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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== | | ==References== |
| {{Reflist}} | | {{Reflist}} |