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The frequency of deaths due to diabetic ketoacidosis has been dramatically reduced by improved therapy of young diabetics, but this complication remains a significant risk in the aged and in patients in profound coma in whom treatment has been delayed Acute myocardial infarction and infarction of the bowel following prolonged hypotension worsen the outlook A serious prognostic sign is renal failure, and prior kidney dysfunction worsens the prognosis considerably because the kidney plays a key role in compensating for massive pH and electrolyte abnormalities Cerebral edema has been reported to occur rarely as metabolic deficits return to normal This is best prevented by avoiding sudden reversal of marked hyperglycemia Maintaining glycemic levels of 200 300 mg/dL for the initial 24 hours after correction of severe hyperglycemia reduces this risk

Kitabchi AE et al Management of hyperglycemic crises in patients with diabetes Diabetes Care 2001 Jan;24(1):131 53 [PMID: 11194218]

ketoacidosis may retard recognition of the syndrome and delay therapy until dehydration becomes more profound than in ketoacidosis Reduced intake of fluid is not an uncommon historical feature, due to either inappropriate lack of thirst, nausea, or inaccessibility of fluids to elderly, bedridden patients Lethargy and confusion develop, progressing to convulsions and deep coma Physical examination confirms the presence of profound dehydration in a lethargic or comatose patient without Kussmaul respirations

Hyperglycemia > 600 mg/dL Serum osmolality > 310 mosm/kg No acidosis; blood pH above 73 Serum bicarbonate > 15 mEq/L Normal anion gap (< 14 mEq/L)

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(Table 27 12) Severe hyperglycemia is present, with blood glucose values ranging from 600 mg/dL to 2400 mg/dL In mild cases, where dehydration is less severe, dilutional hyponatremia as well as urinary sodium losses may reduce serum sodium to 120 125 mEq/L, which protects to some extent against extreme hyperosmolality However, as dehydration progresses, serum sodium can exceed 140 mEq/L, producing serum osmolality readings of 330 440 mosm/kg Ketosis and acidosis are usually absent or mild Prerenal azotemia is the rule, with serum urea nitrogen elevations over 100 mg/dL being typical

On examination, a hyperdynamic RV can usually be palpated If the PA is enlarged, it may be palpated along the left sternal border P2 will be palpable in pulmonary hypertension and both systolic and diastolic thrills are occasionally noted On auscultation, the second heart sound may be widely split due to prolonged RV systole Systolic clicks may be noted as well as a right-sided gallop In high-pressure pulmonic regurgitation, the pulmonary diastolic (Graham Steell) murmur is readily audible It is often due to a dilated pulmonary annulus The murmur increases with inspiration and diminishes with the Valsalva maneuver It is often confused with the murmur of aortic regurgitation In low-pressure pulmonic regurgitation, the PA diastolic pressure may be only a few mm Hg higher than the RV diastolic pressure, and there is little diastolic gradient to produce a murmur or characteristic echocardiography/Doppler findings At times, only contrast angiography of the main PA will show the free flowing pulmonic regurgitation in this situation The ECG is generally of little value The chest radiograph may show only the enlarged RV and PA Echocardiography may demonstrate evidence of RV volume overload (paradoxic septal motion), and Doppler can determine peak systolic RV pressure and reveal any associated tricuspid regurgitation The size of the main PA can be determined and color flow Doppler can demonstrate the pulmonic regurgitation, particularly in the high-pressure situation Cardiac MRI and CT can be useful for assessing the size of the PA, for imaging the jet lesion, for excluding other causes of pulmonary hypertension (eg, thromboembolic disease, peripheral PA stenosis), and for evaluating RV function MRI provides a regurgitant fraction to help quantitate the degree of pulmonic regurgitation

Documents | Sales Document Header | Assign Sales Area To Sales Document Types [OVAZ] You may assign reference sales organizations as well as reference distribution channels and divisions Do not confuse this referencing with the assignment of common distribution channels and common divisions The referencing done here is only used by the system to determine which sales documents are permitted for which sales areas If all sales document types are allowed for use by all sales areas, leave the assignment fields blank

Pulmonic regurgitation rarely needs specific therapy other than treatment of the primary cause In low-pressure pulmonic regurgitation due to surgical patch repair of tetralogy of Fallot, pulmonary valve replacement may be indicated if RV enlargement or dysfunction is present In carcinoid heart disease, pulmonary valve replacement with a porcine bioprosthesis may be undertaken, though the plaque from this disorder eventually covers the prosthetic valve and this tends to limit the lifespan of these valves In

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