PEDIATRIC DIABETIC KETOACIDOSIS (DKA) - Faculty Disclosure - CECentral

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PEDIATRIC DIABETIC KETOACIDOSIS (DKA) - Faculty Disclosure - CECentral
6/15/2019

      PEDIATRIC DIABETIC
      KETOACIDOSIS (DKA)
                                Alba E. Morales, MD
                         Associate Professor of Pediatrics
               Barnstable Brown Diabetes Center/ UK Healthcare
                                    June 15, 2019

Faculty Disclosure
•   No relevant financial relationships to disclose.

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PEDIATRIC DIABETIC KETOACIDOSIS (DKA) - Faculty Disclosure - CECentral
6/15/2019

Objectives
Upon completion of this educational activity, you will be able to:

•   Describe the diagnostic criteria of pediatric DKA
•   Calculate the fluid and insulin requirements for a child with DKA
•   Identify the risk factors for cerebral edema in pediatric DKA

Expected Outcome
•   Participants will become familiar with the early assessment and management of
    pediatric DKA

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PEDIATRIC DIABETIC KETOACIDOSIS (DKA) - Faculty Disclosure - CECentral
6/15/2019

CASE
•   10 month old female                          •   Sent to nearby emergency department
                                                     Labs‐ large ketonuria, hyperglycemia,
•   Unremarkable past medical history                acidosis, HbA1c= 9.8%
•   Looked sick for 3 days, anorexia for 1
    day
•   To clinic for fast breathing
•   Finger‐stick “Hi” in clinic
•   1 lb. weight loss as per clinic chart

Symptoms and signs of diabetes in
childhood
Neonates and infants                         Toddlers, older children
•   Shock                                    •   New or worsening enuresis (parents
                                                 expect UTI)
•   Weight loss
                                             •   Daytime “accidents”
•   Sepsis‐like picture
                                             •   Weight loss, obesity + weight loss
•   Tachypnea, respiratory distress
                                             •   Acute abdomen, vomiting
                                             •   “by the book” presentation
                                             •   Yeast infection

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PEDIATRIC DIABETIC KETOACIDOSIS (DKA) - Faculty Disclosure - CECentral
6/15/2019

ED
•   Drowsy
•   Grunting respirations, RR= 60‐75,
    HR=120‐166
•   Dry lips and tongue
•   Clear lungs
•   Tachycardia but no murmur
•   Soft benign abdomen
•   Cap refill?

Definition of DKA
•   1. Hyperglycemia > 200 mg/dl AND
•   2. Ketonemia (BOHB > 1 mmol/L) AND
•   3. Venous pH < 7.3 or HCO3 < 15 mEq/L
•   Classification‐

    •   mild pH 16
    •   moderate pH
PEDIATRIC DIABETIC KETOACIDOSIS (DKA) - Faculty Disclosure - CECentral
6/15/2019

Source of Metabolic Acidosis in DKA
•   Ketonemia (insulin deficiency)
    •   Lactic acidosis (dehydration)
    •   Renal dysfunction (dehydration)‐ loss of bicarbonate in urine

Other causes of metabolic acidosis
•   Sepsis/septic shock
•   Hyperosmolar non‐ketotic diabetic coma
•   Alcoholic ketoacidosis
•   Uremia due to underlying kidney or liver disease
•   Salicylate overdose

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PEDIATRIC DIABETIC KETOACIDOSIS (DKA) - Faculty Disclosure - CECentral
6/15/2019

   Who is at risk of DKA?
New onset diabetes (Type 1 most
commonly)                                          Established diabetes
   • Age < 4 years                                 •   1‐10% per patient/ year= risk of DKA
   •   Children with NO    1st   degree relative   •   Poor metabolic control
       with diabetes
                                                   •   Previous episodes of DKA
   •   Lower SE status
                                                   •   Adolescent girls
   •   Unusual triggers:
       •   Steroids                                •   Youth with eating disorders/ other
                                                       psychiatric illness
       •   Atypical antipsychotics
       •   Diazoxide                               •   Difficult family circumstances/ low SE
       •   Immunosuppressive drugs                     status

   Morbidity and Mortality of DKA in
   Children
   •   Mortality has been constant at 0.15% (USA)
   •   Cerebral edema (CE) accounts for 57‐87% of all DKA deaths
   •   Depending on the study, CE incidence in patients with DKA varies from 1‐4%
       approximately and has been stable over last decade or so
   •   Mortality rates from CE in population studies have been reported as high as 25%

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PEDIATRIC DIABETIC KETOACIDOSIS (DKA) - Faculty Disclosure - CECentral
6/15/2019

Other causes of mortality and severe
morbidity‐
•   Hypokalemia
•   Hyperkalemia
•   Hypoglycemia
•   Other CNS complications
•   Hematoma, thrombosis, sepsis, infections, ARDS
•   Late sequelae of cerebral edema (hypothalamic/ pituitary deficiencies)

Pathophysiology
•   Complete or relative insulin deficiency gives rise to accelerated, unchecked
    ketogenesis and hyperglycemia (CATABOLIC STATE)
•   Hyperglycemia causes progressive dehydration that can lead to renal dysfunction
    and severe loss of electrolytes (HYPOKALEMIA)
•   Volume depletion and acidosis cause increased production of counter‐regulatory
    hormones which in turn worsen the above
    •   Glucagon, catecholamines, GH, cortisol all contribute to increased gluconeogenesis and
        impaired peripheral glucose utilization leading to worsening hyperglycemia and
        hyperosmolality

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PEDIATRIC DIABETIC KETOACIDOSIS (DKA) - Faculty Disclosure - CECentral
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DKA is caused by insulin deficiency

      SEVERE DEPLETION OF WATER AND ELECTROLYTES FROM THE INTRA ‐AND
      EXTRA‐ CELLULAR FLUID COMPARTMENTS

Diabetic Ketoacidosis
•   PREVENTION is best
•   All families with diabetic children are educated on DKA prevention
•   Provided with an educational magnet to keep handy

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PEDIATRIC DIABETIC KETOACIDOSIS (DKA) - Faculty Disclosure - CECentral
6/15/2019

                                                            DKA prevention magnet
                                                            provided to all families

Where should DKA be managed?
•   Unit should have
    •   Experienced nursing staff trained in monitoring and management
    •   Written guidelines for DKA management in children
    •   Access to laboratories able to provide frequent and timely measurements of
        biochemical variables
    •   Specialist/ consultant pediatrician with training and expertise to guide management
    •   Severe DKA, those with mental status changes, compromised circulation, and children
        under age 4‐5 should be managed in an intensive care setting

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PEDIATRIC DIABETIC KETOACIDOSIS (DKA) - Faculty Disclosure - CECentral
6/15/2019

Disposition
•   Admission
    •   New onset diabetes
    •   Mild and moderate DKA to floor if no other risk factors for Cerebral edema
    •   Unable to manage DM, ketosis at home

•   Discharge mild DKA with no risk factors home after consultation with specialist
    •   Insulin pump malfunction‐ must have access to long acting insulin, injections at home
    •   Good PO intake
    •   Well‐trained family

Disposition
New onset T1DM                                      Established T1DM
•   Will always need hospital admission              •   Mild DKA and improving, tolerating
                                                         PO and well trained family‐ may be
•   PICU                                                 discharged home
•   Floor                                            •   Severe and Moderate DKA‐
                                                         admission will be required
                                                         •   PICU
                                                         •   Floor

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Disposition‐ consider intensive care transfer‐
  o Presenting BUN > 30
  o Patient received IV bicarbonate or insulin bolus
  o Calculated mOsm > 350
  [Calculated osmolality= 2xNa + (glucose/18) + (BUN/2.8)]
  o Patient received > 40 mL/kg total initial volume replacement (include fluids
  received prior to arrival to SCH)
  o Corrected Na< 140 mEq/L or decreasing at 2 hour labs
  [Corrected Na = Measured Na + (Serum glucose – 100)/100 X 1.6)]

  ED
  •   10 cc/kg NS bolus via IO line
  •   Transferred to PICU

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Assessment, new diabetes diagnosis, confirm DKA
(Ideally within first 30 minutes)
Consider RISK factors       HPI                     Signs                      Laboratory investigation

 Prior DKA episodes           Polyuria             Dehydration               Blood glucose
 Insulin omission (poor       Polydipsia           Kussmaul breathing        Blood gas
  adult supervision)           New enuresis         Fruity smell of breath    Na, K, Cl, HCO3, Ca,
 Adolescent females           Nocturia             Emesis                     Mg, Phos
 Negative Social factors      Weight loss          Abdominal tenderness      BUN, Cr
 Recent illness,              Abdominal pain        (diffuse)                 BOHB
  infection                    Severe fatigue       Mental status changes     Blood culture if febrile
 Psychiatric disorder         Nausea               Lethargy
 Eating disorder              Weakness
 Surgery, trauma,             Headache
  obesity                      Confusion
 Use of diabetogenic          Candida infection
  meds                         Drowsiness

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ABCD and WEIGHT
•   Airway (PALS)
•   Breathing (PALS)‐ deep rhythmic fast (Kussmaul) , hypoxia
•   Circulation‐ shock? Dehydration‐ cap refill time > 2 sec, etc.
•   Disability/ Neurological evaluation
    •   GCS at admission and at least every hour for at least 12 hours
    •   Headache history documentation
    •   Developmental delay, non‐verbal patients *

•   Will need exact weight to calculate all fluids and insulin doses

Assess neurologic stability
•   Glasgow coma scale in children > 5 years of age
•   Verbal response criteria for children under 5 years

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GCS

Disposition‐ consider intensive care transfer‐
o Age ≤ 24 months
o Developmental delay or any condition that compromises communication
o GCS ≤ 13 after volume resuscitation
o Abnormal neurological exam after volume replacement
o Other organ system dysfunction
o Presenting pH ≤ 7.15
o Presenting HCO3 ≤ 5
o Presenting PCO2 < 10

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      Goals of therapy
•   Resolve acidosis as evident by anion gap < 15

•   Prevent complications such as cerebral edema, hypoglycemia, hypokalemia, etc.

•   Supportive therapy, including improvement in hydration status and management of
    electrolyte abnormalities

      Reverse DKA
      Rehydrate                                      Stop ketogenesis
      • 1st HOUR:                                    •   INSULIN
          •   resuscitation fluids (10‐20 ml/kg          •   No bolus needed and may be
              0.9%NS bolus, repeat if needed up to           associated with increased risk for
              30 ml/kg total)                                cerebral edema
          •   Overt shock‐ 20 ml/kg 0.9% NS bolus
                                                     •   0.1 unit/ kg/hour regular insulin is
      •   Subsequent fluids need to be                   default rate
          calculated to replace deficit and
          provide maintenance fluids using
          body weight as reference

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Rehydration
•   10 ml/kg 0.9%NS bolus over one hour, may repeat if needed up to 30 ml/kg total
    resuscitation fluids
•   Subsequent fluids: (in tandem with insulin infusion)
•   Assume 7% dehydration (replace deficit and calculate maintenance fluids over 24‐
    36 hours)
•   Equal to 1.5‐2X maintenance rate
•   2 bag system (D10 bag and NS or ½ NS bag with additives)

Example
•   35 Kg child with BG= 380 mg/dl; serum K=4.8; Na= 138
•   350 ml NS bolus over 1 hour, then re‐assess need for another bolus
•   AFTER NS bolus:
    •   DO NOT give insulin bolus
    •   Start insulin 0.1 unit/kg/hr In tandem with rehydration fluids
    •   1.5‐2 X maintenance for 35 kg child= 2700‐3600/ 24 hours = 112 – 150 ml/hr
    •   Replacement IV fluid order for this child: (remember to add potassium)
    •   0.9%NS + 20 meq KCL and 20 meq/L Kphos at 112‐150 ml/hr
    •   Insulin‐ 3.5 units/hr

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Subsequent IV fluids order:
•   12 hours after first bolus or once serum chloride is ~ 110 meq/L (still using 2 bags)
    •   Bag # 1‐‐‐‐D10 ½ NS + 20 meq KCL + 20 meq Kphos
    •   Bag #2‐‐‐‐½ NS+ 20 meq KCL + 20 meq Kphos
        • BG > 300‐ use only fluids with no dextrose
        • BG 200‐300 use both types of fluids (50‐50)
        • Bg < 200 use only D10 containing fluids

    •   Decreasing NaCl content in IV fluids will help avoid hyperchloremic acidosis, a common
        complication of DKA therapy

Sodium trend

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Hyperglycemia vs acidosis

How much dextrose in IV fluids?
                                   D10 + 40 meq K bag                  NS or ½ NS + 40 meq K bag
BG > 300                           n0                                  100 % of rate
BG 200‐300                         50% of rate                         50% of rate
BG< 200                            100 % of rate                       n0
If BG < 70 and still acidotic‐ consider use of D12.5 or increase rate of D10 bag, if acidosis resolved,
should be able to eat and transition to SQ insulin

UK PICU DKA Protocol

Hyperglycemia will always resolve faster than acidosis

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Hypokalemia‐ common complication

Monitoring
•   Continuous cardiorespiratory monitoring
•   Bedside finger‐stick BG q 1 hour – alert MD if BG < 70 or > 400
•   Neurochecks q 1 hour if ANY mental status alteration or risk factors for CE present
•   BMP q 4 hours , measure serum BOHB (β‐hydroxybuterate) ‐ < 1 mmol/L indicates
    resolution of DKA
    •   Bedside ketonemia monitoring available ( ideally using handheld meters that measure
        both glucose and ketones in capillary blood)

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Monitor I’s and O’s very closely
use HR, perfusion as hydration indicators

   DKA complications

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   Take home messages
   DO                                                    AVOID
    •   Have a high index of suspicion for               •   Use of Bicarbonate
        diabetes in children of all ages
        (incidence of T1DM has been                      •   > 40 ml/kg as bolus
        increasing in infants and toddlers)
                                                         •   Lowering insulin infusion rate due to
    •   Know diagnostic criteria for DKA                     dropping BG levels if acidosis still
    •   Timely rehydration will normalize                    present
        intravascular volume/ peripheral                 •   Using imaging studies to “confirm”
        perfusion and will help normalize                    suspected cerebral edema
        counter‐regulatory hormone levels
    •   Insulin will shut down ketogenesis
        and will reverse catabolic state

Boston, MA, Chicago, IL, Columbus, OH, Denver, CO, Houston,
TX, New York, NY, Philadelphia, PA, Providence, RI, Sacramento,
CA, Salt Lake City, UT, St. Louis, MO, Washington, DC, and
Wilmington, DE.

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Therefore‐ new suggested fluid guidelines

Key points in regards to cerebral edema
•   Regard cerebral edema as a complication of DKA that can happen at any time during
    presentation (BEFORE and during DKA therapy)
•   Detailed and frequent monitoring for CNS changes is key for early intervention
•   Markers of severity of DKA (AT PRESENTATION) are useful as markers for increased risk of
    cerebral edema:
    •   Increased BUN
    •   Greater hypocapnia
    •   Severity of acidosis
    •   Younger age= delayed diagnosis and more severe DKA
    •   Use of bicarbonate for treatment of acidosis
    •   Attenuated rise in serum Na during treatment
        •   Serum sodium should rise by approximately 1.6 mEq/L for every 100 mg/dL (5.5 mmol/L) decrease in
            glucose concentration

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     Clinical Cerebral Edema assessment
Diagnostic Criteria *                  Major Criteria                         Minor Criteria
Abnormal motor or verbal response      Altered mentation/ fluctuating level Emesis
to pain                                of consciousness
Decorticate or decerebrate posture     Sustained heart rate deceleration      Headache (especially if new/
                                       (more than 20/min) not attributable    recurrent after therapy started or if
                                       to improved intravascular volume       worsening in nature)
                                       or sleep
Cranial nerve palsy (especially III, IV, Age‐inappropriate incontinence       Lethargy ; not easily arousable
and VI) may result in double vision
Abnormal neurogenic respiratory                                               Diastolic BP > 90 mm Hg
pattern (grunting, central
hyperventilation, apneusis, Cheyne‐
Stokes)
                                                                              Age < 5 years
• 1 diagnostic, or 2 major, or 1 major and 2 minor criteria have a sensitivity of 92%, a specificity of 96% and a
  false positive rate of only 4% for the recognition of DKA CE early enough for effective intervention
• In children < 5; 1 major and 1 minor criteria could be sufficient

     Emergent Treatment of Cerebral Edema
     •   Maintain patent airway, ventilation/oxygenation and stable hemodynamics
     •   Elevate HOB 30 degrees
     •   Mannitol 1 g/kg I V (cerebral edema); 3% NS (5ml/kg) can also be used if not
         responding to Mannitol
     •   STAT non contrast CT scan of the head, look for CE, thrombosis, hemorrhage
     •   STAT neurosurgery consult
     UK PICU Protocol

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Bibliography
1. Waller SL, Delaney S, Strachan MWJ . Does an integrated care pathway enhance the management              •   9. Glaser N, Kuppermann N. Fluid treatment for children with diabetic ketoacidosis: How do the
   of diabetic ketoacidosis? Diabetic Medicine.2007:24;359 ‐63.                                                 results of the pediatric emergency care applied research network Fluid Therapies Under
                                                                                                                Investigation in Diabetic Ketoacidosis (FLUID) Trial change our perspective? Pediatr Diabetes.
2. I lag LL, Kronick S, Ernst RD, Grondin L. Alaniz C. Liu L. Herman WH . Impact of a critical pathway on
                                                                                                                2019;20:10–14. https://doi.org/10.1111/pedi.12795
   inpatient management of diabetic ketoacidosis. Diabetes Research and Clinical Practice.
   2003:62;23‐32.
                                                                                                            •   PECARN DKA FLUID Study Group. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic
3. Bull SY, Douglas IS, Foster M , Albert RK. Mandatory protocol for treating adult patients with               Ketoacidosis. N Engl J Med. 2018 June 14; 378(24): 2275–2287.
   diabetic ketoacidosis decreases intensive care unit and hospital lengths of stay: results of a               doi:10.1056/NEJMoa1716816
   nonrandomized trial. Critical Care Medicine. 2007:35;4 I‐46
                                                                                                            •   Wolfsdorf JI, Glaser N, Agus M, et al.ISPAD Clinical Practice Consensus Guidelines 2018:
4. Dunger DB, Sperling MA , Acerini CL, etal. European Society for Paediatric Endocrinology/ Lawson             Diabeticketoacidosis and the hyperglycemic hyperosmolar state.Pediatr Diabetes.
   Wilkins Pediatric Endocrine Society Consensus Statement on Diabetic Ketoacidosis i n Children and            2018;19(Suppl. 27):155–177. https://doi.org/10.1111/pedi.12701
   Adolescents. Pediatrics 2004; 113;e 133‐e 140.

5. Felner EI, White PC. Improving Management of Diabetic Ketoacidosis in Children. Pediatrics
   2001:108; 735.

6. Wolfsdorf J, Glaser N, Sperling, M. Diabetic Ketoacidosis i n I nfants, Children, and Adolescents.
   Diabetes Care 2006;29; 1 150‐1 158.

7. Joseph Wolfsdorf, Maria E Craig, Denis Daneman, David Dunger, Julie Edge, WR Warren Lee,
   Arlan Rosenbloom, Mark A Sperling, Ragnar Hanas. Published in Pediatric Diabetes 2009(Suppl
   12);10:118‐133. (International Society for Pediatric and Adolescent Diabetes Clinical Practice
   Consensus Guidelines chapter 10).

8. Modified with permission from: Muir AB, Quisling RG, Yang MC, Rosenbloom AL. Cerebral
   edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early
   identification. Diabetes Care 2004; 27:1541. Copyright ©2004 The American Diabetes
   Association.

Thank you!
•   Questions
•   Contact info
•   AMO278@uky.edu

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Re‐examining theories about CE cause
•   Elevated urea nitrogen levels (suggesting greater dehydration) and hypocapnia,
    both with the potential to decrease cerebral perfusion, have been associated with
    risk of brain injury in several well‐controlled studies
•   Elevated levels of inflammatory mediators during DKA have been documented in
    both human and animal studies, and findings in studies by same group document
    patterns of inflammation consistent with those observed in ischemia/ reperfusion
    injury
•   Cerebral injury may be more common than previously thought; clinically apparent
    cerebral injury may depend on severity of DKA at presentation
•   Rate and composition of IV fluids may not be relevant to risk of cerebral injury

Poor outcome factors‐
•   Risk factors for death or survival in a vegetative state were identified in a
    retrospective multicenter study of 61 children

    •   Elevated blood urea nitrogen at the time of initial presentation

    •   Intubation with aggressive hyperventilation (targeting a partial pressure of carbon dioxide
        [pCO ] of less than 22 mmHg)

    •   Severe neurologic compromise at diagnosis of cerebral injury (all patients who either died
        or survived in a persistent vegetative state had Glasgow Coma Scale [GCS] scores ≤7 when
        cerebral injury was diagnosed)

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                                                     The PECARN FLUID Trial found no
                                                     significant differences
New since 2018‐                                      between study arms in either mental status
                                                     changes (assessed by GCS
                                                     and digit span scores) during DKA
                                                     treatment, clinical diagnoses of
                                                     brain injury, or cognitive testing scores at
                                                     follow‐up

In plain terms:
•   Fast administration rate of fluids= 2X maintenance for initial 12 hours, then 1.5
    maintenance over next 24 hours (given after 20 cc/kg/NS bolus)
    •   NS vs ½ NS to replace deficit

•   Slow administration of fluids= 1.5 maintenance for 48 hours duration of IV fluids (given
    after a 10 cc/kg bolus)
    •   NS vs ½ NS to replace deficit

•   No difference in GCS outcomes; brain injury; or short term memory after DKA episode
•   Children with severe DKA who were rehydrated at a faster rate improved their short term
    memory sooner than those who were rehydrated at the slower rate (not significant).

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Fluids‐ modern take
•   In summary, the PECARN FLUID Trial provided the first high‐quality data
    investigating the effects of fluid infusion rates and NaCl content on neurological
    outcomes of DKA in children. The FLUID Trial data suggest that a range of fluid
    infusion protocols can be used safely in children with DKA and intravenous fluids
    should not be restricted unnecessarily due to concerns about causing brain
    injuries. Children with DKA should receive fluid resuscitation similar to children
    with other conditions involving similar degrees of dehydration.

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