The mortality rate from dka in children ranges from 0. Diabetic ketoacidosis dka and hyperglycemic hyperosmolar state hhs are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. Hyperglycemia develops as a result of three processes. In brief treatment guidelines for diabetic emergencies are well described in patients with normal to moderately impaired kidney function. Hyperglycemic crises are also economically burdensome with. The management of the hyperosmolar hyperglycaemic state. A persons breath may develop a specific fruity smell. Kim cathcart, ms, rn, rrt, started working in the field of inhalation therapy in 1976 and by 1979 had completed her first test to become a registered respiratory therapist.
Published on jul 31, 2011 a lecture on the recognition, pathogenesis, and treatment of diabetic ketoacidosis and the hyperosmolar hyperglycemic state. Current diagnosis and treatment of hyperglycemic emergencies brian corwell, mda, brandi knight, mdb, laura olivieri, mdb, george c. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes. Diabetic ketoacidosis dka and the hyperosmolar hyperglycemic state hhs are the two most serious acute metabolic complications of diabetes. The criteria for hyperglycemic hyperosmolar state hhs include.
Table 1 comparison of diabetic ketoacidosis to hyperosmolar hyperglycemic state. Hyperglycemic crises in adult patients with diabetes diabetes care 2009 jul. Omission of insulin is the most common precipitant of dka. Pdf diabetic ketoacidosis dka is one of the acute complications of diabetes mellitus with increased mortality, and results from an absolute insulin deficiency associated with an increase in. Treatment of diabetic ketoacidosis dkahyperglycemic. Diabetic ketoacidosis and hyperglycemic hyperosmolar state find, read and cite all the research. A variety of pharmacological agents a variety of pharmacological agents affect glucose homeostasis resulting in either hypo or hyperglycemia. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Hyperglycemic emergency management dkahhs1 adult does patient have a diagnosis of hyperglycemic emergency.
Standards of medical care in diabetes2011 diabetes care. Diagnosis and management of hyperglycemic emergencies. Diabetic ketoacidosis dka and hyperglycemic hyperosmolar state hhs are the most serious and lifethreatening hyperglycemic emergencies in diabetes. Hyperglycemic crises often require critical care management and are associated with significant health care costs, morbidity, and mortality. Hyperosmolar hyperglycemic state is a relatively common, lifethreatening endocrine emergency that is reported in all age groups,1 but it most frequently affects older patients with type 2 diabetes. She earned a bachelors degree in general studies and a masters degree in educational administration from the. Novel advances in the management of hyperglycemic crises uk versus usa ketan k. There was a decline in mortality from 2000 to 2014 across all age groups and both sexes with largest absolute decrease among persons aged. Dka that is seen in type 2 diabetics happens under what circumstances. In 2010, among adults aged 20 years or older, hyperglycemic crisis caused 2,361 deaths.
Pathophysiological considerations and suggested guidelines for treatment phil zeitler, md, phd, andrea haqq, md, arlan rosenbloom, md, and nicole glaser, md for the drugs and therapeutics committee of the lawson wilkins pediatric endocrine society h yperglycemic hyperosmolar syndrome hhs, charac. Geraci3 1division of endocrinology, department of medicine, university of mississippi school of medicine. The findings by semler et al 10 and findings from other smaller studies, calls into question whether normal saline is the best crystalloid to manage dka and hhs. The mortality rate for dka and hyperglycemic crises has been falling over the years figure 1b. Mortality of hyperglycemic crisis dka is the most common cause of death in children and adolescents with type 1 diabetes. Treatment of diabetic ketoacidosis dkahyperglycemic hyperosmolar state hhs. Dka most often occurs in patients with type 1 diabetes, but patients with type 2 diabetes are susceptible to dka under stressful conditions such as trauma, surgery or infections. Hyperglycemic crises in adult patients with diabetes a consensus statement from the american diabetes association abbas e. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome hhs are life threatening complications that occur in patients with diabetes. However, management of patients with endstage renal disease esrd is an ongoing challenge. Increasing evidence indicates that the hyperglycemia in patients with hyperglycemic crises is associated with a severe inflammatory state characterized by an elevation of proinflammatory cytokines tumor necrosis factor. Typically, dka presents in type i diabetics while hhs presents in type ii diabetics. Diabetic ketoacidosis treatment algorithm bmj best.
Common symptoms and signs include polyuria, polydipsia, polyphagia, weakness, weight loss, tachycardia, dry mucous membranes, poor skin turgor, hypotension, and, in s. Diabetic ketoacidosis and the hyperosmolar hyperglycemic state are the most serious acute metabolic complications of diabetes. Umpierrez and others published hyperglycemic crises. In those previously diagnosed, the disease may have been managed by diet, oral hypoglycaemic agents or insulin. Diabetic ketoacidosis dka and hyperglycemic hyperosmolar state hhs are the two most serious hyperglycemic emergencies in patients with diabetes mellitus. In 2009, an international expert committee that included representatives of the ada, the international diabetes federation idf, and the european association for the study of diabetes. The purpose of this study was to evaluate the efficacy and safety of an adult hyperglycemic crises protocol based upon the 2009 american diabetes association ada consensus statement. Diabetic ketoacidosis is characterized by a biochemical triad of hyperglycemia, ketonemia, and acidemia, with rapid symptom onset.
Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. People who use the rapidacting insulin analog lispro brand name humalog, aspart novolog, or glulisine apidra in an insulin pump need to be particularly alert to pump malfunctions. Dka is more common in young people with type 1 diabetes and hhs in adult and elderly patients with type 2 diabetes. The criteria of the american diabetes association ada were used for the definition of dka as follows. Diabetes mellitus is becoming more common in the united states, as the prevalence has nearly tripled from 5. This article describes a retrospective study comparing the rates of adverse glucose events defined as hypoglycemia. In 2010, among adults aged 20 years or older, hyperglycemic crisis caused 2,361 deaths in the u. Hyperglycemic crises in adult patients with diabetes. Impact of a hyperglycemic crises protocol endocrine practice. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. In 2009, there were 140,000 hospitalizations for diabetic ketoacidosis dka with an average length of stay of 3. 3department of medicine, university of mississippi school. Pdf hyperglycemic crises in adult patients with diabetes. In rare instances, mechanical problems with insulin pumps, such as blocking or kinking of the tubing, can stop insulin delivery and result in extreme hyperglycemia.
The estimated mortality rate in patients with hhs remains alarmingly high world wide at 520% in developed countries. They are part of the spectrum of hyperglycemia, and each represents an extreme in the spectrum. Full text management of adult diabetic ketoacidosis dmso. Evaluation of the treatment of diabetic ketoacidosis in. This 40minute course discusses common causes of hyperglycemia and strategies to get blood glucose levels to goal. Druginduced serum glucose alterations manifested as hyperglycemia or.
Diabetic ketoacidosis and hyperosmolar hyperglycemic. Diagnosis and management of hyperglycemic emergencies niyutchai chaithongdi1, jose s. Diabetic ketoacidosis dka and hyperosmolar hyperglycemic state hhs, also known as hyperosmotic hyperglycemic nonketotic state hhnk are two of the most serious acute complications of diabetes. At presentation, they have markedly impaired insulin secretion and insulin action, but aggressive management with. Table 1 outlines the diagnostic criteria for dka and hhs. Dka is responsible for more than 500,000 hospital days per year 1,2 at an estimated annual direct medical expense and indirect cost of 2. It is uncommon, but has a higher mortality than dka delaney 2000. Use of the va and stanford namelogos is only to indicate my academic. For decades, the diagnosis of diabetes was based on plasma glucose criteria, either the fasting plasma glucose fpg or the 2h value in the 75g oral glucose tolerance test ogtt. In 2005, dka was responsible for approximately 120,000 hospital discharges in the usa, amounting to 7.
Overview of the diabetic ketoacidosis dka hyperglycemic. Diabetic ketoacidosis dka is a potentially lifethreatening complication of diabetes mellitus. Evidencebased management of hyperglycemic emergencies in. A lecture on the recognition, pathogenesis, and management of diabetic ketoacidosis and the hyperosmolar hyperglycemic state. Fisher, md 1 d iabetic ketoacidosis dka and the hyperosmolar hyperglycemic state hhsarethetwomostseriousacute. Hormones such as insulin, glucagon, catecholamines, growth hormone, and cortisol, among others, contribute to normoglycemia. The 2009 american diabetes association ada hyperglycemic crises consensus guidelines further subdivides dka into mild dka serum bicarbonate of 15 to 18 meql 15 to 18 mmoll, ph 7. Managing acute complications of diabetes about the authors. Hyperglycemic crises in adult patients with diabetes abbas e. Willis, mdb introduction hyperglycemia is a common occurrence in emergency department patients. This article is published with open access at abstract. Intracerebral crises during treatment of diabetic ketoacidosis. Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management is key to the successful resolution of dka and hhs. The goals of therapy in patients with hyperglycemic crises include.331 1241 1061 880 1453 565 416 600 400 670 1423 16 1345 734 1217 1523 465 694 1115 564 722 463 1579 1555 910 463 643 263 1002 179 1354 644 588 486 1436 1120 1370 781 191