v. Urine ketones. Renal Fellow Network: Pseudohyponatremia: is that a thing? MUST have heparin prophylaxis. The corrected serum sodium level should be evaluated as this is used to guide appropriate fluid replacement. Hyponatremia in Pediatric Diabetic Ketoacidosis ... Severe symptomatic hyponatremia typically occurs at a serum sodium < 120 mEq/L though the rapidity of the change in sodium is a key factor in the development of symptoms. Thus, no specific treatment is required [4,6]. a laboratory artifact known as "pseudohyponatremia." However, the sodium concentration will be . Significant hyperlipidemia may accompany DKA, resulting in pseudohyponatremia (see Chapter 43). Hyperglycemia, Diabetic Ketoacidosis (DKA) and Hyponatremia The term pseudohyponatremia is often erroneously used for hyponatremia caused by hyperglycemia, which increases the blood osmolality what results in the movement of water from the cells into the blood and therefore in dilutional hyponatremia, which is true hypertonic hypervolemic . (Posm >295 mOsm/kg H2O) Table 4. Ketones are concentrated in the urine, so the absence of ketonuria usually rules out DKA. Severe Hyponatremia. Also, in actual pseudohyponatremia, the serum osmolality would be in the normal range. DKA & HHS B4 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State (4 of 10) 1Elderly patients w/ cardiac comorbidities may require a central venous line 2In the case of pseudohyponatremia, corrected Na = measured Na + 0.016 x [glucose (mg/dL) - 100] Dehydration Hypovolemic shock Cardiogenic shock Mild hypotension Hyperglycemia Electrolyte imbalance DKA . This is a "dilutional" hyponatremia. A few years ago, there was a change of attitude within seizure medicine that manifested itself as new terminology. Mortality rates are 2-5% for DKA and 15% for HHS, and mortality is usually a consequence of the underlying precipitating cause(s) rather than a result of the metabolic . Pseudohyponatremia Page 8. Table 4. Pseudohyponatremia is an artefact; measured serum sodium is reduced but actual plasma sodium is normal. Corrected Sodium in Hyperglycemia. Pseudohyponatremia is caused by a displacement of serum water by elevated concentrations of serum lipids or proteins. EKG. In other words, the corrected sodium is 166. DKADiabetic ketoacidosis DIAGNOSIS AND TEATEMENT 2/1/2019 DKA BY DR.BAKUNDA 1 2. Diabetic ketoacidosis (DKA) is an acute, major, life- threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but it can occur in some patients with type 2 diabetes. Hyperlipidemia is a common feature of DKA, and in a small minority of these patients, including this young boy, hyperlipidemia is of sufficient severity to cause pseudohyponatremia. More recent calculations suggest coefficients ranging from 1.35 to 2.0. However, be-cause high blood glucose levels may cause a falsely low sodium level (many electronic health records systems have a calculator to DKA and HHS: Head-to-head comparison . (Normal or increased level indicates pseudohyponatremia. Won Frerichs and Dreschfeld first described the disorder around 1880. Treatment involves careful correction of the sodium deficit and/or fluid imbalance. [healthcommunities.com] […] exercise. Severe hyperlipidemia, which is occasionally seen in DKA, could reduce serum glucose and sodium levels, factitiously leading to pseudohypo- or normoglycemia and pseudohyponatremia, respectively, in laboratories still using volumetric testing or dilution of samples with ion-specific electrodes. Insulin deficiency increase free fatty acid (FFA) and amino acids release from adipose tissue and muscle, respec- Hyperglycemic Crises. Case example focusing on treatment of K+ disorders in a patient with DKA Page 9-10. The risk factors are omission of insulin, infection, trauma and acute pan-creatitis (2, 3). Hyponatremia or hypernatremia may be present. Miller-Keane Encyclopedia and Dictionary of . ICD-10-CM Diagnosis Code E34.8 [convert to ICD-9-CM] Other specified endocrine disorders. Diabetic ketoacidosis can occur in persons of all ages, with 14 percent of cases occurring in . Therefore, rapid comprehensive diagnostic and therapeutic measures with close monitoring of vital and laboratory parameters are required. Showing 1-25: ICD-10-CM Diagnosis Code E20.1. Mortality rates are 2-5% for DKA and 15% for HHS, and mortality is usually a consequence of the underlying precipitating cause(s) rather than a result of the metabolic . Diabetic ketoacidosis (DKA) is an acute metabolic complica-tion that occurs mainly in type 1 diabetes mellitus (1). diabetic ketoacidosis (DKA). Menchine et al evaluated the accuracy of blood gas vs biochemistry testing in Emergency Room patients presenting with diabetic ketoacidosis (DKA). Why does Hyperglycemia cause Hyponatremia? Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. . Hyperosmolar hyperglycemic state occurs due to a relative deficiency of insulin or . Hypertriglyceridemia is a common lipid abnormality that has serious consequences, such as acute pancreatitis and premature atherosclerosis. The proposed formula was: corrected sodium = measured sodium + [1.6 (glucose - 100) / 100]. vi. The treatment of DKA and H … The same can be said for hyponatremia. This chapter focuses on the medical side of DKA, including its causes, manifestations, complications, and management strategies. This problem is most commonly seen in type 2 diabetes. 2,3 A . Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dL, a pH less than 7.3, a serum bicarbonate level less than 18 mEq per L, an elevated serum ketone level . Essentially, it is the result of water moving into the extracellular fluid to dilute whatever extraneous osmotically active agent is present there. ! Some conditions with very high protein (e.g., multiple myeloma) or glucose levels (e.g., DKA) in the blood may result in a laboratory artifact of falsely low serum sodium concentrations (pseudohyponatremia). In 1973, Katz 1 theorized that sodium concentration should decrease by 1.6 mmol/L for every 100-mg/dL increase in serum glucose concentration (to convert serum glucose to millimoles per liter, multiply by 0.0555). Excess keto-acids results in acidosis . Pseudohyponatremia occurs when too much water is drawn into the blood; it is commonly seen in people with hypoglycemia (low blood sugar). Hyperglycemia causes an osmotic diuresis with significant fluid and electrolyte loss. The human body will maintain a serum [Na +] between 135 and 145 mEq/L. Diabetic ketoacidosis is characterized by hyperglycemia and ketoacidosis due to an absolute insulin deficiency. Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are serious, acute complications of diabetes mellitus. [convert to ICD-9-CM] Diabetic ketoacidosis [DKA] is an acute pathological process that is characterised by increased blood glucose, ketone bodies, and subsequent metabolic acidosis. Positive in DKA; Possibly small in HNS Ketones (for DKA); leukocyte esterase, WBC (for UTI) Urinalysis Treatment of DKA. Laurence H. Beck , MD Cleveland Clinic Journal of Medicine August 2001, 68 (8) 673-674; CDI Blog - Volume 13, Issue 40. by Howard Rodenberg, MD, MPH, CCDS. Hyponatremia in the context of hypergylcemia is a commonly discussed problem. Cyst of pineal gland; Hutchinson-gilford syndrome; Pineal cyst; Progeria syndrome; pseudohypoparathyroidism (E20.1); Pineal gland dysfunction; Progeria. hyperkalemia first during acidosis as acidosis resolves it will become hypokalemic. Kelly A-M. Diabetic ketoacidosis is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. Canine Diabetic Ketoacidosis - ACVIM 2008 - VIN. - When glucose falls < 250, can add D5 to IVFs or can ½ rate of insulin administration. . The corrected serum sodium level should be evaluated as this is used to guide appropriate fluid replacement. Pseudohyponatremia is often present: correct the Na value (Na concentration falls by 2 mEq/L for each 100 mg/mL increase in glucose) Potassium: will often be normal on serum values, but DKA represents a state of significant relative potassium deficit due to urinary losses and shifting of potassium extracellularly with insulin deficiency. Diabetic Ketoacidosis: Evaluation and Treatment. Diabetic ketoacidosis can occur in persons of all ages, with 14 percent of cases occurring in . This activity reviews the evaluation and management of pseudohyponatremia and highlights the role of the interprofessional team in managing patients with this finding. Westerberg DP. Can occur in both Type I Diabetes and Type II Diabetes In type II diabetics with insulin deficiency/dependence The . o Hyponatremia may be due to fluid shifts as a result of hyperglycemia [pseudohyponatremia], increased free water and its retention, including total body sodium loss from . Pseudohyponatremia should be distinguished from true hyponatremia lest injudicious therapy be instituted. Diabetic ketoacidosis (DKA) is a severe form of complicated diabetes mellitus (DM) which requires emergency care. Introduction Diabetic ketoacidosis (DKA) represents a profound insulin-deficient state characterized by hyperglycemia (>200 mg/dL [11.1 mmol/L]) and acidosis (serum pH <7.3, bicarbonate <15 mEq/L [15 mmol/L]), along with evidence of an accumulation of ketoacids in the blood (measurable serum or urine ketones, increased anion gap). Diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) represent potentially life-threatening situations in adults. Historically, such hyponatremia has not yet appeared in the CICM fellowship exam. Definition: Hyponatremia is defined as any serum sodium < 135 mEq/L. DKA is a complex disordered metabolic state characterized by hyperglycemia, ketoacidosis, and ketonuria. The clinical manifestations define the severity of the hyponatremia (i.e. The condition can only arise if the serum lipid or protein concentration is markedly increased and plasma sodium is measured using either indirect ISE or flame photometer. . Trachtenbarg DE. Only two (flame photometry and indirect potentiometry) of the three current … rapid drop and hypokalemia. dr.Bobi Ahmad S, S. Kep Diabetic Ketoacidosis (DKA) A state of absolute or relative insulin deficiency aggravated by ensuing hyperglycemia, dehydration, and acidosis-producing derangements in intermediary metabolism, including production of serum acetone. Hyperglycemia osmotically draws water into the vascular space, decreasing serum sodium concentration. Teresa A. Hillier, MD, MS, is a practicing endocrinologist and senior investigator at the Kaiser Permanente Center for Health Research. Diabetic Ketoacidosis. It presents with hyponatremia (<135 mEq/L) in the setting of increase plasma osmolality. This lowered blood pH (acidosis) is a direct result of the produced ketones that are acidic in chemical nature. ICD-10-CM Diagnosis Code E34.8. The patient has hypernatraemia and, in fact, is even more hypernatraemic than is immediately apparent. Diabetic ketoacidosis refers to a physiological state in a diabetic patient, where even in the presence of high serum concentrations of glucose, there is extreme ketogenesis (i.e. hypovolemic osmotic diuresis--> hypovolemia. Dr. During treatment of DKA with severe hypertriglyceridemia, pseudohyponatremia or pseudonormoglycemia due to laboratory interference may lead to delay of proper management. The equation for conventional units is: corrected sodium (mEq/L) = measured sodium (mEq/L) + 0.016 . If you suspect pseudohyponatremia, consider checking a lipid panel. regular insulin remains the standard of care, but it has been shown (including in a systematic review by Andrade-Castellanos and colleagues) that uncomplicated, mild-to-moderate DKA (pH ≥7.0, serum bicarbonate 10-18 mEq/L, anion gap >12, and alert or drowsy mental status) can be safely and effectively . Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dL, a pH less than 7.3, a serum bicarbonate level less than 18 mEq per L, an elevated serum ketone level . Hence, while some may call this as pseudohyponatremia (noting that the hyponatremia in this case does not mean hypo-osmolarity), I would argue that the better designation is dilutional hyponatremia. 2005; 71 (9): p.1705-14. For a patient with moderate DKA with a pH of 7.1, bicarbonate of 13 and K+ of 3.8. Treating DKA outside of the ICU. Should the actual or the corrected serum sodium be used to calculate the anion gap in diabetic ketoacidosis? Pseudohyponatremia is an uncommonly encountered laboratory abnormality defined by a serum sodium concentration of less than 135 mEq/L in the setting of a normal serum osmolality (280 to 300 mOsm/kg). Serum acetones. Severe hyperlipidemia, which is occasionally seen in DKA, could reduce serum glucose and sodium levels, factitiously leading to pseudohypo- or normoglycemia and pseudohyponatremia, respectively . This is an unusual finding, but is totally game-changing.) (in DKA must add D5 cannot stop insulin infusion!) Figure S1. To correct this, use a DIRECT ISE method to re-measure the serum sodium, such as with an ABG analyzer. Spurious sodium results (1) - pseudohyponatremia. Alternately, in the presence of high serum chylomicron concentration, pseudonormoglycemia and pseudohyponatremia may occur in DKA. labs to obtain for hyponatremia of unclear etiology Full set of serum electrolytes (including Ca/Mg/Phos) & glucose. As used in the new MELD score, to correct Na in the setting of hyperglycemia. Thyroid-stimulating hormone (TSH) & cortisol levels. Differential effect of mineral versus organic acidosis on . Diabetic Ketoacidosis, Very Severe Hypertriglyceridemia, and Pseudohyponatremia Successfully Managed With Insulin Infusion Ramzi Ibrahim , Mohammed Salih , Chirine Elmokdad , Amreetpal Sidhu 1. DKA comes up frequently in the CICM SAQs, but usually as an ABG interpretation exercise. The calculation is: [Na+] + (glucose -10)/3. Her research includes how modifiable risk factors earlier in life can affect future risk of endocrine diseases, including gestational diabetes, obesity, metabolic syndrome, type 2 diabetes, and osteoporosis. In 1973, Katz 1 theorized that sodium concentration should decrease by 1.6 mmol/L for every 100-mg/dL increase in serum glucose concentration (to convert serum glucose to millimoles per liter, multiply by 0.0555). the serum . They described patients with diabetes mellitus with profound hyperglycemia and glycosuria without the classic Kussmaul breathing or acetone in the . o Hyponatremia may be due to fluid shifts as a result of hyperglycemia [pseudohyponatremia], increased free water and its retention, including total body sodium loss from . More recent calculations suggest coefficients ranging from 1.35 to 2.0. Pseudohyponatremia is often present: correct the Na value (Na concentration falls by 2 mEq/L for each 100 mg/mL increase in glucose) Potassium: will often be normal on serum values, but DKA represents a state of significant relative potassium deficit due to urinary losses and shifting of potassium extracellularly with insulin deficiency Pseudohyponatremia is an uncommon laboratory artifact finding that can lead to severe morbidity and mortality if not recognized promptly. The serum osmolality would be significantly elevated in the hyperglycemic patient. Pseudohyponatremia is an artefact; measured serum sodium is reduced but actual plasma sodium is normal. DKA occurs mostly in type 1 diabetes mellitus (DM). The resulting expansion of the extracellular compartment produces a dilution of the remaining electrolytes. Alternately, in the presence of high serum chylomicron concentration, pseudonormoglycemia and pseudohyponatremia may occur in DKA. It causes nausea, vomiting, and abdominal Frier et al. Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, USA Corresponding author: Ramzi Ibrahim, ramziibrahim@mail.rossmed.edu Abstract The case for venous rather than arterial blood gases in diabetic ketoacidosis. Am Fam Physician. Occasionally the measured sodium concentration may be misleadingly low as a result of the phenomenon of pseudohyponatremia, in which DKA-associated hyperlipidemia is so severe that the serum is milky and contains less water and therefore less sodium.
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