Diabetic ketoacidosis as the initial presentation of type 1 diabetes in children and adolescents: epidemiological study in southern brazil / Cetoacidose diabética como apresentação inicial de diabetes tipo 1 em crianças e adolescentes: estudo epidemiológico no sul do brasil

ABSTRACT Objective: To analyze the variables associated with the presence of diabetic ketoacidosis in type 1 diabetes mellitus (T1DM) diagnosis and its impact on the progression of the disease. Methods: We reviewed the records of 274 children and adolescents under 15 years, followed in a Pediatric Endocrinology clinic of a university hospital in Curitiba-PR. They had their first appointment between January 2005 and April 2015. Results: Most patients received their T1DM diagnosis during a diabetic ketoacidosis episode. The associated factors were: lower age and greater number of visits to a physician's office prior to diagnosis; diabetic ketoacidosis was less frequent in patients who had siblings with T1DM and those diagnosed at the first appointment. Nausea and vomiting, abdominal pain, tachydyspnea, and altered level of consciousness were more common in the diabetic ketoacidosis group. There was no association with socioeconomic status, duration of symptoms before diagnosis, and length of the honeymoon period. Conclusions: Prospective studies are necessary to better define the impact of these factors on diagnosis and disease control. Campaigns to raise awareness among health professionals and the general population are essential to promote early diagnosis and proper treatment of diabetes mellitus in children and adolescents.

RESUMO Objetivo: Avaliar as variáveis associadas ao diagnóstico de diabetes melito tipo 1 (DM1) na vigência de cetoacidose diabética e seu impacto na evolução da doença. Métodos: Foram avaliadas 274 crianças e adolescentes com idade até 15 anos acompanhados em um ambulatório de endocrinologia pediátrica de um hospital universitário de Curitiba, Paraná, cuja primeira consulta ocorreu entre janeiro de 2005 e abril de 2015. Resultados: A maioria dos pacientes teve diagnóstico de DM1 na vigência de cetoacidose diabética. Os fatores associados foram: menor idade e maior número de consultas prévias ao diagnóstico; a cetoacidose diabética foi menos frequente quando havia um irmão com DM1 e quando o diagnóstico foi feito na primeira consulta médica. Náuseas ou vômitos, dor abdominal, taquidispneia e alteração do nível de consciência foram mais frequentes no grupo com cetoacidose diabética ao diagnóstico. Não se observou associação com nível socioeconômico, tempo de sintomas antes do diagnóstico e duração do período de lua de mel. Conclusões: São necessários estudos prospectivos para definir melhor o impacto desses fatores no diagnóstico e no controle da doença. Campanhas de conscientização dos profissionais de saúde e da população são necessárias para que haja diagnóstico precoce e tratamento adequado do diabetes melito em crianças e adolescentes.

Recurrent diabetic ketoacidosis

ABSTRACT Objective The purpose of this study is to examine risk factors for recurrence of diabetic ketoacidosis and determine interventions to prevent future admissions. Materials and methods Review article. Results Recurrent diabetic ketoacidosis is a serious and not uncommon health problem. Diabetic ketoacidosis is associated with severe morbidity and mortality and hospital admissions due to this problem constitute a serious economic burden on the healthcare system. Younger age at diabetic ketoacidosis onset, poor baseline glycemic control and elevated HbA1C, patient comorbidities, depression, alcohol or substance abuse, particularly active cocaine use, have been associated with recurrent diabetic ketoacidosis. In addition, socioeconomic factors (such as ethnic minority status, use of public health insurance and underinsurance), psychosocial, economic, and behavioral factors (including financial constraint, stretching a limited insulin supply, and homelessness) have been all reported to be associated with readmission among diabetic ketoacidosis patients. Conclusions Identifying high-risk patients during the first diabetic ketoacidosis admission and performing relevant interventions (repeated instructions of insulin use, social help and involvement of family members in medical treatment, collaboration with the patient's primary care physician in order to establish a close and frequent follow up program) may help prevent future admissions. Further studies need to take place to determine whether early interventions with those factors prevent future admissions.

Estudio descriptivo de las cetoacidosis atendidas en urgencias de un hospital de la Comunidad de Madrid mediante la herramienta Savana Manager / Diabetic ketoacidosis in a emergency department of a hospital in Madrid (Spain) using the Savana Manager tool

Objetivo: El objetivo del estudio fue describir las características y evolución de los pacientes que acudieron a las urgencias de nuestro hospital y fueron diagnosticados de cetoacidosis diabética (CAD) utilizando la novedosa herramienta de Big Data Savana. Método: Estudio retrospectivo descriptivo de los pacientes atendidos en urgencias del Hospital Universitario Infanta Leonor durante los años 2011 al 2016 con diagnóstico de CAD. La búsqueda se realizó con Savana Manager. Resultados: Se diagnosticaron 95 episodios de CAD en 68 pacientes. Del total de episodios de CAD, 57 fueron en diabéticos tipo 1 (de ellos 4 LADA), 25 en diabéticos tipo 2, 2 en diabéticos postpancreatectomía y 12 fueron debuts diabéticos. Del total, 61 (64,2%) requirieron ingreso hospitalario, de ellos 23 (24,2%) ingresaron en UCI. La media de HbA1c fue de 10,6 ± 2,1%. Tres pacientes requirieron reingreso tras el alta. La mortalidad fue muy baja con el fallecimiento en 1 paciente diagnosticado simultáneamente de cáncer pulmonar. Los desencadenantes de la CAD fueron: 35 casos (36,8%) falta de adherencia al tratamiento, 31 (32,6%) infecciones, 12 (12,6%) debuts, 8 (8,4%) varias causas y 9 (9,5%) no se pudo determinar la causa. Se clasificaron como CAD de gravedad leve un 28%, un 38% como de gravedad moderada y 34% como graves. La duración del ingreso no se relacionó con la severidad de la cetoacidosis. Conclusiones: La CAD es una complicación grave que afecta tanto a diabéticos tipo 1 como a tipo 2 con elevado porcentaje de ingresos hospitalarios y en UCI, aunque con baja mortalidad en nuestro medio. La duración de los ingresos no se relaciona con la severidad del cuadro.

Objective: the study was designed to describe the clinical features and evolution of the diabetic patients attended in our hospital emergency department with diabetic ketoacidosis (DKA) using the novel Big Data tool Savana. Method: Retrospective descriptive study of the patients attended in the emergency room of the Infanta Leonor University Hospital during the years 2011 to 2016 with diagnosis of CAD. The search was made with Savana. Results: 95 episodes of DKA were diagnosed in 68 patients. Of the total episodes of CAD 57 were in type 1 diabetics (of which 4 were LADA), 25 in type 2 diabetics, 2 in diabetics postpancreatectomy and 12 were new onset of diabetes. Of the total, 61 (64.2%) required hospital admission, of which 23 (24.2%) were admitted to the intensive care unit (ICU). The mean HbA1c was 10.6 ± 2.1%. Three patients required readmission after discharge. Mortality was very low with death in 1 patient simultaneously diagnosed of lung cancer. The triggers of CAD were: 35 cases (36,8%) lack of adherence to treatment, 31 (32.6%) infections, 12 (12.6%) new onset, 8 (8,4%) various causes and 9 (9.5%) the cause could not be determined. They were classified as mild DKA 28%, 38% as moderate and 34% as severe. The duration of admission was not related to the severity of ketoacidosis. Conclusions: DKA is a serious complication that affects both, type 1 and type 2 diabetics patients, with a high percentage of hospital and ICU admissions, although with low mortality in our environment. The lenght of the stay in hospital is not related to the severity of the DKA.

Perfil clínico de niños con cetoacidosis diabética en una unidad de paciente crítico / Clinical profile of children with diabetic ketoacidosis in a critical care unit

INTRODUCCIÓN: La cetoacidosis (CAD) es la principal causa de morbimortalidad en niños con diabetes mellitus tipo 1 (DM1) debido a las alteraciones bioquímicas asociadas, siendo el más temido el edema cerebral, con altas tasas de mortalidad y secuelas neurológicas a largo plazo. OBJETIVO: caracterizar el perfil clínico y las complicaciones de pacientes con CAD ingresados en una unidad de paciente crítico pediátrico. PACIENTES Y MÉTODO: Revisión retrospectiva de pacientes con CAD atendidos en el Hospital Clínico de la Pontificia Universidad Católica de Chile (UPCPUC) entre los años 2000 y 2015. Se evaluaron características demográficas, manifestaciones clínicas, alteraciones bioquímicas, tratamiento, complicaciones y pronóstico. Se compararon pacientes con debut de DM1 versus diabéticos conocidos, analizándose variables según distribución. RESULTADOS: Se identificaron 46 episodios de CAD. El 67% de éstos correspondió a un debut de DM1. El 66% de los diabéticos conocidos ingresaron por mala adherencia al tratamiento. Los principales síntomas de presentación fueron: 63% polidipsia, 56% poliuria, 48% vómitos, 39% pérdida de peso y 35% dolor abdominal, con medias de Glicemia 522 mg/dL, pH 7,17 y osmolaridad plasmática 305 mOsm/L. El 89% recibió insulina en infusión. El 37% presentó hipokalemia. No se registraron episodios de edema cerebral ni muertes. CONCLUSIONES: La mayoría de los ingresos por CAD correspondió a debut de DM1. En el grupo de diabéticos conocidos, la mala adherencia al tratamiento fue la principal causa de descompensación. No se presentaron complicaciones graves ni muertes asociadas al manejo de la CAD durante el período estudiado. El diagnóstico precoz y el tratamiento adecuado y estandarizado pudieran contribuir a reducir la morbilidad y mortalidad en niños con CAD.

INTRODUCTION: Diabetic ketoacidosis (DKA) is the main cause of morbidity and mortality in children with type 1 diabetes mellitus (T1DM) due to clinical and biochemical alterations associated, cerebral edema as one of the most critical because of the high mortality rates and long-term neurological se quelae. OBJECTIVE: To analyze the clinical characteristics and complications of patients with DKA ad mitted to a pediatric intensive care unit. PATIENTS AND METHODS: Retrospective study of DKA patients treated at the Hospital Clínico, Pontificia Universidad Católica de Chile (UPCPUC) between 2000 and 2015. Demographic characteristics, clinical manifestations, biochemical alterations, treatment, complications, and prognosis were assessed. Patients with T1DM onset were compared with those patients already diagnosed with diabetes, analyzing variables according to distribution. RESULTS: 46 DKA events were identified, 67% of them were the first episode of DKA. 66% of patients already diagnosed with diabetes were admitted due to poor adherence to treatment. The main symptoms described were: 63% polydipsia, 56% polyuria, 48% vomiting, 39% weight loss and 35% abdominal pain, and mean blood sugar levels of 522 mg/dL, pH 7.17, and plasma osmolality of 305 mOsm/L. 89% of patients received insulin infusion, and 37% presented hypokalemia. No episodes of cerebral edema or deaths were registered. CONCLUSIONS: Most of the DKA admissions were due to T1DM onset. In the group of patients already diagnosed with diabetes, the poor adherence to treatment was the main cause of decompensation. There were no serious complications or deaths associated with DKA management during the studied period. Early diagnosis and proper and standardized treatment contributed to reducing morbidity and mortality in children with DKA.

Asociación entre cetoacidosis diabética y acromegalia / Association between diabetic ketoacidosis and acromegaly

La diabetes mellitus ocurre en cerca del 10% de los pacientes con acromegalia y es secundaria a la insulino resistencia causada por altos niveles de hormona de crecimiento. La cetoacidosis diabética ha sido descripta como una rara complicación de la acromegalia, resultado de una relativa deficiencia de insulina causada por exceso de hormona de crecimiento. Describimos el caso de un hombre de 38 años de edad que se presentó en el servicio de emergencias con historia de polifagia, polidispsia y poliuria con pérdida de peso de 6 semanas de evolución. Agregó en las últimas 48 horas náuseas, vómitos y dolor abdominal. A su ingreso, la glucosa plasmática fue 880 mg/dl, osmolaridad plasmática 368 mOsm/l, pH arterial 7.06 y bicarbonato plasmático 8.6 mEq/l. No tenía antecedentes personales ni familiares de diabetes. No se encontraron causas precipitantes de cetoacidosis. En el examen clínico presentaba características compatibles con acromegalia. La resonancia magnética nuclear mostró un macroadenoma pituitario y los dosajes de hormona de crecimiento fueron elevados. Luego de la resección del tumor, los niveles de glucosa plasmáticos resultaron normales. Este caso mostró la rara asociación de acromegalia con cetoacidosis diabética. La cirugía fue la modalidad definitiva de tratamiento.

Diabetes mellitus occurs in nearly 10% of patients with acromegaly and is secondary to insulin resistance caused by high levels of growth hormone. Diabetes ketoacidosis has been described as a rare complication of acromegaly, resulting from a relative insulin deficiency caused by growth hormone excess. We described the case of a 38 year-old man who presented to the emergency room with a 6-week history of polydipsia, polyuria, polyphagia and weight loss. He also had nausea, vomiting and abdominal pain from two days before admission. His plasma glucose level was 880 mg/dl, plasma osmolarity 368 mOsm/l, arterial pH 7.06 and serum bicarbonate 8.6 mEq/l. At the clinical examination, he had features of acromegaly. Magnetic resonance imaging showed a pituitary macro adenoma and growth hormone dosages were abnormally high. After tumor removal, plasma glucose levels became normal. This case shows the rare association between diabetic ketoacidosis and acromegaly. Surgery, in this case, was the definite modality of treatment.

Diabetic ketoacidosis in a pediatric intensive care unit / Cetoacidose diabética em uma unidade de terapia intensiva pediátrica

Abstract Objective: To describe the characteristics of children aged 0-14 years diagnosed with diabetic ketoacidosis and compare the following outcomes between children with prior diagnosis of type 1 diabetes mellitus and children without prior diagnosis of type 1 diabetes mellitus length of hospital stay, severity on admission, insulin dosage, time of continuous insulin use, volume of fluids infused during treatment, and complications. Methods: A retrospective descriptive study with review of medical records of patients admitted to the pediatric intensive care unit of a referral hospital from June 2013 to July 2015. The following data regarding 52 admissions were analyzed: age, sex, weight, body surface area, signs, symptoms and severity on admission, blood gas, blood glucose, glycated hemoglobin, serum osmolarity, and index of mortality. The insulin dosage, time of continuous insulin use, volume administered in the expansion phase and in the first 24 h, length of stay, and complications such as electrolyte disturbances, hypoglycemia, cerebral edema, and death were compared between the two groups. Results: Patients without a previous diagnosis of DM1 were younger at admission, with mean age of 8.4 years (p < 0.01), reported more nausea or vomiting, polydipsia and polyuria, and showed more weight loss (p < 0.01). This study also observed a higher prevalence of hypokalemia (p < 0.01) and longer hospital stay in this group. Conclusions: No differences in severity between groups were observed. The study showed that children without prior diagnosis of type 1 diabetes mellitus were younger at admission, had more hypokalemia during the course of treatment, and had greater length of hospital stay.

Resumo Objetivo: Descrever as características de pacientes até 14 anos admitidos com diagnóstico de cetoacidose diabética e comparar desfechos entre os pacientes com diabete melito tipo 1 prévio e aqueles sem diabete melito tipo 1 prévio: tempo de internação, gravidade na admissão, dose de insulina usada, tempo de insulinização contínua, volume de líquido infundido durante o tratamento e complicações. Métodos: Estudo descritivo retrospectivo com revisão de prontuários de pacientes internados na UTI pediátrica de um hospital de referência de junho de 2013 a julho de 2015. Analisamos os seguintes dados referentes a 52 internações: idade, sexo, peso, superfície corporal, sinais, sintomas, gravidade na admissão, gasometrias, glicemia, hemoglobina glicada, osmolaridade sérica e índice de mortalidade. As crianças com diabete já diagnosticado foram comparadas com aquelas sem diagnóstico prévio quanto à dose de insulina, tempo de insulinização contínua, volume infundido na fase de expansão e nas primeiras 24 horas, tempo de internação e complicações como distúrbios hidroeletrolíticos, hipoglicemia, edema cerebral e morte. Resultados: Os pacientes sem diagnóstico prévio de DM I eram mais jovens no momento da admissão, com média de 8,4 anos (p < 0,01). Relataram mais sintomas como vômitos, polidipsia e poliúria e apresentaram mais perda de peso (p < 0,01). Observamos maior prevalência de hipocalemia (p < 0,01) e maior tempo de internação no grupo acima citado. Conclusões: Não observamos diferenças quanto à gravidade entre os grupos. Pacientes diabéticos prévios eram mais jovens na admissão, apresentaram mais hipocalemia durante o tratamento e permaneceram mais tempo internados.

Cetoacidosis diabética en niños menores de 15 años / Diabetic ketoacidosis in children under 15 years

Introducción: la Cetoacidosis diabética constituye un problema clínico y es la causa más común de hospitalización en los niños que presentan Diabetes Mellitus Tipo 1. Objetivo: identificar las características clínicas de la Cetoacidosis diabética en niños menores de 15 años. Métodos: se realizó un estudio descriptivo y transversal en 18 pacientes menores de 15 años ingresados en el Hospital Pediátrico "Luis Ángel Milanés Tamayo" de Bayamo, Granma, con el diagnóstico de Cetoacidosis diabética, en el período comprendido de Junio de 2006 a Junio de 2012. Se estudiaron variables como: edad, sexo, factores desencadenantes, edad de debut, dosis diaria de insulina, complicaciones agudas y crónicas. Para establecer la relación entre número de episodios por cetoacidosis y esquema de tratamiento habitual se determinó el coeficiente de contingencia c. Resultados: se observó el predominio del grupo de 9-12 años con un total de 9 casos 50,0 porciento. Los factores desencadenantes estudiados más frecuentes resultaron las transgresiones dietéticas presentes en 10 de los casos estudiados 55,55 por ciento y las omisiones del tratamiento en 8 pacientes 44,44 por ciento. La edad media de debut de la cetoacidosis fue 6,5 años DS 2,40, y la dosis media diaria de insulina por kilogramo de peso corporal fue de 0,8 unidades DS 0,23. Se presentaron complicaciones crónicas en 4 pacientes 22,22 por ciento, que incluyeron 2 casos de retinopatía y nefropatía respectivamente. Las complicaciones agudas relacionadas con el tratamiento fueron, 4 casos con hipopotasemia y 2 con edema cerebral. Conclusiones: los pacientes más afectados pertenecían al grupo de edades de 9-12 años y entre los factores desencadenantes se destacaron las transgresiones dietéticas y la omisión del tratamiento. Los episodios de cetoacidosis se asociaron con mayor frecuencia al esquema de tratamiento de tipo convencional...

Introduction: diabetic ketoacidosis is a clinical problem and it is the most common cause of hospitalization in children with Type 1 Diabetes Mellitus. Objective: to identify the clinical characteristics of diabetic ketoacidosis in children under 15 years. Methods: a descriptive cross-sectional study was conducted in 18 patients younger than 15 years admitted to the Paediatric Hospital in Bayamo, Granma, with the diagnosis of diabetic ketoacidosis, from June 2006 to June 2012. Variables such age, sex, precipitating factors, age of onset, daily insulin dose, acute and chronic complications were studied. The contingency coefficient c was determined in order to establish the relationship between the number of ketoacidosis episodes and the usual treatment. Results: the group aged 9-12 years prevailed with a total of 9 cases 50.0 percent. The most common triggers studied were dietary transgressions present in 10 of the cases studied 55.55 percent and omission of treatment in 8 patients 44.44 percent. The average age of ketoacidosis onset was 6.5 years SD 2.40, and mean daily insulin dose per kilogram of body weight was 0.8 units SD 0.23. Chronic complications in 4 patients 22.22 percent, which included 2 cases of retinopathy and nephropathy were respectively presented. Acute complications were related to treatment, 4 patients with hypokalemia and 2 with cerebral edema.Conclusions: the most affected patients were in the group aged 9-12 years and dietary transgressions and failure of treatment are highlighted among triggers. Ketoacidosis episodes were most frequently associated with conventional treatment...

Diabetic ketoacidosis as a presenting symptom of complicated pancreatic cancer

No abstract available.

Cetoacidosis diabética como forma de presentación de la diabetes gestacional en una embarazada de 25 semanas / Diabetic ketoacidosis as the onset of gestational diabetes in a pregnant woman at 25 weeks of gestation

La cetoacidosis diabética (CAD) es infrecuente en paciente diabéticas gestacionales, sin embargo es una condición grave que tiene consecuencias maternas y fetales serias. Reportamos el caso de una embarazada, sin antecedentes mórbidos previos, con una glicemia de inicio de control prenatal normal, que debuta con CAD a las 25 semanas de embarazo. Recomendamos mantener un índice de sospecha elevado y solicitar una evaluación de glicemia a toda paciente embarazada que acude al servicio de urgencia con cuadro de náuseas y vómitos y/o deshidratación, aunque no tenga el diagnóstico de diabetes.

Diabetic ketoacidosis (DKA) is a rare, but life-threatening condition among women with gestational diabetes mellitus (GDM). We report the case of a pregnant woman without significant past medical history and with a normal prenatal fasting glucose level, that present with DKA at 25 weeks gestation. We recommend suspecting this condition and request glycaemia levels on any pregnant woman presenting to emergency room because of nausea, vomiting and dehydration, even in the absence of prior diagnosis of diabetes.

Profile of diabetic ketoacidosis at a teaching hospital in Benghazi, Libyan Arab Jamahiriya

This study described the profile of 100 cases of diabetic ketoacidosis [DKA] at a teaching hospital in Benghazi, Libyan Arab Jamahiriya. DKA was more frequent in young women with type 1 diabetes and mostly due to preventable causes, e.g. disrupted insulin treatment and/or infection. DKA also occurred in type 2 diabetics, with a higher mortality rate, as they were older patients with co-morbidity. Polyurea, fatigue, abdominal pain and vomiting were the most common clinical features, while coma was rarer. A high number of cases were first presentations of type 1 diabetes; hence this diagnosis should be considered in all patients with acute abdomen or decreased level of consciousness. The reasons for high mortality rate in this study [10%] were multifactorial

Uso de bicarbonato de sódio na acidose metabólica do paciente gravemente enfermo / Sodium bicarbonate in the critically ill patient with metabolic acidosis

A acidose lática é um distúrbio do equilíbrio ácido-base muito frequente em pacientes internados em unidades de terapia intensiva e está associado a um mau prognóstico. Embora exista um acúmulo substancial de evidências de que níveis cítricos de acidemia provocam inúmeros efeitos adversos sobre o funcionamento celular, a utilização de bicarbonato de sódio para o tratamento da acidose lática em pacientes gravemente enfermos permanece alvo de controvérsias. Neste artigo, pretendemos:1) analisar as principais diferenças entre as acidoses hiperclorêmicas e as acidoses orgânicas, com ânion gap (AG) elevado, visando embasar a discussão sobre os fundamentos da terapia com bicarbonato de sódio nas acidoses metabólicas; 2) avaliar os riscos associados à persistência de níveis críticos de acidemia, contrastando-os com os riscos do uso de bicarbonato de sódio; 3) analisar criticamente as evidências da literatura sobre o uso de bicarbonato de sódio no tratamento da acidose lática do paciente crítico, com ênfase em ensaios clínicos randomizados em seres humanos; 4) fornecer um fundamento para a utilização judiciosa de bicarbonato de sódio nesta situação.

Lactic acidosis is a disorder of acid-base balance very common in patients hospitalized in intensive care units and is associated with a poor prognosis. Although there is a substantial accumulation of evidence that levels of citric acidemia leading to numerous adverse effects on cell function, the use of sodium bicarbonate to treat lactic acidosis in critically ill patients remains a subject of controversies. In this article we will: 1) analyze the main differences between the hyperchloremic acidosis and organic acidosis with anion gap (AG) high, in order to base the discussion on the fundamentals of therapy with sodium bicarbonate in metabolic acidosis, 2) assess the risks associated with the persistence of critical levels of acidemia, contrasting them with the risks of using sodium bicarbonate, 3) critically examine the evidence in the literature about the use of sodium bicarbonate in treating lactic acidosis in critically ill patients, with emphasis on tests clinical trials in humans, 4) provide a foundation for the judicious use of sodium bicarbonate in this situation.

Cetoacidosis diabética en adultos: causas y su manejo en un hospital regional / Management of diabetic ketoacidosis: retrospective analysis of 117 episodes

Background: In 2005, the Chilean Ministry of Health developed Clinical Guidelines to ensure the correct diagnosis and acute treatment of diabetic ketoacidosis (DKA). Aim: To analyze the real impact of the use of the Clinical Guidelines, comparing the diagnosis and treatment of DKA beforeand after 2005. Patients and Methods: Retrospective analysis of clinical records of adults with DKA, treated between 2001 and 2008 in a regional hospital. Results: One hundred seventeen DKA episodes, that occurred in 82 patients aged 15 to 90 years (47 percent females), were analyzed. Eightytwo percent of patients were known diabetics. Treatment discontinuation was the cause of DKA in 37 percent of patients, followed by infections in 37 percent and onset of diabetes mellitus in 17 percent. Ninety seven percent of patients previous episode of DKA were using insulin. Two patients died (1.7 percent) and DKA complications were uncommon. Bicarbonate and potassium were over prescribed despite therecommendation of Clinical Guidelines (p < 0.05). The use of infusion pumps increased after the incorporation of the Clinical Guidelines. Conclusions: A low impact of Clinical Guidelines on themanagement of DKA was observed in this group of patients. Insulin users have a higher risk for developing DKA.

Cetoacidose diabética em crianças: perfil de tratamento em hospital universitário / Diabetic ketoacidosis in children: treatment profile at a university hospital

OBJETIVO: Avaliar as características de crianças com cetoacidose diabética (CAD) tratadas no Hospital de Clínicas da UNICAMP. MÉTODOS: Estudo retrospectivo e descritivo de variáveis clínicas e laboratoriais de 74 internações por CAD em 49 pacientes no período de janeiro de 1994 a dezembro de 2003. RESULTADOS: Doze pacientes tiveram mais de uma internação, 27 eram do sexo feminino e a idade variou de 0,9 a 14,5 anos. O tempo médio de DM1 foi de 3 ± 3,1 anos, sendo em 20 casos a primeira manifestação do DM1. A CAD foi classificada em grave em 51 por cento e moderada em 30 por cento, 17 apresentaram choque e 13 coma na admissão. O tempo decorrido para a normalização da glicemia, do pH e do bicarbonato apresentou correlação significativa positiva com o valor inicial. Em apenas três internações foi usado o bicarbonato endovenoso. O potássio inicial variou de 3,1 a 5,9 mEq/l, sendo 8 por cento com valores abaixo de 3,5 e 62 por cento acima de 4,5. A hipoglicemia ocorreu em 10 internações e o edema cerebral com óbito em uma. O tempo total de tratamento correlacionou-se significativamente com o tempo de fluidoterapia, o local de internação e o tempo para normalização do pH. CONCLUSÃO: Na amostra estudada houve predomínio de pacientes do sexo feminino, abaixo de 10 anos, com manifestação grave da doença, porém com boa evolução e poucas complicações. As internações corresponderam, em sua maioria, a um pequeno número de pacientes.

OBJECTIVE: To evaluate the profile of children with diabetic ketoacidosis (DKA) treated at the UNICAMP "Hospital de Clínicas". METHODS: Retrospective and descriptive study of clinical and laboratory variables of 74 admissions related to 49 patients bearers of DKA, between January 1994 and December 2003. RESULTS: Twelve patients were admitted more than once, 27 were females and ages ranged from 0.9 to 14.5 years. The mean time from DM1 diagnosis to admission was 3 ± 3.1 years and 20 cases presented with DKA at the onset of DM1. DKA was severe in 51 percent and moderate in 30 percent, at admission 17 patients presented with shock and 13 coma. The time needed for normalization of glycemia, pH, and bicarbonate had a significant positive correlation with the initial value. Intravenous bicarbonate was administered in only 3 admissions. The initial potassium value ranged from 3.1 to 5.9 mEq/l; in 8 percent the value was lower than 3.5 and in 62 percent higher than 4.5. Hypoglycemia occurred in 10 admissions and cerebral edema and death in one. The total time of treatment had a significant correlation with the time of fluid replacement, place of admission and time needed for pH normalization. CONCLUSION: The analyzed sample showed a predominance of female patients, less than ten years of age with a severe manifestation of the disease. However, evolution was good with few complications. Most of the admissions refer to a small number of patients.

Diabetes melito tipo 1 e gestação: [revisão] / Type 1 diabetes mellitus and pregnancy: [review]

As gestações em mulheres com diabetes têm apresentado resultados que melhoraram dramaticamente nas últimas décadas, em razão dos progressos com a monitorização das glicemias e administração de insulina. A gravidez nas mulheres com diabetes tipo 1 está associada a aumento de risco tanto para o feto quanto para a mãe. Antes da concepção, a prioridade é normalizar a glicemia para prevenir malformações congênitas e abortamentos espontâneos. Com o progresso da gestação, a mãe tem um risco aumentado de hipoglicemias e cetoacidose. Mais tarde existe risco de piora na retinopatia, hipertensão induzida pela gestação, pré-eclâmpsia-eclâmpsia, infecções de trato urinário e poliidrâmnios. No final da gestação, existe o risco de macrossomia e morte súbita intra-uterina do feto. Todas essas complicações podem ser prevenidas ou, pelo menos, minimizadas pelo planejamento da gestação e pelo controle intensivo das oscilações das glicemias, mantendo-as próximo ao normal.

As a result of the advances in glucose monitoring and insulin administration, there has been a dramatic improvement in the outcomes of pregnancy in diabetic women over the past decades. Pregnancy in type 1 diabetic women is associated with an increase in risk both to the fetus and to the mother. The normalization of blood glucose in order to prevent congenital anomalies and spontaneous abortions is considered a priority. As the pregnancy progress, the mother is at an increased risk for hypoglycemia or diabetic ketoacidosis. Later in the pregnancy, she is at risk of accelerated retinopathy, pregnancy-induced hypertension and preeclampsia-eclampsia, urinary tract infection, and polyhydramnios. At the end of pregnancy, there is also an increased risk of macrosomia and sudden death of the fetus in uterus. All of these complications can be prevented or, at least, minimized with careful planning of the pregnancy and intensive tight glucose control.

Relato de caso: diabetes Flatbush - da cetoacidose ao tratamento não-farmacológico / Case report: diabetes Flatbush - from ketoacidosis to non pharmacological treatment

Um subgrupo de pacientes, em sua maioria negros ou hispânicos e obesos, tem a cetoacidose diabética (CAD) como forma de apresentação de diabetes mellitus (DM), mas, devido à sua evolução clínica, posteriormente é classificado como DM tipo 2. Estes indivíduos têm pesquisa de auto-anticorpos anti-GAD, anti-IA2 e anti-insulina negativa, mas freqüentemente em associação com HLA classe II de risco para DM tipo 1 (DRB1*03 e/ou DRB1*04). Este subtipo peculiar de DM é denominado diabetes flatbush. Neste artigo, relatamos o caso de uma paciente de origem caucasiana com tais características, na qual foi possível retirada da insulinoterapia. Os possíveis fatores associados a esta evolução favorável serão discutidos.

A subgroup of patients presents diabetic ketoacidosis at the onset of diabetes mellitus (DM) but later is classified as type 2 DM based on the clinical follow-up. These individuals, most commonly obese of African or Hispanic origin, have negative auto-antibodies associated with type 1 DM, but frequently HLA class II DRB1*03 and/or DRB1*04 are detected. This peculiar subtype of DM is commonly referred to as diabetes flatbush. Here we report the case of a Caucasian patient that exhibited the described evolution and in whom it was possible to withdraw insulin therapy. The possible factors associated with this favorable development are also discussed.

Tratamiento dental en pacientes con cetoacidosis diabética: caso clínico / Dental treatment in patients with diabetic ketoacidosis: a clinical case

La cetoacidosis diabética (CD) es un estado de deficiencia relativa o absoluta de insulina. Se da principalmente en pacientes con diabetes tipo 1. La causas más comunes son infecciones subyacentes, interrupción del tratamiento con insulina y el inicio de una diabetes. La CD está típicamente caracterizada por hiperglicemia y acidosis con cetonemia y cetonuria. Presentamos un caso de absceso dentoalveolar en un paciente con CD. El reconocimiento y tratamiento de los factores desencadenantes y monitoreo frecuente de los pacientes son considerados los aspectos más cruciales del manejo de la CD.

Diabetic ketoacidosis (DKA) is a state of absolute or relative insulin deficiency. It is seen primarily in patients with type 1 diabetes. The most common causes are underlying infection, disruption of insulin treatment, and new onset of diabetes. DKA is typically characterized by hyperglycemia and acidosis with ketonemia and ketonuria. We reported a case of dental abscess in a patient with DKA. Recognition and treatment of precipitating factors and frequent monitoring of patients are considered the most crucial aspects of the management of DKA.

Insulin pump therapy in type 1 diabetes mellitus

OBJETIVO: Rever a experiência com a utilização da bomba de infusão de insulina em crianças e adolescentes, a fim de orientar o pediatra quanto às suas indicações e complicações. FONTE DOS DADOS : Foi realizada revisão sistemática de artigos publicados em literatura que abordassem a utilização da bomba de infusão de insulina, suas indicações, complicações e resposta ao tratamento. Dessa forma, todos os artigos publicados entre 1995 e 2005 foram resgatados através do levantamento em banco de dados MEDLINE e LILACS. As palavras-chave utilizadas foram: insulin pumps, type 1 diabetes mellitus e diabetes mellitus. Foram separados os artigos que, além disso, versassem sobre o assunto na faixa etária descrita SíNTESE DOS DADOS: O uso da bomba de infusão de insulina em pacientes com diabetes melito tipo 1 não é uma necessidade para todos os pacientes, visto que, com tratamentos intensivos, os resultados conseguidos são muito parecidos, em termos de hemoglobina glicada e de controle de complicações a médio e longo prazo. No entanto, a bomba permite um maior conforto ao paciente, no sentido de que ele não precisa ficar tão restrito a horários rígidos de refeição e pode levar uma vida com melhor qualidade. Um primeiro requisito para quem pretenda usar a bomba é adaptar-se a aparelhos conectados ao corpo e a ter uma rotina de monitorização glicêmica rigorosa, pois, sem isso, as vantagens da bomba serão anuladas. As complicações, com os avanços tecnológicos de que dispomos atualmente, são muito infreqüentes. O custo, no entanto, é maior que nos tratamentos convencionais. CONCLUSÃO: Com a evolução das bombas de infusão e dos monitores de glicemia, incluindo sistemas de monitorização contínua, abre-se caminho para as "bombas inteligentes", e estaremos com um verdadeiro "pâncreas artificial", que pode mesmo ser implantado no paciente, permitindo uma vida com todas as regalias de uma pessoa não diabética.

OBJECTIVE: To review the current experience with insulin pump therapy in children and adolescents in order to guide pediatricians regarding indications and complications. SOURCES OF DATA : Systematic review of articles published in the literature referring to the use of insulin pump therapy, indications, complications and response to treatment. All articles published between 1995 and 2005 and appearing in the MEDLINE and LILACS databases were reviewed. The keywords were: insulin pump, type 1 diabetes mellitus and diabetes mellitus. The articles covering the subject of interest and referring to children and adolescents were selected. SUMMARY OF THE FINDINGS : Insulin pump therapy is not required for all patients with type 1 diabetes, since intensive treatments produce very similar results in terms of glycated hemoglobin and control of complications over the medium and long terms. However, the pump allows for greater comfort for patients, with less rigid meal schedules and better quality of life. The first requirement for patients intending to use the pump is getting used to having a device attached to the body and following strict glucose control; otherwise, pump therapy is not advantageous. Complications are rare due to the technologies currently available. The cost, however, is greater than with conventional treatments. CONCLUSION: The development of infusion pumps and glucose monitors, including continuous monitoring systems, will lead to "intelligent pumps," so that a true "artificial pancreas" will be available, which can even be implanted in the patient, allowing non-diabetic persons to lead a normal life.

Diabetic ketoacidosis in children.

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM). The frequency of DKA at the onset of DM correlates inversely with the incidence of type 1 DM and is more common in young children, children without a first degree relative with type 1 DM and individuals whose families are from a lower socioeconomic status. The mortality rate for DKA in children is 0.15%-0.3%. A high index of suspicion with timely administration of appropriate intravenous fluids, rational use of sodium bicarbonate, continuous rather than bolus insulin infusion and monitoring in an intensive care unit are associated with a better outcome.

Insulin and glucagon ratio in the patho-physiology of diabetic ketoacidosis and hyperosmolar hyperglycemic non-ketotic diabetes

To assess the role of insulin / glucagon ratio in pathophysiology of diabetic ketoacidosis and hyperosmolar hyperglycemic non-ketotic diabetes. Case control, analytical study. Military Hospital, Rawalpindi from September 2003 to August 2004. The study included 7 patients with diabetic ketoacidosis, 3 patients with hyperosmolar hyperglycemic non-ketotic diabetes, 8 patients with uncontrolled type 1 diabetes mellitus and 12 patients with uncontrolled type 2 diabetes mellitus. Twenty non-diabetic persons having blood glucose level less than 6 mmol/L were selected as control group. Patients' detailed history was taken and general physical examination was done. Plasma samples of all the patients and control subjects were assayed for plasma glucose, glycosylated hemoglobin, plasma insulin and glucagon levels. Presence or absence of ketone bodies in urine was also determined. Seven patients with diabetic ketoacidosis, 3 females and 4 males, were found to be hyperglycemic [p < 0.001], hypoinsulinemic [p < 0.05] and hyperglucagonemic [p < 0.001] as compared to control group. Three patients with hyperosmolar hyperglycemic non-ketotic diabetes, 1 male and 2 females, were hyperglycemic [p < 0.001]. Eight patients with uncontrolled type I diabetes mellitus, 6 males and 2 females, were having hyperglycemia [p< 0.001] along with hyperglucagonemia [p < 0.001]. Twelve patients with uncontrolled type 2 diabetes mellitus, 6 males and 6 females, were found to be hyperglycemic [p < 0.001] and hyperinsulinemic [p < 0.001] as compared to control group. The insulin / glucagon ratio was found to be 1: 0.9 in diabetic ketoacidosis, 1: 0.15 in hyperosmolar hyperglycemic non-ketotic diabetes, 1: 0.24 in type 1 diabetics, 1: 0.08 in type 2 diabetics, and 1: 0.1 in the control group. It was concluded that if insulin / glucagon ratio in type 2 diabetics reduces to 1: 0.9 then these patients may develop ketoacidosis instead of hyperosmolar hyperglycemic non ketotic diabetes. Hence, it is the balance and interplay of insulin and glucagon which predicts the type of acute hyperglycemic emergencies [diabetic ketoacidosis and hyperosmolar hyperglycemic non-ketotic diabetes] being observed in diabetic patients and not the type of diabetes mellitus