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| ==Late signs==
| | #REDIRECT [[Diabetic ketoacidosis]] |
| At this point, DKA is life-threatening and medical attention should be sought immediately.
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| * Emesis ([[vomiting]]), although this is not always a sign of late-stage ketoacidosis, and can occur both in early-stage ketoacidosis and in non-ketoacidic hyperglycaemia.
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| * Confusion.
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| * Abdominal pain.
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| * Loss of appetite.
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| * [[Influenza|Flu]]-like symptoms.
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| * [[Lethargy]] and [[apathy]].
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| * Extreme weakness.
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| * [[Kussmaul breathing]] ("air hunger"). Patients breathe more deeply and/or rapidly.
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| * Unconsciousness ([[diabetic coma]]) after prolonged DKA. At this stage, speedy medical attention is imperative.
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| ==Complications==
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| People with diabetic ketoacidosis need close and frequent monitoring for complications. Surprisingly, the most common complications of DKA are related to the treatment:
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| * [[Hypokalemia]] and often, [[potassium depletion]]
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| * [[Cerebral edema]] <ref name=mayo>{{cite web | By Mayo Clinic Staff | title = Diabetic ketoacidosis | publisher=Mayo Foundation for Medical Education and Research | work = Diabetic ketoacidosis | url=http://www.mayoclinic.com/health/diabetic-ketoacidosis/DS00674/DSECTION=7 | year = 2006 | accessdate=2007-06-15}}</ref>
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| * [[Hyperglycemia]]
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| * [[Ketoacidemia]]{{Fact|date=September 2007}}
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| * Fluid and electrolyte depletion <ref name=AMN>{{cite web | Umesh Masharani, MB, BS, MRCP | title = Diabetic Coma > Diabetic ketoacidosis | publisher=Armenian Medical Network | work = Diabetic ketoacidosis | url=http://www.health.am/db/diabetic-ketoacidosis/ | year = 2006 | accessdate=2007-06-15}}</ref>
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| * Aspiration
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| * Unrecognized [[renal tubular necrosis]]{{Fact|date=September 2007}}
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| * [[Pulmonary edema]] <ref name=monitor>{{cite web | title = Diabetic ketoacidosis complications| publisher=The Diabetes Monitor | work = Diabetic ketoacidosis | url=http://www.diabetesmonitor.com/dmemerh/sld033.htm | year = 2007 | accessdate=2007-06-15}}</ref>
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| * [[Myocardial Infarction]]
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| ==Treatment==
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| Treatment consists of [[hydration]] to lower the [[osmolality]] of the blood, replacement of lost [[electrolyte]]s, insulin to force glucose and [[potassium]] into the cells, and eventually glucose simultaneously with insulin in order to correct other [[metabolic]] abnormalities, such as lowered blood potassium ([[hypokalemia]]) and elevated ketone levels. Many patients require admission to a step-down unit or an [[intensive care unit]] (ICU) so that [[vital signs]], urine output, and blood tests can be monitored frequently. Brain [[edema]] is not rare, and so this may suggest intensive monitoring as well. In patients with severe alteration of mental status, [[intubation]] and [[mechanical ventilation]] may be required. Survival is dependent on how badly-deranged the metabolism is at presentation to a [[hospital]], but the process is only occasionally fatal.
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| DKA occurs more commonly in type 1 diabetes because insulin deficiency is most severe, though it can occur in type 2 diabetes. In about a quarter of young people who develop type 1 diabetes, insulin deficiency and hyperglycemia lead to ketoacidosis before the disease is recognized and treated. This can occur at the onset of type 2 diabetes as well, especially in young people. In a person known to have diabetes and being adequately treated, DKA usually results from omission of [[insulin]], mismanagement of acute [[gastroenteritis]], the flu, or the development of a serious new health problem (e.g., [[bacterial infection]], [[myocardial infarction]]).
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| Insulin deficiency switches many aspects of metabolic balance in a [[catabolic]] direction. The liver becomes a net producer of glucose by way of [[gluconeogenesis]] (from protein) and [[glycogenolysis]] (from glycogen, though this source is usually exhausted within hours). Fat in [[adipose tissue]] is reduced to [[triglycerides]] and fatty acids by [[lipolysis]]. Muscle is degraded to release amino acids for gluconeogenesis. The rise of fatty acid levels is accompanied by increasing levels of ketone bodies ([[acetone]], [[acetoacetate]] and [[beta-hydroxybutyrate]]; only one, acetone, is chemically a ketone -- the name is an historical accident). As ketosis worsens, it produces a [[metabolic acidosis]], with [[anorexia]], abdominal distress, and eventually vomiting. The rising level of glucose increases the volume of urine produced by the kidneys (an osmolar [[diuresis]]). The high volume of urination ([[polyuria]]) also produces increased [[losses of electrolytes]], especially [[sodium]], [[potassium]], [[chloride]], [[phosphate]], and [[magnesium]]. Reduced fluid intake from [[vomiting]] combined with amplified urination produce dehydration. As the [[metabolic acidosis]] worsens, it induces obvious [[hyperventilation]] (termed [[Kussmaul respiration]]). Kussmaul's respirations are the body's attempt to remove carbon dioxide from the blood that would otherwise form [[carbonic acid]] and further worsen the ketoacidosis. See also [[arterial blood gas]].
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| On presentation to hospital, patients in DKA are typically suffering dehydration and breathing both fast and deeply. [[Abdominal pain]] is common and may be severe. Consciousness level is typically normal until late in the process, when [[obtundation]] (dulled or reduced level of alertness or consciousness) may progress to [[coma]]. Dehydration can become severe enough to cause shock. Laboratory tests typically show [[hyperglycemia]], [[metabolic acidosis]], normal or [[elevated potassium]], and severe [[ketosis]]. Many other tests can be affected.
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| At this point the patient is urgently in need of [[intravenous fluids]]. The basic principles of DKA treatment are:
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| * Rapid restoration of adequate circulation and perfusion with [[isotonic]] intravenous fluids
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| * Gradual rehydration and restoration of depleted electrolytes (especially sodium and potassium), even if serum levels appear adequate
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| * Insulin to reverse ketosis and lower glucose levels
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| * Careful monitoring to detect and treat complications
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| Treatment usually results in full recovery, though death can result from inadequate treatment or a variety of complications, such as cerebral edema (occurs mainly in children).
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| ==References==
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| {{Reflist}}
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| [[Category:Diabetes]]
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| {{WikiDoc Help Menu}}
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| {{WikiDoc Sources}}
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| [[es:Cetoacidosis diabética]]
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| [[ko:당뇨병케톤산증]]
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| [[ja:糖尿病性ケトアシドーシス]]
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| [[pl:Kwasica ketonowa]]
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| [[vi:Toan xêtôn do đái tháo đường]]
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