of ketones, it leads to metabolic acidosis which causes nausea and vomiting, as a result fluid and electrolytes are lost (Gibbs). There are many complications of diabetic ketoacidosis, some of the most prevalent are: Cerebral Edema, Hypoglycemia, and Acute Pancreatitis.
In our society today, the number of people diagnosed with diabetes is increasing. Diabetes is caused by many factors, like genetics, inactivity, and obesity. With obesity on the rise in our country, so is diabetes, especially in young children. With the fattening and unhealthy foods provided by fast food chains and grocery stores, children are the ones that diabetes affects the most, causing them to have higher chances of being diagnosed with diabetes. According to Kim and Lee (2008), the rates of childhood obesity have tripled over the past three decades.