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- Severe metabolic derangement in patients with diabetes mellitus secondary to insulin deficiency and/or stress hormone excess
- Clinical features include hyperglycemia, ketosis, metabolic acidosis, dehydration, and electrolyte deficits.
- Diabetes ketoacidosis (DKA) occurs more commonly in type 1 diabetes (T1D) but can also occur in type 2 diabetes (T2D).
- 20–40% of children with new-onset T1D present in DKA
- Risk of DKA in established T1D is 1–10% per patient per year (most episodes caused by insulin omission/diabetes mismanagement).
- DKA accounts for majority of diabetes-related deaths in childhood (most secondary to cerebral edema/brain injury).
- For T1D presenting as DKA:
- Very young children (<5 years)
- Ethnic minority
- Inadequate health insurance
- A missed diagnosis of diabetes in preceding clinic visits is frequent in DKA patients (~35%).
- For DKA in established diabetes:
- Lack of health insurance
- Poor glycemic control
- Ethnic minority
- Low socioeconomic status (SES)
- Prompt diagnosis of new-onset diabetes (e.g., urinalysis in patients with poor weight gain, polyuria, influenza-like symptoms, vomiting)
- Patient/parental education regarding ketone testing (with any symptoms of illness or unexplained high blood glucose level)
- Strict supervision of long-acting (glargine, detemir) insulin injections by parents
- Detection and avoidance of insulin pump interruptions by frequent blood glucose testing and strict protocols for changing infusion sets
- Excess of counterregulatory “stress” hormone concentrations (glucagon, cortisol, and epinephrine) in relation to insulin concentrations occurs, either as a result of insulin absence (new-onset diabetes or insulin omission) or illness (raising stress hormone levels).
- Imbalance between counterregulatory hormones and insulin results in increased glycogenolysis and gluconeogenesis and decreased peripheral glucose uptake (causing hyperglycemia) as well as lipolysis and ketogenesis (causing ketosis).
- Hyperglycemia causes osmotic diuresis resulting in dehydration and electrolyte losses.
- Ketogenesis results in metabolic acidosis, causing vomiting and tachypnea.
- Dehydration causes poor tissue perfusion, raising lactate levels and is contributing to metabolic acidosis.
- Insulin deficiency
- New diagnosis of diabetes
- Insulin omission (diabetes mismanagement or insulin pump malfunction)
- Acute illness (leading to rise in counterregulatory hormone levels)
Commonly Associated Conditions
- Acute illness as a precipitating factor
- Autoimmune disorders (especially hypothyroidism) for persons with T1D