(Thread from Diabetes) #: 804189 S16/Ask the Doc (CIS:DIABETE) 01-Jun-98 22:59:14 Sb: What is DKA? Fm: Conrad Kageyama 76703,1010 To: ALL Replies: 1 TID: 5184 Par: 0 Chd: 804207 Sib: 0 What is DKA exactly? I mean, what is the sequence of events that leads from high bgs to DKA?.. connie #: 804207 S16/Ask the Doc (CIS:DIABETE) 01-Jun-98 23:54:10 Sb: What is DKA? Fm: WIZOP-David Groves 76703,4223 To: Conrad Kageyama 76703,1010 (X) Replies: 1 TID: 5184 Par: 804189 Chd: 804210 Sib: 0 DKA is shorthand for diabetic ketoacidosis. Its cause is lack of insulin to properly manage ketones generated for energy in the absence of *useable* glucose. It is one of the distinguishing differences between Type 1 and Type 2 diabetes though it is far from 100% accurate. It is a presenting symptom/sign set for Type 1 diabetes in 30-60% of new cases. It can and does impact Type 2s but rather rarely. All Type 1s are subject to it after 3-4 days without injected insulin. Joslin's "Diabetes Mellitus" defined DKA as: "One of the greatest difficulties encountered in reporting the incidence, epidemiology, and mortality rate for DKA has been the lack of a uniformly accepted definition for this condition. The syndrome consists of a triad of hyperglycemia [often now missing with he speed of Human R and Humalog-dgg], ketosis, and acidemia, each of which may independently be associated with other clinical conditions. [Hyperglycemic states, Diabetes Mellitus, Non-ketotic Hyperosmolar Coma, Impaired Glucose Tolerance or Stress Hyperglycemia; Other Ketotic states, Ketotic Hypoglycemia, Alcoholic Ketosis; Other metabolic acidotic states, Lactic Acidosis, Hyperchloremic Acidosis, Uremic Acidosis, Drug Induced Acidosis] The consensus amongst most workers in the field that an arterial pH less than 7.3, a bicarbonate level less than 15meq/L, and a blood glucose greater than 250mg/dl with a moderate amount of ketonemia and ketonuria (as determined by the nitroprusside method) are necessary for the diagnosis. ... [various reasons now compounded by Humalog and Human R] ... Therefore, the level of blood glucose should NOT be a primary factor in the diagnosis of DKA." Precipitating factors in DKA: Infection 38% Omission of or inadequate Insulin 28% Unknown 2% Newly Diagnosed DM 22% Other(1) 10% Other causes include Alcohol Abuse, pulmonary embolism, pancreatitis, gastrointestinal obstruction, pleural effusion, surgery for undescended testicles, gunshot wound with 60% pancreatectomy, steroid treated lupus, acute asthma attack, and IV dextrose during oral surgery. Sample size = 202 The primary symptoms indicating DKA include nausea, vomiting and abdominal distress. (Remember the McNicholas case?) 95-98% of DKA is survived depending upon which country we are dealing with. Sadly, Hyperosmolar Hyperglycemic Nonketotic coma kills over 25% of it's victims and it is the primary problem for Type 2 with uncontrolled diabetes. Ironically, 4-13% (likely much more) of diabetic death in insulin users is caused by insulin. DKA is often caused by anorexia or bulemia. A week or two with DKA will cause up to a 40% weight loss without killing the victim. Life expectancy with untreated DKA may be under 8 hours or over 2 years. DKA can hit pumpers in under 4 hours with Humalog, but generally takes a day or two and the nausea and vomiting render the victim very strongly inclined to see an MD. (Though like all things re diabetes, nothing is always true for all diabetics!!) That cover it? #: 804210 S16/Ask the Doc (CIS:DIABETE) 02-Jun-98 00:08:13 Sb: What is DKA? Fm: Conrad Kageyama 76703,1010 To: WIZOP-David Groves 76703,4223 (X) Replies: 1 TID: 5184 Par: 804207 Chd: 804211 Sib: 0 >> DKA is shorthand for diabetic ketoacidosis. Its cause is lack of insulin >> to properly manage ketones generated for energy in the absence of >> *useable* glucose. Lemme see if I got that... In other words, if you don't have enough insulin to properly break down the glucose for energy, then ketones are generated instead?.. connie #: 804211 S16/Ask the Doc (CIS:DIABETE) 02-Jun-98 02:52:06 Sb: What is DKA? Fm: WIZOP-David Groves 76703,4223 To: Conrad Kageyama 76703,1010 (X) Replies: 1 TID: 5184 Par: 804210 Chd: 804223 Sib: 0 Message text written by Conrad Kageyama >Lemme see if I got that... In other words, if you don't have enough insulin to properly break down the glucose for energy, then ketones are generated instead?.. connie< I'll give you 50% on that one, Connie. Would that it were so simple! It is more complex. You can get ketones from exercise, starvation or diabetes, either by hyper (the usually considered route) OR hypoglycemia! One of the classic errors made by many hospitals and MDs is to assume that the presence of ketones means NSF of insulin. This is part of the reason so many diabetics (especially those on "Human" insulin) get grossly overmedicated and die. Type 2 is a condition of "relative" insulin insufficiency where Type 1 is a condition of absolute insulin insufficiency. For all the zeal for pumping, pump users are much more likely to go DKA than those who use slower acting insulins. It takes very little insulin to prevent DKA and most Type 2s produce enough to NOT go DKA ever, Type 1s are always at high risk and it is a very ugly picture. The key to DKA is absolute insulin deficiency. Does that make sense? #: 804223 S16/Ask the Doc (CIS:DIABETE) 02-Jun-98 10:32:00 Sb: What is DKA? Fm: Conrad Kageyama 76703,1010 To: WIZOP-David Groves 76703,4223 (X) Replies: 1 TID: 5184 Par: 804211 Chd: 804242 Sib: 0 >> The key to DKA is absolute insulin deficiency. Does that make sense? Okay, that paints a better picture. That said, then DKA is more of a Type 1 problem than a Type 2 problem. For Type 2s, then, what is the manifestation of going too high with the bgs? I mean, I know about the complications that arise from diabetes and high bgs over the longer term, but I mean in the short term. What happens if a Type 2's bgs start skyrocketing uncontrolled? Will he keel over or suddenly get very sick in one form or another? Or do Type 2s only have to protect against lows?.... connie #: 804242 S16/Ask the Doc (CIS:DIABETE) 02-Jun-98 13:42:12 Sb: What is DKA? Fm: WIZOP-David Groves 76703,4223 To: Conrad Kageyama 76703,1010 (X) Replies: 1 TID: 5184 Par: 804223 Chd: 804263 Sib: 0 >> For Type 2s, then, what is the manifestation of going too high with the bgs? I mean, I know about the complications that arise from diabetes and high bgs over the longer term, but I mean in the short term. What happens if a Type 2's bgs start skyrocketing uncontrolled? Will he keel over or suddenly get very sick in one form or another? Or do Type 2s only have to protect against lows?.... connie << Type 2s have a huge risk from hyperglycemia variously called HONK or HHNS. (Hyperosmolar Hyperglycemic Non-Ketotic Syndrome-Coma). Where DKA only kills about 5% of its victims, HONK kills over 25% and is almost the exclusive domain of Type 2 diabetes. Type 2s can get DKA and would show the classic symptoms of a Type 1 in DKA. For HHNS: "HHNS is diagnosed by finding the following biochemical profile: 1) plasma glucose > 600mg/dl (33.33mmol/L); 2)serum osmolality >330mOsm/L; 3) absence or minimal level of serum ketones; 4) arterial pH > 7.3; 5) serum bicarbonate > 20meq/L; 6) moderate to severe mental obtudation; and 7) negative or small amounts of urine ketones." Precipitating factors for HHNS Infection 60% New-onset Diabetes 33% Discontinued Insulin 0% Unknown/Misc. 7% ... the hallmark of HHNS is dehydration and severe hyperglycemia, the biochemical mechanism underlying the pathgenesis of these two components has not been fully elucidated. In general, 3 major mechanisms have been proposed to account for the greater dehydration and lack of significant ketogenesis in HHNS compared to DKA: 1) higher levels of counterregulatory hormones and free fatty acids in DKA vs HHNS; 2) relatively higher levels of endogenous insulin reserve in HHNS, ie insulin adequate to prevent lipolysis but inadequate to prevent hepatic glucose production and/or stimulate glucose utilization; and 3) inhibition of lipolysis by the hyperosmolar state decreasing ketogenesis." Symptomatically, there is little distinction between DKA and HHNS though with HHNS the patient is usually much warmer (99.6F). That round it out fer ya? #: 804263 S16/Ask the Doc (CIS:DIABETE) 02-Jun-98 16:02:13 Sb: What is DKA? Fm: Conrad Kageyama 76703,1010 To: WIZOP-David Groves 76703,4223 (X) Replies: 0 TID: 5184 Par: 804242 Chd: 0 Sib: 0 >> That round it out fer ya? yep, that does the trick, Dave. thanx!... connie