Diabetes care
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During 1880 patient-months of treatment with continuous subcutaneous insulin infusion in 101 patients with IDDM, 36 episodes of acute, severe loss of glycemic control, including 29 with significant ketoacidosis, occurred in 20 patients. Fifteen episodes were attributable to failure of insulin delivery to the patient while 13 were precipitated by infection. ⋯ Thirst, nausea, and vomiting were the common clinical manifestations of decompensation; and the degree of acidemia was often mild in relation to the degree of hyperglycemia. Response to conventional management was usually prompt.
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A number of changes in therapy of uncontrolled diabetes have occurred in recent years. These include low-dose insulin regimens, often routine phosphate repletion, more cautious bicarbonate replacement, infusion of larger fluid volumes, the use of hypotonic solutions in hyperosmolar states, and recently magnesium repletion. These modalities (with the exception of routine magnesium repletion) have been employed at North Central Bronx Hospital since its opening in 1976. ⋯ The major categories of causes of death in the series included sepsis, adult respiratory distress syndrome (ARDS), metabolic, cardiovascular, and shock. With the exception of ARDS, these categories were not different from other reported series. There were few thromboembolic events in this series.(ABSTRACT TRUNCATED AT 250 WORDS)
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Both diabetic ketoacidosis (DKA) and hyperglycemic, hyperosmolar nonketotic coma (HHNC) are stressful metabolic occurrences brought about by the orchestration of numerous events. Adequate hydration and replacement of electrolytes, along with physiologic doses of insulin, are treatment objectives for both of these conditions. Additionally, the physician must search for the factors precipitating these events and frequently evaluate the patient's overall condition.
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A 19-yr-old woman developed ketoacidosis 7 wk after the delivery of her first child. Despite breast feeding, she had been on a weight reduction diet resulting in a loss of 12 kg/body wt. ⋯ Therapy with adequate calories, intravenous fluids, and an appropriate antimicrobial agent resulted in prompt normalization of the laboratory abnormalities and resolution of the patient's symptoms. The hypothesis is advanced that the postpartum status of the patient put her at particular risk for development of ketoacidosis and that this may represent the first reported episode of "bovine ketosis" in a human.
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Case Reports
The significance of the cerebrospinal fluid examination in the management of chlorpropamide-induced hypoglycemia.
Chlorpropamide-induced hypoglycemia is often overlooked, misdiagnosed, and mistreated, because of the atypical, insidious, and intermittent clinical picture and because of the normal serum glucose level in some of the patients when arriving at the hospital. These facts are demonstrated in three case reports. ⋯ A high index of suspicion should exist in the presence of any atypical encephalopathy, mainly in the elderly diabetic patient treated with chlorpropamide and suffering from impaired cerebral, hepatic, or renal function. By suspecting and identifying neuroglycopenia, disabling residual deficits and even death could eventually be prevented.