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Chapter 11: Diabetic ketoacidosis and hyperglycemic hypersmolar state
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Dear Members,
Dear Friends
 
Diabetes Ketoacidosis (DKA) is the second most severe and dangerous complication of diabetes – after severe hypoglycemia. DKA is caused by a decrease in the effective circulating insulin level associated with increases in counter-regulatory hormone concentrations. DKA most commonly appears at the onset of diabetes – but there is wide geographic variation. Frequencies range from approximately 15% to 70% in Europe and North America.
DKA at diagnosis is more common in younger children (especially <2 years of age), it is also more common in ethnic minority groups, and in children whose families do not have ready access to medical care for social or economic reasons. DKA is often the consequence of diagnostic error or delayed treatment.
In recurrent DKA, insulin omission or failure to follow sick day or pump failure management guidelines accounts for almost all episodes. Management of an episode of DKA is not complete until its cause has been identified and rectified.
The risk of DKA in established type 1 diabetes is 1% to 10% per patient per year and is increased mainly in children who omit insulin and in those with poor metabolic control or previous episodes of DKA. It is also strongly associated with psychosocial circumstances.

The ISPAD Guidelines Chapter: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state focuses on DKA is a must read for any clinician. It consists of basic information about DKA, and specified guidelines for its treatment. Regarding the previous edition of this chapter, recommendations concerning fluid management have been modified to reflect recent findings from a randomized controlled clinical trial showing no difference in cerebral injury in patients rehydrated at different rates with either 0.45% or 0.9% saline.
To learn more about the recurrent DKA check the presentations from Michael Harris: Prevention and Treatment of DKA: Psychosocial and economic aspects  and Nicole Glaser: New perspectives on intravenous fluid protocols and risk of cerebral injury that describes recent findings from a randomized clinical trial.
 

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