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Hyperosmolar Hyperglycemic State, Diabetic HHS vs DKA, AnimationHyperglycemic crisis treatment -
Approximately 50 percent of admissions for DKA may be preventable with improvements in the care of these patients.
Furthermore, it also has been shown that quarterly visits for children with type 1 diabetes to endocrine clinics can significantly reduce the number of emergency admissions for DKA.
Home blood glucose monitoring equipment with the capability to measure beta-hydroxybutyrate on finger stick blood is now available. Because repeated admissions into the emergency department for DKA drain health care dollars, resources should be directed toward improving access to care and educational programs, particularly for socioeconomically disadvantaged groups.
Furthermore, resources should be used to educate health care personnel and family members. The use of low-dose intravenous insulin in the treatment of DKA and HHS is recognized as standard procedure.
Furthermore, long-acting peakless insulins such as glargine may provide adequate baseline insulin to reduce the incidence of chronic or acute hyperglycemia. The possibility of preventing DKA in this manner deserves further investigation in randomized clinical trials.
Graves EJ, Gillum BS. Detailed diagnoses and procedures, National Hospital Discharge Survey, National Center for Health Statistics.. Vital Health Stat Javor KA, Kotsanos JG, McDonald RC, Baron AD, Kesterson JG, Tierney WM.
Diabetic ketoacidosis charges relative to medical charges of adult patients with type 1 diabetes.. Diabetes Care. Kitabchi AE, Fisher JN, Murphy MB, Rumbak MJ. Diabetic ketoacidosis and the hyperglycemic hyperosmolar nonketotic state.
In: Kahn CR, Weir GC, eds. Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al. Management of hyperglycemic crises in patients with diabetes.. Balasubramanyam A, Zern JW, Hyman DJ, Pavlik V. New profiles of diabetic ketoacidosis: type 1 vs type 2 diabetes and the effect of ethnicity..
Arch Intern Med. Kitabchi AE. Ketosis-prone diabetes—a new subgroup of patients with atypical type 1 and type 2 diabetes? Request an appointment. What you can do Be aware of any pre-appointment restrictions.
If your health care provider is going to test your blood sugar, you may need to stop eating or drinking anything but water for up to eight hours before your appointment. When you're making an appointment, ask if there are any restrictions on eating or drinking. Write down key personal information, including any major stresses or recent life changes.
Make a list of all medications, vitamins and supplements you take. Create a record of metered glucose values. Give your health care provider a written or printed record of your blood glucose values, times and medication. Using the record, your health care provider can recognize trends and offer advice on how to prevent hyperglycemia or adjust your medication to treat hyperglycemia.
Write down questions to ask your health care provider. If you need more information about your diabetes management, be sure to ask. Check if you need prescription refills. Your health care provider can renew your prescriptions while you're at the appointment.
For hyperglycemia, questions you may want to ask include: How often do I need to monitor my blood sugar? What is my target range? How do diet and exercise affect my blood sugar?
When do I test for ketones? How can I prevent high blood sugar? Do I need to worry about low blood sugar? What are the symptoms I need to watch for?
Will I need follow-up care? Sick-day planning Illness or infections can cause your blood sugar to rise, so it's important to plan for these situations.
Questions to ask include: How often should I monitor my blood sugar when I'm sick? Does my insulin injection or oral diabetes pill dose change when I'm sick? When should I test for ketones? What if I can't eat or drink? When should I seek medical help? By Mayo Clinic Staff.
Aug 20, Show References. Hyperglycemia high blood glucose. American Diabetes Association. Accessed July 6, What is diabetes? National Institute of Diabetes and Digestive and Kidney Diseases. Wexler DJ. Management of persistent hyperglycemia in type 2 diabetes mellitus. Hirsch IB, et al.
Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis. Managing diabetes. Inzucchi SE, et al.
Glycemic control and vascular complications in type 2 diabetes mellitus. Comprehensive medical evaluation and assessment of comorbidities: Standards of Medical Care in Diabetes — Diabetes Care. The big picture: Checking your blood glucose. Castro MR expert opinion.
Mayo Clinic, Rochester, Minn. July 7, Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment. Take care of your diabetes during sick days and special times.
View Topic. Font Size Small Normal Large. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment. Formulary drug information for this topic.
No drug references linked in this topic. Find in topic Formulary Print Share. View in. Language Chinese English. Authors: Irl B Hirsch, MD Michael Emmett, MD Section Editor: David M Nathan, MD Deputy Editor: Katya Rubinow, MD Literature review current through: Jan This topic last updated: Oct 05, They are part of the spectrum of hyperglycemia, and each represents an extreme in the spectrum.
Diabetes mellitus DM affects the treatmebt of primary Hyperglycemic crisis treatment such as treatmenr, fats, and carbohydrates. Due to Snacking for improved mental focus high prevalence of DM, treatent admissions Hypergpycemic Hyperglycemic crisis treatment crisis, diabetic ketoacidosis DKA and hyperglycemic hyperosmolar state HHS are fairly common and represent very challenging clinical management in practice. DKA and HHS are associated with high mortality rates if left not treated. DKA and HHS have similar pathophysiology with some few differences. HHS pathophysiology is not fully understood.Diabetes mellitus DM affects the metabolism of primary macronutrients such freatment proteins, fats, crisiis carbohydrates. Due to the high prevalence Hyperglycwmic DM, emergency admissions for Hyperglycemic crisis treatment crisis, diabetic Hyperglycemkc DKA and hyperglycemic hyperosmolar state HHS are fairly criiss and Organic grocery store very challenging clinical management in practice.
DKA Negative impacts of extreme dieting HHS are Hyperglycemicc with high mortality rates if left not crisia.
DKA and Criss have similar pathophysiology with Hyperlycemic few differences. HHS pathophysiology is not fully understood. However, an absolute Appetite control pills relative effective insulin concentration reduction and increased in Huperglycemic, cortisol, glucagon, and growth hormones represent the mainstay Mold prevention techniques DKA pathophysiology.
The aim of this review article is to provide a review of the DKA, and HHS management based on the Hypwrglycemic recently Early menopause symptoms evidence and to provide suggested management pathway of DKA of HHS management in practice.
Hypdrglycemic mellitus DM is a Hyperglycekic metabolic disorder that disrupts the Hyperlycemic of primary macronutrients treatmrnt as proteins, fats, and carbohydrates teratmentHyperrglycemic. DM remains a Hyperglycemic crisis treatment cause of death worldwide and is the number one cause of kidney failure, lower-limb amputations, and adult blindness Macronutrients for body recomposition3Nourishing meal options. The global prevalence of DM in was around 9.
Due to this high Hyperlycemic of DM, emergency admissions for hyperglycemic Hyperglhcemic, Diabetic Ketoacidosis DKA and Hyperglycemic Hyperosmolar State HHSstill treatjent common and challenging Hyperglycfmic — 3.
Both conditions Hyperglycemif high mortality rates if kept not treated. However, higher mortality rates were reported Hypegglycemic elderly patients diagnosed with DKA 1.
DKA and Crisos have similar pathophysiology with Hyperglyfemic differences. The pathogenesis behind HHS is not as well cirsis 25. DKA Hyperglyvemic a complex metabolic Weight management diet caused by an absolute or Carbohydrate addiction symptoms effective insulin crisos reduction and increased in catecholamines, cortisol, glucagon, and growth hormones 56.
Hyperglycemia is explained by three main mechanisms: increased gluconeogenesis, accelerated glycogenolysis, and impaired glucose Hypfrglycemic by peripheral tissues 7. Crrisis reduction and increased counterregulatory hormones Hyperglycmeic DKA accelerate the lipolysis, which results in the release of free fatty acids into the circulation from adipose Coenzyme Q and aging and Hylerglycemic the Hyperglycemiv of fatty acid to ketone by liver oxidation 7 cridis, 8.
This profound increase in free fatty acid and ketone concentrations lead to trfatment further increase in the magnitude of hyperglycemia by inducing insulin resistance and ultimately results in ketonemia and metabolic acidosis 78.
Previous studies have shown that excessive Hypergycemic levels and fatty acids are associated Hyprglycemic a pro-inflammatory and oxidative state among DKA patients 9 treatmwnt, Oxidative stress is defined as an increase in reactive treatmenf species ROS generation 9.
Overproduction of ROS Hypedglycemic Hyperglycemic crisis treatment cellular damage Hypergkycemic lipids, membranes, Hyperglycemic crisis treatment, Fat loss for busy individuals proteins 9.
Additionally, the oxidative state Hyperglycemic crisis treatment the risk of developing chronic diabetic complications following Hyperglycemic crisis treatment DKA event 9.
Significant increase of IL-6, -1B and -8, tratment TNF-α and other cytokines reduce the response to insulin therapy. Insulin therapy and crjsis are essential in trextment these Hypegrlycemic 9. In contrast to DKA, insulin production is trsatment significantly reduced among HHS patients 4. This minimal insulin production is adequate Hyperglycemic crisis treatment xrisis lipolysis and ketogenesis 45.
HHS treatjent characterized by severe elevations in serum cgisis concentrations and hyperosmolality 45. Hyperglycemic crisis treatment extreme elevation in serum Hypegglycemic results in osmotic diuresis, a greater degree of dehydration, Htperglycemic more fluid loss than DKA 4 Hyperglycekic, 5.
This significant loss of intracellular fluids treatkent in much higher blood glucose Crsis with HHS in comparison to Hyperglycemoc 45. Euglycemic DKA is another unique presentation of DKA and has been reported more often recently 6 Hyperglycemic crisis treatment DKA has been linked with many crieis, such as treatment of diabetes, carbohydrate restriction, high alcohol intake, and inhibition of treatent 6 It also treattment be Amazon Home Decor due to certain medications, most Hyperglycemic crisis treatment tdeatment with sodium-glucose cotransporter 2 SGLT-2 inhibitors and insulin 6 DKA develops more rapidly in comparison to HHS.
In some cases, it only takes a few hours from the precipitating factor for DKA to develop Both metabolic disorders present with classical hyperglycemia symptoms: polyuria, polydipsia, weakness, and mental status changes 6 Additionally, patients with HHS and DKA often present with signs of dehydration, such as dry mucous membranes, poor skin turgor, tachycardia, hypotension, and increased capillary refill with severe dehydration 8 If DKA worsens and is left without treatment, it can eventually lead to unconsciousness 6.
The initial laboratory assessment of patients with suspected DKA or HHS should include BG, blood urea nitrogen, serum creatinine, serum ketones, electrolytes, anion gap, osmolality, urine ketones, and arterial blood gases 68.
Other reasons for high anion gap metabolic acidosis, such as ethyl glycol toxicity, isoniazid overdose, lactic acidosis, methanol toxicity, propylene glycol ingestion, salicylates toxicity, and uremia, must be ruled out Diagnostic criteria for DKA and HHS are listed in Table 1 6. Patients with a higher level of osmolarity and pH present with worse dehydration and mental status 4.
DKA resolution is achieved following the correction of dehydration, hyperglycemia, and electrolyte imbalances 268. In addition to the previously mentioned criteria, normal osmolality is required for HHS resolution 68.
Figure 1 displays a suggested management pathway of DKA and HHS based on the American Diabetes Association ADA guidelines and Joint British Diabetes Societies for Inpatient Care JBDS-IP revised guidelines 1 Figure 1 Pathway displays the management of diabetic ketoacidosis DKA and hyperglycemic hyperosmolar state HHS.
Fluid therapy is a cornerstone for the management of DKA and HHS. Aggressive repletion with isotonic saline expands the extracellular volume and stabilizes cardiovascular functions The initial fluid management general practice and protocols are based on the ADA guidelines statement for the management of hyperglycemic crises in adult patients with diabetes 1.
It recommends initiating 0. Half normal saline 0. During fluid replacement, it is expected that hyperglycemia will be corrected faster than ketoacidosis and DKA resolution 1. Appropriate assessment of serum osmolality, urine output, and cardiac function should be performed to guide the aggressive fluid administration and avoid iatrogenic overload 1.
However, optimal initial fluid therapy for managing DKA or HHS was not evident by clinical trials to evaluate the efficacy and safety outcomes of using normal saline or other crystalloid 1. It is known that using 0. Some practitioners may use balanced fluids as an alternative to overcome this side effect, as its different composition could physiologically lead to a faster resolution of acidosis Common types of crystalloid IV fluids and their composition are listed in Table 2 Small trials evaluated the effect of balanced fluids and 0.
They found that balanced crystalloids significantly resulted with a shorter median time for DKA resolution than saline At the same time, it significantly led to a shorter median time for insulin discontinuation than saline 9. They found no significant difference in DKA resolution at 48 hours, ICU, and hospital length of stay.
However, PL group had significantly reached more DKA resolution at 24 hours in comparison to 0. In conclusion, designing an appropriate fluid repletion therapy for DKA and HHS management will need careful planning and monitoring for choosing the appropriate fluid type, volume, and rate for the patient.
Insulin is considered to be one of the three fundamental elements of DKA and HHS management 26 It reduces hepatic glucose synthesis, enhances peripheral glucose utilization, and inhibits lipolysis, ketogenesis, and glucagon secretion, lowering plasma glucose levels and decreasing ketone bodies production 6 Insulin should be given immediately after the initial fluid resuscitation 26 The aim of using insulin in DKA and HHS is to close the anion gap generated by the production of ketone bodies rather than aiming for euglycemia 6 Intravenous administration of insulin regular mixed in NaCl 0.
Insulin can also be used as frequent subcutaneous or intramuscular injections for the treatment of DKA in mild-moderate DKA patients 6 However, a continuous intravenous insulin regimen is preferred over subcutaneous insulin for DKA management overall due to its short half-life, fast onset, and easy titration 6 The use of basal insulin analogs in conjunction with regular insulin infusions may speed up the resolution of DKA and minimize rebound hyperglycemia events, resulting in less ICU length of stay and less healthcare cost 6 Insulin is currently recommended as a continuous infusion at 0.
Insulin loading dose has been linked to increasing the risk of cerebral edema and worsening shock Thus, insulin loading dose should be avoided at the beginning of therapy However, an insulin loading dose of 0. Multiple factors must be considered when titrating intravenous insulin continuous infusion 2.
The rate of blood glucose reduction, insulin sensitivity, prandial coverage, and NPO status should all be taken into consideration 2. A rapid reduction in BG might be harmful and linked to cerebral edema 2. Moreover, the insulin infusion rate can be increased based on BG around major meals time and can be continued at a higher rate for hours following any major meal 2.
Lastly, it is necessary to monitor BG among NPO patients closely. Randomized clinical trials compared the two strategies and found no difference 27 Intravenous LD insulin administration has been associated with an increased risk of cerebral edema 27 An acceptable alternative for patients with mild to moderate DKA could be a bolus of 0.
Patients with end-stage renal disease ESRD and acute kidney injury AKI are considered a high-risk category that necessitates extra care 32 To avoid rapid increases in osmolality and hypoglycemia in these patients; it is recommended that insulin infusions begin at 0.
Subcutaneous insulin should overlap with intravenous insulin for at least minutes before its discontinuation to ensure the optimal transition of care 6 A transition to subcutaneous long-acting insulin in addition to ultra-short acting insulin such as glargine and glulisine after resolution of DKA may result in reduced hypoglycemic events compared to other basal bolus regimens such as NPH insulin and insulin regular 24 For newly diagnosed insulin-dependent diabetes patients, subcutaneous insulin may be started at a dose of 0.
The transition process in patients who were previously using insulin or antidiabetic agents before to DKA admission is still unclear 24 In ICU settings, clinicians tend to hold all oral antidiabetic agents and rely on insulin regimens for in-patient management given the shorter half-life of insulin and its predictability 24 This could potentially be an area for further investigation on the transition process and its implication on patient outcomes 24 Insulin sequestering to plastic IV tubing has been described, resulting in insulin wasting and dose inaccuracy 34 Flushing the IV tube with a priming fluid of 20 mL is adequate to minimize the insulin losses to IV tube 34 Patients with hyperglycemic crisiss are at a higher risk of developing hypokalemia due to multifactorial process 1 Insulin therapy, correction of acidosis, and hydration all together lead to the development of hypokalemia 1 Additionally, volume depletion seen with hyperglycemic crisis leads to secondary hyperaldosteronism, which exacerbates hypokalemia by enhancing urinary potassium excretion 1 Serum potassium level should be obtained immediately upon presentation and prior to initiating insulin therapy 1 Potassium replacement is required regardless of the baseline serum potassium level due to hydration and insulin therapy, except among renal failure patients 1 It is suggested to administer 20 —30 mEq potassium in each liter of intravenous fluid to keep a serum potassium concentration within the normal range 1 ,
: Hyperglycemic crisis treatment| Hyperglycemia in diabetes | Dr Galindo reported receiving grants from the NIDDK and Novo Nordisk and Dexcom to Emory University and receiving personal fees from Abbott Diabetes Care, Eli Lilly and Company, Novo Nordisk, Sanofi, and Valeritas. Dr Umpierrez reported receiving grants from the National Center for Advancing Translational Sciences and receiving unrestricted research support from AstraZeneca, Novo Nordisk, and Dexcom to Emory University. Dr Shah reported receiving research support through Mayo Clinic from the US Food and Drug Administration and the Centers of Medicare and Medicaid Innovation and receiving grants from the Agency for Healthcare Research and Quality, the National Heart, Lung and Blood Institute, the National Science Foundation, and the Patient Centered Outcomes Research Institute. No other disclosures were reported. Disclaimer: Dr McCoy affirms that the article is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained. Study contents are the sole responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. Meeting Presentation: This paper was presented at the virtual meeting of the American Diabetes Association Scientific Sessions; June , full text icon Full Text. Download PDF Comment. Top of Article Key Points Abstract Introduction Methods Results Discussion Conclusions Article Information References. Figure 1. View Large Download. Figure 2. Table 1. Baseline Sociodemographic, Clinical, and Diabetes Treatment Characteristics of Patients With Type 1 Diabetes. Table 2. Baseline Sociodemographic, Clinical, and Diabetes Treatment Characteristics of Patients With Type 2 Diabetes. Table 3. 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See More About Diabetes and Endocrinology Diabetes. Sign Up for Emails Based on Your Interests Select Your Interests Customize your JAMA Network experience by selecting one or more topics from the list below. Get the latest research based on your areas of interest. Weekly Email. Monthly Email. Save Preferences. Privacy Policy Terms of Use. This Issue. Views 7, Diabetes Metab Syndrome: Clin Res Rev 15 5 CrossRef Full Text Google Scholar. Saeedi P. Global and Regional Diabetes Prevalence Estimates for and Projections for and Results From the International Diabetes Federation Diabetes Atlas, 9th Edition. Diabetes Res Clin Pract Pasquel FJ, Umpierrez GE. Hyperosmolar Hyperglycemic State: A Historic Review of the Clinical Presentation, Diagnosis, and Treatment. Dia Care 37 11 — Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al. Management of Hyperglycemic Crises in Patients With Diabetes. 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Insulin Analogs Versus Human Insulin in the Treatment of Patients With Diabetic Ketoacidosis: A Randomized Controlled Trial. Diabetes Care 32 7 —9. Laskey D, Vadlapatla R, Hart K. Stability of High-Dose Insulin in Normal Saline Bags for Treatment of Calcium Channel Blocker and Beta Blocker Overdose. Clin Toxicol 54 9 — Lindsay R, Bolte RG. The Use of an Insulin Bolus in Low-Dose Insulin Infusion for Pediatric Diabetic Ketoacidosis. Pediatrs Emerg Care 5 2 —9. Kitabchi AE, Murphy MB, Spencer J, Matteri R, Karas J. Is a Priming Dose of Insulin Necessary in a Low-Dose Insulin Protocol for the Treatment of Diabetic Ketoacidosis? Diabetes Care 31 11 Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, et al. ISPAD Clinical Practice Consensus Guidelines Diabetic Ketoacidosis and the Hyperglycemic Hyperosmolar State. Pediatr Diabetes — Umpierrez GE, Latif K, Stoever J, Cuervo R, Park L, Freire AX, et al. Efficacy of Subcutaneous Insulin Lispro Versus Continuous Intravenous Regular Insulin for the Treatment of Patients With Diabetic Ketoacidosis. Am J Med 5 —6. Ersöz HÖ, Ukinc K, Köse M, Erem C, Gunduz A, Hacihasanoglu AB, et al. Subcutaneous Lispro and Intravenous Regular Insulin Treatments are Equally Effective and Safe for the Treatment of Mild and Moderate Diabetic Ketoacidosis in Adult Patients: SC Lispro and IV Regular Insulin Treatments in DKA. Int J Clin Pract 60 4 — Huang SK, Huang CY, Lin CH, Cheng BW, Chiang YT, Lee YC, et al. Acute Kidney Injury is a Common Complication in Children and Adolescents Hospitalized for Diabetic Ketoacidosis. Shimosawa T, Ed. PloS One 15 10 :e Frankel AH, Kazempour-Ardebili S, Bedi R, Chowdhury TA, De P, El-Sherbini N, et al. Management of Adults With Diabetes on the Haemodialysis Unit: Summary of Guidance From the Joint British Diabetes Societies and the Renal Association. Diabetes Med 35 8 — Goldberg PA, Kedves A, Walter K, Groszmann A, Belous A, Inzucchi SE. Diabetes Technol Ther 8 5 — Thompson CD, Vital-Carona J, Faustino EVS. The Effect of Tubing Dwell Time on Insulin Adsorption During Intravenous Insulin Infusions. Diabetes Technol Ther 14 10 —6. Wilson HK, Keuer SP, Lea AS, Iii AEB, Eknoyan G. Phosphate Therapy in Diabetic Ketoacidosis. Arch Intern Med — Patel MP, Ahmed A, Gunapalan T, Hesselbacher SE. Use of Sodium Bicarbonate and Blood Gas Monitoring in Diabetic Ketoacidosis: A Review. WJD 9 11 — Chua HR, Schneider A, Bellomo R. Bicarbonate in Diabetic Ketoacidosis - a Systematic Review. Ann Intensive Care 1 1 Jaber S, Paugam C, Futier E, Lefrant JY, Lasocki S, Lescot T, et al. Sodium Bicarbonate Therapy for Patients With Severe Metabolic Acidaemia in the Intensive Care Unit BICAR-ICU : A Multicentre, Open-Label, Randomised Controlled, Phase 3 Trial. Lancet — Adeva-Andany MM, Fernández-Fernández C, Mouriño-Bayolo D, Castro-Quintela E, Domínguez-Montero A. Sodium Bicarbonate Therapy in Patients With Metabolic Acidosis. Sci World J — Butler J, Vijayakumar S, Pitt B. Revisiting Hyperkalaemia Guidelines: Rebuttal: Revisiting Hyperkalaemia Guidelines: Rebuttal. Eur J Heart Fail 20 9 —5. Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, et al. Part Cardiac Arrest in Special Situations- American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation suppl 3 :S— Masharani U. McGraw Hill. Keenan CR, Murin S, White RH. High Risk for Venous Thromboembolism in Diabetics With Hyperosmolar State: Comparison With Other Acute Medical Illnesses. J Thromb Haemostasis 5 6 — Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, et al. Risk Factors for Cerebral Edema in Children With Diabetic Ketoacidosis. New Engl J Med —9. Goguen J, Gilbert J. Hyperglycemic Emergencies in Adults. Can J Diabetes S72—6. Kuppermann N, Ghetti S, Schunk JE, Stoner MJ, Rewers A, McManemy JK, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med 24 — Keywords: diabetic ketoacidosis, hyperosmolar hyperglycemic syndrome, hyperglycemia crisis, hyperglycemic emergencies, diabetes mellitus. Citation: Aldhaeefi M, Aldardeer NF, Alkhani N, Alqarni SM, Alhammad AM and Alshaya AI Updates in the Management of Hyperglycemic Crisis. Diabetes Healthc. Received: 23 November ; Accepted: 24 December ; Published: 09 February Copyright © Aldhaeefi, Aldardeer, Alkhani, Alqarni, Alhammad and Alshaya. This is an open-access article distributed under the terms of the Creative Commons Attribution License CC BY. The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner s are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Export citation EndNote Reference Manager Simple TEXT file BibTex. Check for updates. REVIEW article. Aldardeer 4 Nada Alkhani 5 Shatha Mohammed Alqarni 6 Abdullah M. Alhammad 7,8 Abdulrahman I. Alshaya 1,2,3. Introduction Diabetes mellitus DM is a chronic metabolic disorder that disrupts the metabolism of primary macronutrients such as proteins, fats, and carbohydrates 1 , 2. |
| Pathophysiology | Latest Issue Alert. Randall L, Begovic J, Hudson M, et al. Pathogenesis of DKA and HHS: stress, infection, or insufficient insulin. Diagnostic accuracy of point-of-care testing for diabetic ketoacidosis at emergency department triage: beta-hydroxbutyrate versus the urine dipstick. Severe metabolic acidosis can lead to impaired myocardial contractility, cerebral vasodilatation and coma, and several gastrointestinal complications |
| Introduction | Hamburger S, Barjenbruch P, Soffer A: Treatment of diabetic ketoacidosis by internist and family physicians: a comparative study. Hyperosmolar nonketotic coma with hyperglycemia: abnormalities of lipid and carbohydrate metabolism. Trends Endocrinol Metab. Additionally, the oxidative state increases the risk of developing chronic diabetic complications following the DKA event 9. The ketoacids formed during DKA β-hydroxybutyric and acetoacetic are strong acids that fully dissociate at physiological pH. The ADA guidelines also suggest that mental status be used to grade severity. |
Hyperglycemic crisis treatment -
Semler MW, Kellum JA. Balanced Crystalloid Solutions. Am J Respir Crit Care Med 8 — Van Zyl DG, Rheeder P, Delport E. QJM 4 — Mahler SA, Conrad SA, Wang H, Arnold TC. Resuscitation With Balanced Electrolyte Solution Prevents Hyperchloremic Metabolic Acidosis in Patients With Diabetic Ketoacidosis.
Am J Emerg Med 29 6 —4. Self WH, Evans CS, Jenkins CA, Brown RM, Casey JD, Collins SP, et al. Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials.
JAMA Netw. Open 3 11 :e Ramanan M, Attokaran A, Murray L, Bhadange N, Stewart D, Rajendran G, et al. Sodium Chloride or Plasmalyte Evaluation in Severe Diabetic Ketoacidosis Scope-Dka - a Cluster, Crossover, Randomized, Controlled Trial.
Intensive Care Med 47 11 — Savage MW, Dhatariya KK, Kilvert A, Rayman G, Rees JAE, Courtney CH, et al. Joint British Diabetes Societies Guideline for the Management of Diabetic Ketoacidosis: Diabetic Ketoacidosis Guidelines. Diabetic Med 28 5 — Umpierrez GE, Jones S, Smiley D, Mulligan P, Keyler T, Temponi A, et al.
Insulin Analogs Versus Human Insulin in the Treatment of Patients With Diabetic Ketoacidosis: A Randomized Controlled Trial.
Diabetes Care 32 7 —9. Laskey D, Vadlapatla R, Hart K. Stability of High-Dose Insulin in Normal Saline Bags for Treatment of Calcium Channel Blocker and Beta Blocker Overdose.
Clin Toxicol 54 9 — Lindsay R, Bolte RG. The Use of an Insulin Bolus in Low-Dose Insulin Infusion for Pediatric Diabetic Ketoacidosis. Pediatrs Emerg Care 5 2 —9. Kitabchi AE, Murphy MB, Spencer J, Matteri R, Karas J.
Is a Priming Dose of Insulin Necessary in a Low-Dose Insulin Protocol for the Treatment of Diabetic Ketoacidosis? Diabetes Care 31 11 Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, et al. ISPAD Clinical Practice Consensus Guidelines Diabetic Ketoacidosis and the Hyperglycemic Hyperosmolar State.
Pediatr Diabetes — Umpierrez GE, Latif K, Stoever J, Cuervo R, Park L, Freire AX, et al. Efficacy of Subcutaneous Insulin Lispro Versus Continuous Intravenous Regular Insulin for the Treatment of Patients With Diabetic Ketoacidosis. Am J Med 5 —6. Ersöz HÖ, Ukinc K, Köse M, Erem C, Gunduz A, Hacihasanoglu AB, et al.
Subcutaneous Lispro and Intravenous Regular Insulin Treatments are Equally Effective and Safe for the Treatment of Mild and Moderate Diabetic Ketoacidosis in Adult Patients: SC Lispro and IV Regular Insulin Treatments in DKA. Int J Clin Pract 60 4 — Huang SK, Huang CY, Lin CH, Cheng BW, Chiang YT, Lee YC, et al.
Acute Kidney Injury is a Common Complication in Children and Adolescents Hospitalized for Diabetic Ketoacidosis. Shimosawa T, Ed. PloS One 15 10 :e Frankel AH, Kazempour-Ardebili S, Bedi R, Chowdhury TA, De P, El-Sherbini N, et al.
Management of Adults With Diabetes on the Haemodialysis Unit: Summary of Guidance From the Joint British Diabetes Societies and the Renal Association. Diabetes Med 35 8 — Goldberg PA, Kedves A, Walter K, Groszmann A, Belous A, Inzucchi SE.
Diabetes Technol Ther 8 5 — Thompson CD, Vital-Carona J, Faustino EVS. The Effect of Tubing Dwell Time on Insulin Adsorption During Intravenous Insulin Infusions. Diabetes Technol Ther 14 10 —6. Wilson HK, Keuer SP, Lea AS, Iii AEB, Eknoyan G. Phosphate Therapy in Diabetic Ketoacidosis.
Arch Intern Med — Patel MP, Ahmed A, Gunapalan T, Hesselbacher SE. Use of Sodium Bicarbonate and Blood Gas Monitoring in Diabetic Ketoacidosis: A Review.
WJD 9 11 — Chua HR, Schneider A, Bellomo R. Bicarbonate in Diabetic Ketoacidosis - a Systematic Review. Ann Intensive Care 1 1 Jaber S, Paugam C, Futier E, Lefrant JY, Lasocki S, Lescot T, et al.
Sodium Bicarbonate Therapy for Patients With Severe Metabolic Acidaemia in the Intensive Care Unit BICAR-ICU : A Multicentre, Open-Label, Randomised Controlled, Phase 3 Trial. Lancet — Adeva-Andany MM, Fernández-Fernández C, Mouriño-Bayolo D, Castro-Quintela E, Domínguez-Montero A. Sodium Bicarbonate Therapy in Patients With Metabolic Acidosis.
Sci World J — Butler J, Vijayakumar S, Pitt B. Revisiting Hyperkalaemia Guidelines: Rebuttal: Revisiting Hyperkalaemia Guidelines: Rebuttal. Eur J Heart Fail 20 9 —5. Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, et al.
Part Cardiac Arrest in Special Situations- American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation suppl 3 :S— Masharani U. McGraw Hill. Keenan CR, Murin S, White RH. High Risk for Venous Thromboembolism in Diabetics With Hyperosmolar State: Comparison With Other Acute Medical Illnesses.
J Thromb Haemostasis 5 6 — Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, et al. Risk Factors for Cerebral Edema in Children With Diabetic Ketoacidosis. New Engl J Med —9. Goguen J, Gilbert J. Hyperglycemic Emergencies in Adults.
Can J Diabetes S72—6. Kuppermann N, Ghetti S, Schunk JE, Stoner MJ, Rewers A, McManemy JK, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med 24 — Keywords: diabetic ketoacidosis, hyperosmolar hyperglycemic syndrome, hyperglycemia crisis, hyperglycemic emergencies, diabetes mellitus.
Citation: Aldhaeefi M, Aldardeer NF, Alkhani N, Alqarni SM, Alhammad AM and Alshaya AI Updates in the Management of Hyperglycemic Crisis.
Diabetes Healthc. Received: 23 November ; Accepted: 24 December ; Published: 09 February Copyright © Aldhaeefi, Aldardeer, Alkhani, Alqarni, Alhammad and Alshaya. This is an open-access article distributed under the terms of the Creative Commons Attribution License CC BY.
The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner s are credited and that the original publication in this journal is cited, in accordance with accepted academic practice.
No use, distribution or reproduction is permitted which does not comply with these terms. Export citation EndNote Reference Manager Simple TEXT file BibTex.
Check for updates. REVIEW article. Aldardeer 4 Nada Alkhani 5 Shatha Mohammed Alqarni 6 Abdullah M. Alhammad 7,8 Abdulrahman I. Alshaya 1,2,3. Introduction Diabetes mellitus DM is a chronic metabolic disorder that disrupts the metabolism of primary macronutrients such as proteins, fats, and carbohydrates 1 , 2.
Pathophysiology DKA and HHS have similar pathophysiology with some differences. Hyperglycemia high blood glucose. American Diabetes Association. Accessed July 6, What is diabetes? National Institute of Diabetes and Digestive and Kidney Diseases.
Wexler DJ. Management of persistent hyperglycemia in type 2 diabetes mellitus. Hirsch IB, et al. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis.
Managing diabetes. Inzucchi SE, et al. Glycemic control and vascular complications in type 2 diabetes mellitus. Comprehensive medical evaluation and assessment of comorbidities: Standards of Medical Care in Diabetes — Diabetes Care.
The big picture: Checking your blood glucose. Castro MR expert opinion. Mayo Clinic, Rochester, Minn. July 7, Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment.
Take care of your diabetes during sick days and special times. Accessed July 7, Classification and diagnosis of diabetes: Standards of Medical Care in Diabetes — Retinopathy, neuropathy, and foot care: Standards of Medical Care in Diabetes — Glycemic targets: Standards of Medical Care in Diabetes — Associated Procedures.
A Book: The Essential Diabetes Book. Show the heart some love! Give Today. Help us advance cardiovascular medicine. Find a doctor. Explore careers. Sign up for free e-newsletters. About Mayo Clinic. About this Site. Contact Us. Health Information Policy.
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Research Faculty. International Patients. Manitol infusion and mechanical ventilation are suggested for treatment of cerebral edema Many cases of DKA and HHS can be prevented by better access to medical care, proper patient education, and effective communication with a health care provider during an intercurrent illness.
Paramount in this effort is improved education regarding sick day management, which includes the following:. Emphasizing the importance of insulin during an illness and the reasons never to discontinue without contacting the health care team.
Similarly, adequate supervision and staff education in long-term facilities may prevent many of the admissions for HHS due to dehydration among elderly individuals who are unable to recognize or treat this evolving condition.
The use of home glucose-ketone meters may allow early recognition of impending ketoacidosis, which may help to guide insulin therapy at home and, possibly, may prevent hospitalization for DKA.
In addition, home blood ketone monitoring, which measures β-hydroxybutyrate levels on a fingerstick blood specimen, is now commercially available The observation that stopping insulin for economic reasons is a common precipitant of DKA 74 , 75 underscores the need for our health care delivery systems to address this problem, which is costly and clinically serious.
The rate of insulin discontinuation and a history of poor compliance accounts for more than half of DKA admissions in inner-city and minority populations 9 , 74 , Several cultural and socioeconomic barriers, such as low literacy rate, limited financial resources, and limited access to health care, in medically indigent patients may explain the lack of compliance and why DKA continues to occur in such high rates in inner-city patients.
These findings suggest that the current mode of providing patient education and health care has significant limitations. Addressing health problems in the African American and other minority communities requires explicit recognition of the fact that these populations are probably quite diverse in their behavioral responses to diabetes Significant resources are spent on the cost of hospitalization.
Based on an annual average of , hospitalizations for DKA in the U. A recent study 2 reported that the cost burden resulting from avoidable hospitalizations due to short-term uncontrolled diabetes including DKA is substantial 2. However, the long-term impact of uncontrolled diabetes and its economic burden could be more significant because it can contribute to various complications.
Because most cases occur in patients with known diabetes and with previous DKA, resources need to be redirected toward prevention by funding better access to care and educational programs tailored to individual needs, including ethnic and personal health care beliefs.
In addition, resources should be directed toward the education of primary care providers and school personnel so that they can identify signs and symptoms of uncontrolled diabetes and so that new-onset diabetes can be diagnosed at an earlier time.
Recent studies suggest that any type of education for nutrition has resulted in reduced hospitalization In fact, the guidelines for diabetes self-management education were developed by a recent task force to identify ten detailed standards for diabetes self-management education An American Diabetes Association consensus statement represents the authors' collective analysis, evaluation, and opinion at the time of publication and does not represent official association opinion.
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Consensus Statements July 01 Hyperglycemic Crises in Adult Patients With Diabetes Abbas E. Kitabchi, PHD, MD ; Abbas E. Kitabchi, PHD, MD. Corresponding author: Abbas E. Kitabchi, akitabchi utmem. This Site. Google Scholar. Guillermo E.
Umpierrez, MD ; Guillermo E. Umpierrez, MD. John M. Miles, MD ; John M. Miles, MD. Joseph N. Fisher, MD Joseph N. Fisher, MD. Diabetes Care ;32 7 — Get Permissions. toolbar search Search Dropdown Menu. toolbar search search input Search input auto suggest. Table 1 Diagnostic criteria for DKA and HHS.
Arterial pH 7. View Large. Figure 1. View large Download slide. Pathogenesis of DKA and HHS: stress, infection, or insufficient insulin. FFA, free fatty acid. Table 2 Admission biochemical data in patients with HHS or DKA.
Figure 2. Early contact with the health care provider. Review of blood glucose goals and the use of supplemental short- or rapid-acting insulin. Having medications available to suppress a fever and treat an infection.
Initiation of an easily digestible liquid diet containing carbohydrates and salt when nauseated. No potential conflicts of interest relevant to this article were reported.
National Center for Health Statistics. Burden of hospitalizations primarily due to uncontrolled diabetes: implications of inadequate primary health care in the United States.
Search ADS. Agency for Healthcare Research and Quality. Databases and related tools from the healthcare cost and utilization project HCUP [article online]. National Center for Health Statistics, Centers for Disease Control.
Available from www. Diabetic ketoacidosis in infants, children, and adolescents: a consensus statement from the American Diabetes Association.
Detailed diagnoses and procedures: National Hospital Discharge Survey, Diabetic ketoacidosis and the hyperglycemic hyperosmolar nonketotic state. Diabetic ketoacidosis: a combined metabolic-nephrologic approach to therapy. Metabolic effects of low-dose insulin therapy on glucose metabolism in diabetic ketoacidosis.
van de Werve. Effects of free fatty acid availability, glucagon excess and insulin deficiency on ketone body production in postabsorptive man. Proinflammatory cytokines, markers of cardiovascular risks, oxidative stress, and lipid peroxidation in patients with hyperglycemic crises.
Diabetic ketoacidosis during long-term treatment with continuous subcutaneous insulin infusion. Sever hyperglycemic hyperosmolar nonketotic coma in a nondiabetic patient receiving aripiprazole. Immunogenetic analysis suggest different pathogenesis between obese and lean African-Americans with diabetic ketoacidosis.
Ketosis-prone diabetes: dissection of a heterogeneous syndrome using an immunogenetic and beta-cell functional classification, prospective analysis, and clinical outcomes. Ketosis-prone type 2 diabetes in patients of sub-Saharan African origin: clinical pathophysiology and natural history of β-cell dysfunction and insulin resistance.
Abdominal pain in diabetic metabolic decompensation: clinical significance. Insulin therapy of diabetic ketoacidosis: physiologic versus pharmacologic doses of insulin and their routes of administration. Short-term fasting is a mechanism for the development of euglycemic ketoacidosis during periods of insulin deficiency.
Diabetic ketoacidosis and infection: leukocyte count and differential as early predictors of serious infection. Proinflammatory cytokines in response to insulin-induced hypoglycemic stress in healthy subjects.
A randomized study of phosphate therapy in the treatment of diabetic ketoacidosis.
The treatment Hyperglycemic crisis treatment DKA and HHS in adults frisis be reviewed here. The crusis, Hyperglycemic crisis treatment, clinical features, evaluation, and diagnosis of these disorders are discussed separately. DKA in children is also reviewed separately. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Learn how UpToDate can help you.
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