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[IPp] Re: Definition of DKA and how to know

       Sorry, but you were confusing in your earlier
post about what comprised DKA--I posted to clarify
things for the "newbies" as you call them.

****Was it when I said: "My daughter only had mild DKA
(as defined by the level of acidosis)"? The mildness,
moderateness, or severeness of the DKA is what is
defined by the level of acidosis. That is a true
statement. I was not talking about what defines DKA
itself (the 3 main criteria you gave and which I've
given before), but what defines the mildness etc (ie:
the level of acidosis.) The more acidosis present, the
sicker you are. I realize I could've worded it better
which is why I came back to clarify it. But it is a
true statement and I do understand what is involved
with DKA, having posted on it numerous times and giving
the same information you did.There are 3 main criteria
for making the diagnosis, but the acidosis can affect
numerous electrolytes and other things. Not everyone
needs the same things corrected so there is some
individual variation where that is concerned.

You said :
 << because pH alone sn't the defining/determining
factor. There are other
things (in the blood, and symptoms) that have to occur
together to make the diagnosis. >>  snipped from your

Yes, however, the other things are as I posted and are
fairly straightforward
for a parent to asess at home: high bgs, and the
presence of ketones.

****I agree. And with quick and aggressive treatment
acidosis is avoided (it is totally preventable).
Ketones can make you very insulin resistant so much,
much more insulin is typically needed than usual.
Insulin is the only thing that shuts off the ketone
production and extra fluids help flush them out. If
these things are not done in a timely manner then
acidosis will eventually develop.
And btw, here is the exact quote from the Precision
Xtra manual:
"[Hydroxybutyrate Reading]1.6 to 3.0 mmol/L
[Interpretation] High blood b-hydroxybutyrate levels.
Patient is at risk for DKA. Consider increasing
short-acting insulin. Follow sick-day monitoring
treatment guidelines. Follow patient closely for
further emergency intervention. >3.0 b-hydroxybutyrate
levels consistent with metabolic acidosis. Strongly
consider emergency intervention."
You made it sound like being consistent with DKA was
the same as being in DKA. This quote clarifies
things...they are not saying you are in DKA if you have
that reading. What they are actually saying is that you
are at risk for it, should monitor more closely and
*consider* emergency treatment (obviously if there is
no improvement). With this reading I would give 20% of
TDD every 2hrs and lots of extra fluids and monitor bgs
and ketones frequently. If things didn't turn around
within a few hours (which normally they will) and/or
there was persistent vomiting, then I would go to the

What we cannot do at home is a venous blood draw to see
if the blood pH is
outside of the normal range.   A doctor determining if
DKA is present or not,
is not faced with a difficult decision, as you seem to
imply, once they have
those lab results.

****I never said or implied the dr would be faced with
a difficult decision. But there is a lot more involved
with DKA once the acidosis sets in (it can begin a
whole host of imbalances within the body). You can
sometimes treat *mild* DKA in the ER (or maybe even in
a dr's office), under close observation in both cases.
The charts on the ISPAD page show what tests are done
and how frequently they are done. I suppose if you are
willing to go back and forth to the hospital or dr's
office for frequent monitoring/testing you could
hypothetically treat it without admission but that's
not how it is typically done. And you definitely won't
see moderate or mild being treated this way as by then
there is marked decompensation. Acidosis isn't
something you want to mess around with and if you have
it you'll likely be kept at least at the ER if not
admitted, to correct it. Extremely acidic blood is not
compatible with life.

You also said: <<I can't say whether or not your child
had DKA as I wasn't
there. The dr could have been wrong and she could've
had mild DKA.>>

Not sure if that was meant for me, because as was
clearly posted in my
message, my daughter was in DKA in August, as
determined by the blood work
showing a pH of 7.15.   Unless perhaps you think the
lab report was wrong?

****I apologize, I think I confused you with someone
else whose dr wasn't sure their child was in DKA or

Also your statement : <<f you notice ketones and high
bgs and the child is
feeling very sick (and even vomits), and you treat it
aggressively and you see it start to turn around within

a few hours, it isn't DKA. >>

Well, I have to disagree here.  You do not know the
blood pH!!  Claire was
looking quite sick when I took her to the hospital, but
after a bit of a rest
in the ER, and without ANY treatment, she looked fairly
perky.  However, she
was in DKA.  She is a very strong little girl.  Two
hours later  (4 hours
after arriving at the hospital) the IV line was finally
started but was
removed two hours after that as it was inserted
improperly and kept
occluding.  Do
ctor thought she might not put another IV line in, if
could drink enough fluid.  Claire was looking very
bright and chipper at this
point, but later  started vomiting the dark red Crystal
Lite she was
drinking. (Ooh, all that red over her white sweater and
the white sheets!!)
She DID NOT look very sick at all.  IV line was started
again at 11 pm, and
the blood draw the following morning did not show much
of an improvement in
the blood pH. Thus she was still in DKA the following
day, by definition of
what DKA is.

****The book I quoted from said that sometimes the
bloodwork (pH being one thing) can be affected by other
things like hyperventilation and some other things.
Were her bgs high, low, or normal? I might have missed
it in my skimming just now but I didn't see any mention
of bgs, just her ketone level and the thing about the
meter saying that 3 was consistent with metabolic
acidosis (which is not the same thing as DKA, but
similar in some aspects). It is possible to have
acidosis without it being DKA (even a diabetic can have
acidosis without it being DKA, like I said there are
several different types of acidosis. Simply vomiting a
lot can put you in acidosis but not necessarily DKA.
Being diabetic and having acidosis doesn't
automatically make it DKA.)
I find it incredible that with moderate DKA your child
didn't feel sick. The more acidosis present (and
moderate DKA would have more than mild DKA) the sicker
you are. If you have more than mild DKA you would
definitely require an admission (both of our sources
concur on this point).

My point of this : YMMV--everyone's child is unique.
Your child may be very,
very ill with mild DKA, while mine appears alright even
in moderate DKA..
Mild DKA is treated with insulin, and fluids.  No need
for an IV if you can
drink on your own..   If you treat this way at home and
the condition
improves, you do not know for sure whether you have
successfully treated DKA
or treated and avoided DKA.

Cerebral edema is a complication of ketoacidosis,
almost exclusively a
condition of childhood.  It can be present at the onset
of DKA or develop
later, usually between 4-12 from the start of
treatment.  Thus is not always
a result of too rapid hydration.   It requires urgent
recognition and
intervention with mannitol.

****The edema is a direct result of the electrolytes
and fluids and volume shifting and bgs being brought
down too suddenly (to quote the ISPAD page it is from
"overhydration, rapid osmolar shifts, hypoxia"), not
caused by the DKA itself. It is a complication of the
*treatment* of DKA (per ISPAD). The ISPAD page and the
book I mentioned discusses this. You do see it in
children and the elderly more, but it can happen to
anyone. Slow hydration is the course of action in DKA
to prevent this from happening.

While mild DKA is treated with insulin and fluids, if
you know it is DKA you
are probably at the emergency room and have received
the blood work results.

****A couple of weeks ago Shannon had a bg of almost
500, moderate and large ketones, and one episode of
vomiting. Her blood ketones were 6 (different meter
than the Precision [this was a BioScanner2000] so I
don't know how this would compare with that meter) and
the expected levels should have been around 2.8 - and
she was not in DKA. It took her 4-6hrs to turn around
but it was not DKA. I know because her bgs were coming
down and her ketones were getting less and less. If
they were going in the other direction I would have
been concerned that DKA may be setting in. If it is
correcting, the acidosis won't set in (the whole reason
it becomes DKA in the first place is because the
ketosis doesn't get corrected in a timely manner.) Some
people would have rushed to the hospital with the same
set of symptoms at the very start of it. (Some think
they are in DKA with just a high bg and ketones.) Some
think you can get DKA at the drop of a hat (it just
doesn't happen that fast...it can happen within 4-12hrs
*if nothing or not enough is done to correct it*).
That's why I say the term gets tossed around too much.
Her endo said she was probably on the verge of DKA but
was not quite there yet. Had she continued to vomit
and/or not been able to keep anything down I would have
taken her to the ER.We didn't do labs so we didn't know
what her blood pH was. But, this was not even close to
the mild DKA that she had before (and like I said, it
was correcting, even though it took her the better part
of the day to do more than lay around). It was
responding too well and too fast. If her condition had
taken a turn, I would have suspected acidosis. The book
(a well respected endocrinology text, btw) that I
quoted last night said that DKA takes a minimum of
about 10-12hrs to turn around. You also stated yourself
that the ISPAD page said the standard treatment was
48hrs of IV hydration and insulin. It never takes that
long to correct Shannon's high bgs, L or M ketones,
etc, but usually 4-6hrs. Quite a big difference there.

It makes sense that you would stay there for a couple
of hours drinking
fluids and checking that your bgs were coming down.
But if that is all that
is being done, I for one would much rather be at home
with my child.  I don't
think there are too many of us that like to spend time
in the ER, especially
at full moon time.

****That's the whole point, that's not all that is
being done. The chart on the ISPAD site tells what
things are being checked for and how often. The book I
mentioned last night goes into even greater detail.

Take care, Kerri
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