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Endocrinology

Diabetic ketoacidosis

Table of contents
Diabetic ketoacidosis
Therapy
Complications of diabetic ketoacidosis

Diabetic ketoacidosis (DKA) remains a serious and life-threatening state. Frequency of emergence and mortality from DKA at children did not change, despite the growing understanding among primary links of health care of the fact that diabetes can meet even at the earliest age. Diabetic ketoacidosis arises at 25% of children with diabetes, and at children under four years this proportion increases up to 40%. Frequency of repeated hospitalization with diabetic ketoacidosis the childhood makes about 0,2 patients a year. About 1% of episodes of diabetic ketoacidosis is complicated by wet brain, and it substantially defines the fact that diabetic ketoacidosis still is the main cause of death of children with diabetes.
The standard definition of diabetic ketoacidosis is not available, but practically this term designates the diabetes decompensation leading to a hyperglycemia, acidosis and availability of ketones. Blood glucose level, as a rule, considerably increases, but approximately in 8% of cases it can be less than 15 mmol/l. Factors which cause developing of diabetic ketoacidosis at children and teenagers differ from adults a little, and are given in table 1.
Let's consider the main origins of diabetic ketoacidosis. Glucose of blood raises as a result of strengthening of its products a liver which arises in response to increase in a ratio glucagon/insulin in portal blood circulation, and reduction of peripheral consumption of glucose owing to deficit of insulin and resistance to it. Levels of all counter-regulatory hormones (catecholamines, cortisol and a growth hormone) increase, promoting glucose hyperproduction by a liver. The hyperglycemia then leads to osmotic diuresis and dehydration. Increase of levels of ketonic bodies, acetoacetate and beta hydroxybutyrate arises owing to deficit of insulin which causes mobilization of free fatty acids from fatty tissue and increase of the relation glucagon/insulin in portal blood that leads to their preferential oxidation in ketonic bodies, but not their reesterifikation in triglycerides for transportation from a liver.

Table 1. Risk factors of diabetic ketoacidosis

Small children

Teenagers

Recently diagnosed diabetes, especially at babies
Emotions and stresses
Infectious diseases, virus and bacterial
Sometimes admissions of injections

Insulin underdosage, including both the admission of an injection, and reduction of a dose for the purpose of prevention of a hypoglycemia
Binges, especially at girls
Alcohol intake, in addition to above-mentioned

DKA are followed by considerable loss of liquid. Water deficit is caused by various combination of such factors as osmotic diuresis, vomiting, hyperventilation, and sometimes a hyperthermia. Losses of sodium can be also various, depending on nature of loss of liquid, and also adequacy of renal perfusion. Always there is exhaustion of potassium ions and phosphorus in fabrics while plasma levels can be both low, and normal or high. As a rule, the child or someone from parents tries to adjust loss of liquid by increase in consumption of various drinks. The bigger amount of water, than sodium is usually lost that induced a great number of authors to assume that the regidratation hypotonic salt solutions would be acceptable. However there are several reasons why it cannot be applied at children, especially in the light of recent ideas concerning a wet brain etiology which are given below.
The Giperosmolyarny coma at children is rare, but sometimes meets; osmolarity of serum usually exceeds 300 mosmol/l, and the ketosis is absent. Tactics at a giperosmolyarny coma is similar that at DKA, except for recommendations about very slow administration of insulin for the purpose of prevention of too fast falling of levels of glucose of blood and osmolarity of plasma.

Clinic.

The clinic of diabetic ketoacidosis is illustrated in Table 2. Small children have an atsidotichesky type of breath and a smell of ketones at breath can indicate existence of a respiratory infection. The asthmatic status or heavy pneumonia, in particular, can be diagnosed for the smallest, but the possibility of diabetic ketoacidosis has to be considered in each case of an illness of the small child, and definition
glucose level in capillary blood is obligatory as effects at the unspecified diagnosis diabetic ketoacidosis can be the most deplorable.

Table 2 Clinical signs of diabetic ketoacidosis

Symptoms

Polyuria

Drowsiness

Thirst, polydipsia

Dehydration

Loss of weight

The blood pressure is normal, is occasionally lowered

Abdominal pain

Kussmaul's breath, or afterwards his fading

Weakness

Smell of ketones in expired air

Vomiting

Body temperature is normal

Shortage of air

Disturbances of consciousness in 20% of cases

Psychosis

Loss of consciousness in 10% of cases

It is necessary to estimate as soon as possible a condition of consciousness of the child degree of dehydration and existence of shock. The child needs to be weighed. If the valid weight cannot be determined because of weight of a state, it is necessary to be guided by data of the last weighing or to calculate it from charts. Recently it was recognized that dehydration degree at children determined by clinical methods often significantly is overestimated and that clinical signs of dehydration, in particular, decrease in turgor or elasticity of skin, arises at dehydration within 3%, but not 5% as it is often quoted. For dehydration assessment small children of useful can have a technique of definition of time of capillary filling.
If during therapy the consciousness is broken, or there are changes in the neurologic status they have to be regarded as a medical emergency. Also the cardial monitor has to be installed.

Laboratory assessment

Table 3. The offered laboratory researches at diabetic ketoacidosis

Research

Notes

Blood glucose

To confirm result of capillary blood

Sodium, potassium, chlorine, phosphates, calcium

Due to the lipidemia are possible in a false manner - the underestimated sodium levels

Urea, creatinine

 

Gas composition of blood, rn, bicarbonates

The fence only from an arterial blood is necessary

General blood test, leukocytic formula

The leukocytosis is characteristic of diabetic ketoacidosis and not necessarily demonstrates existence of an infection

Urine crops

 

Blood crops, thorax X-ray

Only in the presence of the relevant clinic, for example, at temperature increase

Amylase

At the expressed abdominal pains which proceed against the carried-out therapy



 
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