Management of hyperglycemic crises in patients with diabetes

Impact of a hyperglycemic crises protocol

OBJECTIVE

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.

METHODS

We performed a retrospective review of patients treated before and after protocol implementation at a university teaching hospital. A total of 256 adult patients met the criteria for diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) and were treated with an insulin infusion between February 2011 and February 2012 (nonprotocol n = 143, protocol n = 113). Protocol efficacy was evaluated by assessing time to resolution of DKA or HHS, length of stay (LOS) in the intensive care unit (ICU), and LOS in the hospital. Protocol safety was evaluated by assessing the numbers of patients with hypoglycemic and hypokalemic events.

RESULTS

Patients on the hyperglycemic crises protocol experienced a 9.2 hour (95% confidence interval (CI): 4.70-13.70; P<.001) decrease in time to resolution, with nonprotocol patients (n = 143) resolving in 22.78 hours and protocol patients (n = 113) resolving in 13.58 hours. There was no difference in safety outcomes, including the number of patients with moderate hypoglycemia (blood glucose <70 mg/dL), severe hypoglycemia (blood glucose <50 mg/dL), or hypokalemia (K+ <3.3 mmol/L).

CONCLUSION

Implementation of a hyperglycemic crises protocol decreased times to resolution of DKA and HHS without increasing the rate of hypoglycemia or hypokalemia.

Recurrent diabetic ketoacidosis in two community teaching hospitals

OBJECTIVE

To identify the factors that influence recurrent (one or more previous episodes) diabetic ketoacidosis (DKA), which we refer to as recurrent DKA, in two private community teaching hospitals.

METHODS

Retrospective chart review of the demographics, diabetes treatment regimens, diabetes education, medical comorbidities, medical insurance status, and mental illness/psychosocial factors of 80 patients with recurrent DKA who were admitted to the resident teaching services at two Birmingham, Alabama community teaching hospitals, Trinity Medical Center (TMC) and Princeton Baptist Medical Center (PBMC), between May 2006 and May 2012.

RESULTS

The average number of admissions for recurrent DKA was 2.5 per patient. Eighty-four percent of the episodes of recurrent DKA were due to omission of insulin; 44% of patients reported omission of insulin because of illness and 40% stopped insulin for unknown reasons. Medical illnesses, including infection, accounted for only 31% of recurrent DKA admissions.

CONCLUSION

Omission of insulin is the major cause of recurrent DKA. Psychosocial and socioeconomic factors contribute to poor adherence to therapy. Identifying these factors and instituting appropriate interventions may reduce the incidence of recurrent DKA.

Micronutrient status in type 2 diabetes: a review

Type 2 diabetes is characterized by significant losses of important micronutrients due to metabolic basis of the disease and its complications. Evidence of changes in trace mineral and vitamin metabolism as a consequence of type 2 diabetes is reviewed in this chapter. This review is not a meta-analysis but an overview of the micronutrient status, metabolic needs, and potential micronutrient requirements in type 2 diabetics. This chapter will not concentrate on vitamin D and type 2 diabetes as this is a topic that has been extensively reviewed before. The less well-known micronutrients notably zinc, magnesium, chromium, copper, manganese, iron, selenium, vanadium, B-group vitamins, and certain antioxidants are assessed. While some evidence is available to demonstrate the positive influence of micronutrient supplementation on glycemic control, much remains to be investigated. Additional research is necessary to characterize better biomarkers of micronutrient status and requirements in type 2 diabetics. The optimal level of micronutrient supplementation to achieve glucose homeostasis in type 2 diabetics remains a challenge.

[Diabetic ketoacidosis in adults in Sendwe Hospital Lubumbashi: about 51 cases]

L'acidocétose diabétique (ACD) est une décompensation métabolique sévère du diabète sucré. L'objectif de notre étude est de Décrire les aspects épidémiologiques, cliniques et évolutifs de l'acidocétose diabétique chez l'adulte à Lubumbashi (République Démocratique du Congo). Il s'agit d'une étude prospective descriptive réalisée du 1er janvier 2011 au 31 décembre 2012 incluant tous les patients âgés de 18 ans ou plus admis pour acidocétose diabétique dans le service de Médecine Interne de l'hôpital Jason Sendwe de Lubumbashi (République Démocratique du Congo). L’échantillon était exhaustif fait de 51 patients chez qui nous les paramètres épidémiologiques, cliniques et évolutifs étaient étudiés. La prévalence de l'acidocétose diabétique au cours de l’étude a été de 5% et elle a constitué la plus fréquente des complications métaboliques aigues du diabète avec 37,2% des cas. L’âge moyen des patients était de 44,8 ans allant de 20 à 79 ans et les hommes ont été plus touchés (58,8%) avec un sexe ratio de 1,42. L'examen clinique a révélé la respiration de Kussmaul dans 80,4%, des signes de déshydratation dans 76,5% et une odeur cétonique de l'haleine dans 56,9% et 58,8% de nos patients étaient admis dans un tableau de coma. L'infection était en tête des causes de la décompensation acidocétosique (54,9%) suivi de la mauvaise observance thérapeutique (29,4%). La durée moyenne du séjour hospitalier dans notre série a été de 9,3 jours et l'affection a été grevée d'un taux de mortalité de 27,5%. Cette complication métabolique aigue du diabète reste donc relativement fréquente et redoutable dans notre milieu avec une prévalence de 5% et un taux de mortalité de 27,5%. Une conscientisation des patients diabétiques et une amélioration de la prise en charge s'avèrent donc urgente.

Accuracy of capillary blood 3-β-hydroxybutyrate determination for the detection and treatment of canine diabetic ketoacidosis

In human medicine, diagnosis of diabetic ketoacidosis (DKA) is usually based on measurement of capillary 3-β-hydroxybutyrate (3-HB) with a hand held ketone sensor. This study was conducted to determine if measurement of capillary 3-HB could be useful for the diagnosis and monitoring of canine DKA. Fifteen dogs with diabetic ketosis and 10 with DKA were evaluated. Paired measurements of 3-HB of capillary and venous blood samples were analysed by the electrochemical sensor and reference method. Use of capillary 3-HB measurement during DKA management was then evaluated through simultaneous measurements of capillary 3-HB, urinary AcAc and venous blood gas analysis. Good agreement between capillary and venous 3-HB measurement was detected by the electrochemical sensor and reference method. Monitoring treatment of DKA revealed a significant correlation between capillary 3-HB and acidosis markers, while no significant correlation was observed between AcAc and acidosis markers. A cut-off value of capillary blood 3-HB >3.8 mmol/L for diagnosis of DKA resulted in 70% and 92% sensitivity and specificity. The electrochemical sensor accurately measures 3-HB concentration in both capillary and venous blood samples, is accurate in diagnosing canine DKA, and appears to reflect the patient's metabolic status during DKA treatment.

Clinical characteristics of hyperglycemic crises in patients without a history of diabetes

Aims/Introduction

Hyperglycemic crises without a history of diabetes have not been well studied. We compared the clinical characteristics of patients with and without a history of diabetes, and evaluated the glycated hemoglobin levels.

Materials and Methods

Consecutive adult patients (aged >18 years) visiting the emergency department (ED) between January 2004 and December 2010 were enrolled if they met the criteria for a hyperglycemic crisis. Patients were separated into those without and those with a history of diabetes. The 30-day mortality was the primary end-point.

Results

We enrolled 295 patients who made 330 visits to the ED. Patients without a history of diabetes made up 24.5% (81/330) of the hyperglycemic crises. Patients without a history of diabetes were more prone than patients with a history of diabetes to be younger and male, and to have better consciousness and renal function, more significant diabetic signs and symptoms (e.g., thirst, polydipsia, polyuria and bodyweight loss), higher blood sugar, and less opportunity of infection and mortality. Most of the patients (93.8%, 76/81) had glycated hemoglobin of ≥6.5%.

Conclusions

The present study delineates the clinical characteristics of patients with hyperglycemic crises, but without a history of diabetes. Most patients had glycated hemoglobin ≥6.5%, which raises the argument of using this biomarker for routine screening of diabetes.

Inpatient management of women with gestational and pregestational diabetes in pregnancy

For women with type 1 diabetes (T1DM), type 2 diabetes (T2DM), and gestational diabetes (GDM), poor maternal glycemic control can significantly increase maternal and fetal risk for adverse outcomes. Outpatient medical and nutrition therapy is recommended for all women with diabetes in order to facilitate euglycemia during the antepartum period. Despite intensive outpatient therapy, women with diabetes often require inpatient diabetes management prior to delivery as maternal hyperglycemia can significantly increase neonatal risk of hypoglycemia. Consensus guidelines recommend maternal glucose range of 80-110 mg/dL in labor. The most optimal inpatient strategies for the prevention of hyperglycemia and hypoglycemia proximate to delivery remain unclear and will depend upon factors such as maternal diabetes diagnosis, her baseline insulin resistance, duration and route of delivery etc. Low dose intravenous insulin and dextrose protocols are necessary to achieve optimal predelivery glycemic control for women with T1DM and T2DM. For most with GDM however, euglycemia can be maintained without intravenous insulin. Women treated with a subcutaneous insulin pump during the antepartum period represent a unique challenge to labor and delivery staff. Strategies for self-managed subcutaneous insulin infusion (CSII) use prior to delivery require intensive education and coordination of care with the labor team in order to maintain patient safety. Hospitalization is recommended for most women with diabetes prior to delivery and in the postpartum period despite appropriate outpatient glycemic control. Women with poorly controlled diabetes in any trimester have an increased baseline maternal and fetal risk for adverse outcomes. Common indications for antepartum hospitalization of these women include failed outpatient therapy and/or diabetic ketoacidosis (DKA). Inpatient management of DKA is a significant cause of maternal and fetal morbidity and remains a common indication for hospitalization of the pregnant woman with diabetes. Changes in maternal physiology increase insulin resistance and the risk for DKA. A systematic approach to its management will be reviewed.

Diabetic ketoacidosis and hyperglycemic hyperosmolar state

Diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) are potentially fatal hyperglycemic crises that occur as acute complications of uncontrolled diabetes mellitus. The authors provide a review of the current epidemiology, precipitating factors, pathogenesis, clinical presentation, evaluation, and treatment of DKA and HHS. The discovery of insulin in 1921 changed the life expectancy of patients with diabetes mellitus dramatically. Today, almost a century later, DKA and HHS remain significant causes of morbidity and mortality across different countries, ages, races, and socioeconomic groups and a significant economic burden for society.

Microdialysis monitoring of glucose, lactate, glycerol, and pyruvate in patients with diabetic ketoacidosis

PURPOSE

The objective was to assess glucose, lactate, glycerol, and pyruvate concentrations in the interstitial fluid of the adipose tissue as well as the glucose relative recovery coefficient in reference to capillary blood (RC) during the first two days of the standard treatment of diabetic ketoacidosis (DKA) in patients with type 1 and type 2 diabetes.

MATERIALS AND METHODS

The study group consisted of 19 patients (12 with type 1 diabetes and 7 with type 2 diabetes). The metabolic state of the patients was monitored using the microdialysis technique. The analysis of variance was used to investigate whether the type of diabetes and the duration of treatment influenced the assessed parameters.

RESULTS

Concentrations of all the monitored components were stable after the initial 12 h of treatment. Glucose concentration was higher and concentrations of all the other components were lower (p<0.0001) in patients with type 1 diabetes than in patients with type 2 diabetes. Significantly higher RC was observed in patients with type 1 diabetes during the initial 12 h.

CONCLUSIONS

The results suggest that the standard treatment of DKA is effective in stabilizing a concentration of the studied metabolic components in the interstitial fluid in patients with type 1 and type 2 diabetes despite differences in the glucose concentration at the beginning of the treatment.

Two cases of diabetic ketoacidosis in HNF1A-MODY linked to severe dehydration: is it time to change the diagnostic criteria for MODY?

OBJECTIVE

Hepatocyte nuclear factor-1A maturity-onset diabetes of the young (HNF1A-MODY) is a monogenic form of diabetes caused by heterozygous mutations in HNF1A. Currently, a history of diabetic ketoacidosis (DKA) is an exclusion criterion for genetic testing for MODY.

HISTORY AND EXAMINATION

In this article, we describe two unrelated patients aged 17 and 24 years with severe DKA developed several years after the diagnosis of HNF1A-MODY.

INVESTIGATION

Both patients were treated with insulin, but their metabolic control was poor (HbA1c 15%, 140 mmol/mol and 13%, 119 mmol/mol, respectively) due to noncompliance and missed insulin injections. In both patients, DKA followed a course of recurrent vomiting with dehydration and prerenal acute kidney injury. Their glycemia, blood pH, and base excess at admission were 97 mmol/L [1,748 mg/dL], 6.80, and -33 mmol/L (patient 1) and 34 mmol/L [613 mg/dL], 7.03, and -14 mmol/L (patient 2).

CONCLUSIONS

This anecdotal observation supports the notion that a history of DKA does not exclude MODY.

Diabetes ketoacidosis in pregnancy

Diabetic ketoacidosis (DKA) is a serious medical and obstetrical emergency usually occurring in patients with type 1 (insulin-dependent) diabetes mellitus. Although modern management of the patient with diabetes should prevent the occurrence of DKA during pregnancy, this complication still occurs and can result in significant morbidity and mortality for mother and/or fetus. Metabolic changes occurring during pregnancy can predispose a pregnant diabetic to DKA. The diagnosis of DKA can be more challenging during pregnancy as it does not always manifest with the classic presenting symptoms or laboratory findings. In fact, although uncommon, during pregnancy, DKA may develop even in the setting of relative normoglycemia. Prompt diagnosis and management is essential in order to optimize maternal and fetal outcomes. This article will provide the reader with information regarding the pathophysiology underlying DKA complicating pregnancy and will provide practical management guidelines for the diagnosis and management of this condition.

Cancer history, bandemia, and serum creatinine are independent mortality predictors in patients with infection-precipitated hyperglycemic crises

BACKGROUND

Infection is the most common precipitating factor and cause of death in patients with hyperglycemic crises. Treating infection-precipitated hyperglycemic crises includes using empiric antibiotics early; correcting dehydration, hyperglycemia, and electrolyte imbalances; and frequent monitoring. Intensive care unit admission, broad-spectrum antibiotics, and even novel therapy for infection may be beneficial for patients with a high risk of mortality. However, these management options are costly and not beneficial for every patient. Selecting high-risk patients who would most likely benefit is more appropriate. We investigated the independent mortality predictors of patients with infection-precipitated hyperglycemic crises to facilitate clinical decision making.

METHODS

This study was conducted in a university-affiliated medical center. Consecutive adult patients (> 18 years old) visiting the Emergency Department between January 2004 and December 2010 were enrolled when they met the criteria of an infection-precipitated hyperglycemic crisis. Thirty-day mortality was the primary endpoint.

RESULTS

One hundred forty-two patients were enrolled. The infection source did not predict mortality. The presenting variables that were independently associated with 30-day mortality in a multiple logistic regression model were cancer history (odds ratio [OR], 7.4; 95% confidence interval [CI], 2.4-23.2), bandemia (OR, 7.0; 95% CI, 1.6-30.3), and serum creatinine (OR, 1.4; 95% CI, 1.1-1.8). The common sources of infection were the lower respiratory tract (30.3%), urinary tract (49.3%), skin or soft tissue (12.0%), and intra-abdominal (6.3%).

CONCLUSIONS

Cancer history, bandemia, and serum creatinine level are three independent mortality predictors for patients with infection-precipitated hyperglycemic crises. These predictors are both readily available and valuable for physicians making decisions about risk stratification, treatment, and disposition.

Ketoacidosis as the initial clinical condition in nine patients with acromegaly: a review of 860 cases at a single institute

OBJECTIVE

Excess GH causes insulin resistance and impaired glucose metabolism. The objective of this study was to clarify the prevalence of ketoacidosis as the initial presenting symptom of acromegaly.

DESIGN AND METHODS

Data were collected from 860 patients with acromegaly who underwent pituitary surgery at Toranomon Hospital over the last 32 years, between 1980 and 2011.

RESULTS

Nine cases had ketoacidosis before being diagnosed with acromegaly, including seven males and two females with a mean +/- S.D. age of 38.8 +/- 14.2 years. Serum GH and IGF1 levels were 155 +/- 203 ng/ml and 9.86 +/- 0.68 SDS before pituitary surgery and 3.6 +/- 1.7 ng/ml and 3.72 +/- 3.40 SDS after surgery respectively. The maximum tumor diameter was 28.2 +/- 11.6 mm (ranging from 15 to 47 mm, n=8). None of the patients were diagnosed with diabetes mellitus (DM) nor were they positive for antibodies related to type 1 DM. A possible precipitating factor for ketoacidosis in six cases was excessive ingestion of sugar-containing soft drinks. All the cases had invasive pituitary adenomas. After pituitary surgery, plasma glucose levels were under control without requiring insulin in all cases. Furthermore, six patients did not need oral hypoglycemic agents.

CONCLUSIONS

Approximately 1% of patients with acromegaly presented with diabetic ketoacidosis as their first clinical condition.

Acute Diabetes Management

In acute diabetes conditions, management of the following 3 potential complications is required: diabetic ketoacidosis, hyperosmolar hyperglycemic state, and iatrogenic hypoglycemia. The hyperglycemic crises diabetic ketoacidosis and hyperosmolar hyperglycemic state are the 2 most serious metabolic complications of diabetes. Hypoglycemia, specifically iatrogenic hypoglycemia, results from treatments that raise circulating insulin levels and thus lower plasma glucose concentrations to an abnormally low level, which exposes the patient to potential harm. This article reviews the pathogenesis, precipitating or risk factors, diagnosis or identification, and treatment of these critical complications of diabetes. In addition, a case study on diabetic ketoacidosis is provided.

New approaches to the use of insulin in patients with diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is one of the most common and serious acute complications of diabetes and is a significant cause of morbidity and mortality. In the last decade the mortality rate from DKA has declined because of greater recognition and improvements in its management. The current available guidelines state that the most effective means of insulin delivery during DKA is a continuous infusion of regular insulin, usually referred to as continuous low-dose insulin infusion. However, the cost of this treatment is usually quite high, because patients are required to be admitted to an intensive care unit in order to be monitored closely. New analogs of human insulin that have a rapid onset of action have become available in the past decade and represent potential alternatives to the use of regular insulin in the treatment of DKA. In several trials it has been demonstrated that the use of subcutaneous rapid-acting insulin analogs represents a safe, cost-effective and technically simpler treatment that precludes intensive care unit admission without significant differences in outcome in the management of patients with mild to moderate, uncomplicated DKA. The long-acting insulin analog may have a role in facilitating the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy in patients with DKA. This avoids rebound hyperglycaemia and ketogenesis when intravenous insulin is stopped and may avoid excess length of stay.

Clinical significance of troponin elevations in acute decompensated diabetes without clinical acute coronary syndrome

Background

Elevation of cardiac troponin has been documented in multiple settings without acute coronary syndrome. However, its impact on long-term cardiac outcomes in the context of acute decompensated diabetes remains to be explored.

Methods

We performed a retrospective analysis of 872 patients admitted to Temple University Hospital from 2004–2009 with DKA or HHS. Patients were included if they had cardiac troponin I (cTnI) measured within 24 hours of hospital admission, had no evidence of acute coronary syndrome and had a follow up period of at least 18 months. Of the 264 patients who met the criteria, we reviewed the baseline patient characteristics, admission labs, EKGs and major adverse cardiovascular events during the follow up period. Patients were categorized into two groups with normal and elevated levels of cardiac enzymes. The composite end point of the study was the occurrence of a major cardiovascular event (MACE) during the follow up period and was compared between the two groups.

Results

Of 264 patients, 24 patients were found to have elevated cTnI. Compared to patients with normal cardiac enzymes, there was a significant increase in incidence of MACE in patients with elevated cTnI. In a regression analysis, which included prior history of CAD, HTN and ESRD, the only variable that independently predicted MACE was an elevation in cTnI (p = 0.044). Patients with elevated CK-MB had increased lengths of hospitalization compared to the other group (p < 0.001).

Conclusions

Elevated cardiac troponin I in patients admitted with decompensated diabetes and without evidence of acute coronary syndrome, strongly correlate with a later major cardiovascular event. Thus, elevated troponin I during metabolic abnormalities identify a group of patients at an increased risk for poor long-term outcomes. Whether these patients may benefit from early detection, risk stratification and preventive interventions remains to be investigated.

Intravenous insulin infusions: what nurses need to know

Glucose control in the acute setting has long been a debate among leaders in the fields of diabetes and acute care. Providers struggle to maintain euglycemia in critically ill patients and simultaneously prevent hypoglycemia. Intravenous insulin infusions are frequently preferred in the critical care setting to control glucose, because they can be titrated for changing insulin requirements and can be cleared from the system rapidly. This article discusses the basics of the insulin drip, common insulin drips, and the role of the nurse in managing an insulin drip.

New insights into osteoporosis: the bone-fat connection

Osteoporosis and obesity are chronic disorders that are both increasing in prevalence. The pathophysiology of these conditions is multifactorial and includes genetic, environmental and hormonal determinants. Although it has long been considered that these are distinct disorders rarely found in the same individual, emerging evidence from basic and clinical studies support an important interaction between adipose tissue and the skeleton. It is proposed that adiposity may influence bone remodelling through three mechanisms: (i) secretion of cytokines that directly target bone, (ii) production of adipokines that influence the central nervous system thereby changing sympathetic impulses to bone and (iii) paracrine influences on adjacent skeletal cells. Here we focus on the current understanding of bone-fat interactions and the clinical implications of recent studies linking obesity to osteoporosis.

Subcutaneous administration of glargine to diabetic patients receiving insulin infusion prevents rebound hyperglycemia

CONTEXT

Transition of diabetic patients from iv insulin infusion to s.c. insulin frequently results in rebound hyperglycemia.

OBJECTIVES

We hypothesized that initiation of a long-acting insulin therapy concurrently with i.v. insulin infusion would decrease the rate of rebound hyperglycemia after discontinuation of the insulin infusion.

DESIGN AND INTERVENTION

Sixty-one diabetic patients receiving i.v. insulin therapy participated in this prospective randomized study. Subjects in the intervention group received daily injections of glargine s.c. (0.25 U/kg body weight) starting within 12 h of initiation of i.v. insulin infusion. Capillary blood glucose measurements were obtained up to 12 h after discontinuation of insulin infusion. Rebound hyperglycemia was defined as a blood glucose level greater than 180 mg/dl.

SETTING

The study was conducted at the University of Colorado Hospital.

PATIENTS

Sixty-one hospitalized patients with known type 1 or type 2 diabetes receiving i.v. insulin infusion participated in the study.

MAIN OUTCOME

The primary outcome of this study was to compare the rates of rebound hyperglycemia between the control and the intervention groups after i.v. insulin infusion is discontinued.

RESULTS

Overall, 29 subjects in the control group (93.5%) had at least one glucose value above 180 mg/dl during the 12-h follow-up period. This was significantly greater than the rate of rebound hyperglycemia in the intervention group (10 subjects or 33.3%, P < 0.001). The effect of the intervention was apparent in subjects who presented with diabetic ketoacidosis, after solid organ transplantation, and in patients with other surgical and medical diagnoses. There were three hypoglycemic measurements in two control subjects (68, 62, and 58 mg/dl) and none in the intervention group.

CONCLUSIONS

Once-daily s.c. insulin glargine administered during i.v. insulin infusion is a safe method for preventing future rebound hyperglycemia, without increased risk of hypoglycemia.

Endocrine emergencies in critically ill patients: Challenges in diagnosis and management

Endocrine emergencies pose unique challenges for the attending intensivist while managing critically ill patients. Besides taking care of primary disease state, one has to divert an equal attention to the possible associated endocrinopathies also. One of the common reasons for inability to timely diagnose an endocrinal failure in critically ill patients being the dominance of other severe systemic diseases and their clinical presentation. The timely diagnosis and administration of therapeutic interventions for these endocrine disorders can improve the outcome in critically ill patients. The timely diagnosis and administration of timely therapeutics in common endocrine disorders like severe thyroid disease, acute adrenal insufficiency and diabetic ketoacidosis significantly influence the outcome and prognosis. Careful evaluation of clinical history and a high degree of suspicion are the corner stone to diagnose such problems. Aggressive management of the patient is equally important as the complications are devastating and can prove highly fatal. The present article is an attempt to review some of the common endocrine emergencies in intensive care unit and the challenges associated with their diagnosis and management.

[Hyperglycemic crisis in patients with diabetes mellitus]

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the two most acute life-threatening complications of diabetes mellitus and in most cases treatment should be administered in an intensive care unit. Clinically, DKA and HHS differ according to the presence of metabolic acidosis; however, the treatment of DKA and HHS is similar. The main principles are intravenous administration of insulin and correction of fluid and electrolyte abnormalities which are typically present. By the application of a standardized treatment algorithm a low mortality rate can be achieved.

Plasma-Lyte 148 vs 0.9% saline for fluid resuscitation in diabetic ketoacidosis

PURPOSE

The purpose of the study was to determine the effects of Plasma-Lyte 148 (PL) vs 0.9% saline (NS) fluid resuscitation in diabetic ketoacidosis (DKA).

METHODS

A multicenter retrospective analysis of adults admitted for DKA to the intensive care unit, who received almost exclusively PL or NS infusion up until 12 hours, was performed.

RESULTS

Nine patients with PL and 14 patients with NS were studied. Median serum bicarbonate correction was higher in the PL vs NS groups at 4 to 6 hours (8.4 vs 1.7 mEq/L) and 6 to 12 hours (12.8 vs 6.2 mEq/L) from baseline (P < .05). Median standard base excess improved by 10.5 vs 4.2 mEq/L at 4 to 6 hours and by 16.0 vs 9.1 mEq/L at 6 to 12 hours in the PL and NS groups, respectively (P < .05). Chloride levels increased significantly in the NS vs PL groups over 24 hours. Potassium levels were lower at 6 to 12 hours in the PL group. Mean arterial blood pressure was higher at 2 to 4 hours in the PL group, whereas cumulative urine output was lower at 4 to 6 hours in the NS group. There were no differences in glycemic control or duration of intensive care unit stay.

CONCLUSION

Patients with DKA resuscitated with PL instead of NS had faster initial resolution of metabolic acidosis and less hyperchloremia, with a transiently improved blood pressure profile and urine output.

Management of adverse side-effects after chemotherapy in macaques as exemplified by streptozotocin: case studies and recommendations

The chemotherapeutic streptozotocin is used for induction of diabetes in animal models including non-human primates. Being a cytotoxic nitrosourea compound, it can be associated with adverse events (AEs), mainly nausea and emesis, nephrotoxicity, elevated liver transaminase levels, pulmonary oedema and, most prominently, metabolic acidosis: these can be severe in some cases. The incidence and gravity are to some extent related to the characteristics of the individual animal, diagnostic tools, prompt recognition of symptoms and supportive measures. Careful animal selection, dose adaptation and supportive actions such as renal protective hydration are the main tools in managing AEs, but do not fully eliminate unavoidable and sometimes life-threatening conditions. In our centre we have built experience in a cohort of 78 cynomolgus and rhesus macaques in which six cases manifested severe AEs (8%). This experience has prompted implementation of strategies for early detection and management of adverse effects, together with an animal refinement programme. We present here specific pretreatment regimens, post-infusion laboratory evaluations, and flow charts to assess/treat metabolic acidosis and precipitating factors. Case reports of the six animals with severe AEs are presented to illustrate management of AEs, especially metabolic acidosis, and criteria for early euthanasia where appropriate. We conclude that improved monitoring and validated tools allow for optimal management of adverse effects in an early stage of their manifestation. Reduced morbidity and mortality not only improve individual animal wellbeing but also avoid model-induced confounding that diminishes the translational value of the experimental protocol.

Hyperglycemic hyperosmolar syndrome in the pediatric patient: a case report and review of the literature

Hyperglycemic hyperosmolar syndrome (HHS) is a potentially deadly complication of diabetes mellitus that can often be the presenting symptom of the condition in the pediatric population. There is a danger that HHS may not be included in the differential of critical patients because it is still a somewhat rare entity in the pediatric population. However, recent data regarding population trends indicate that HHS will continue to appear more and more commonly in the pediatric population with diabetes. The following case describes an adolescent with many of the typical features of the pediatric patient with HHS as the presenting symptom of diabetes mellitus. The literature regarding HHS in children is still sparse, and much must be extrapolated from adult studies given its relatively recent increased incidence. Included is a brief review of the most recent data regarding epidemiology, treatment, and complications that would be pertinent to the pediatric emergency physician.

Nutritional status and complications in children with diabetic ketoacidosis

OBJECTIVE

Diabetic ketoacidosis in children continues to be an important cause of morbidity and mortality, especially in developing economies as a result of malnutrition, a high rate of infections, and delay in seeking timely medical care. Malnutrition also increases the risk of diabetic ketoacidosis-related complications. The objective of this study was to assess the nutritional status of patients presenting with diabetic ketoacidosis and correlate it with the incidence of complications at presentation and those encountered during the course of illness.

DESIGN

Prospective study.

SETTING

Pediatric emergency and intensive care units, Advanced Pediatrics Centre, PGIMER, Chandigarh, India.

PATIENTS

Thirty-three children between 1 month and 12 yrs of age presenting with diabetic ketoacidosis between July 2008 and June 2009 were enrolled consecutively and assessed for nutritional status by anthropometric parameters (body weight, crown-heel length/height, mid-upper arm circumference, triceps and subscapular skin fold thicknesses), biochemical parameters (serum albumin, zinc, magnesium, vitamin A levels), and preillness dietary history (by pretested Food Frequency Questionnaire). Patients were classified as malnourished or normally nourished based on the weight for age criteria matched for Indian standards. The incidence of complications (electrolyte imbalances, hypoglycemia, sepsis, cerebral edema, etc.) and outcome in terms of survival or death in both the groups were compared with Student's t-test for parametric data, Mann-Whitney U test for nonparametric data, and chi-square test for categorical variables.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Anthropometric assessment showed that 11 of 33 (33.3%) were malnourished. Preillness dietary history revealed that 16 (48.5%) were calorie- and protein-deficient (known diabetic n = 7; new onset n = 9), whereas 11 (33.3%) were only calorie-deficient (known diabetic n = 2). Hypoalbuminemia was seen in 21 (63.6%), hypovitaminosis A in eight (24.2%), and low zinc levels in three (9%). The malnourished and normally nourished groups were similar with respect to demographics, precipitating factors, severity of diabetic ketoacidosis, treatment received, and outcome. However, the incidence and severity of therapy-related hypokalemia (100% vs. 72.7%; p = .05) and hypoglycemia (63.6 vs. 13.6%; p = .004) were significantly higher in the former as compared with the latter. The mean ± SD admission serum potassium levels were similar in both the groups (3.4 ± 0.8 mEq/L in the malnourished vs. 3.5 ± 0.7 mEq/L in the normally nourished) with the malnourished group showing a significant fall at 6 hrs after start the of diabetic ketoacidosis protocol (2.8 ± 0.8 mEq/L vs. 3.6 ± 0.7 mEq/L; p = .033), although the mean rate and dose of insulin infusion were similar. The fall in blood glucose (mean ± SD mg/dL) at 12, 24, and 36 hrs after onset of the diabetic ketoacidosis protocol was also significantly greater in the malnourished group as compared with the normally nourished diabetic ketoacidosis (195 ± 69.1 and 272.61 ± 96.3, p = .02; 171 ± 58.5 and 257 ± 96.3, p = .05; and 153.75 ± 49.6 and 241.71 ± 76.3, p = .04, respectively). The incidence of hypophosphatemia, hypomagnesemia, cerebral edema, renal failure, sepsis, and septic shock was similar in both the groups. There were two deaths, both resulting from complicating cerebral edema and renal failure and unrelated to the nutritional status of the patients.

CONCLUSIONS

The incidence and severity of therapy-related hypokalemia and hypoglycemia were significantly higher in the malnourished as compared to the normally nourished diabetic ketoacidosis. Other diabetic ketoacidosis-related complications and outcome were similar in both the groups.

Fluid management in diabetic-acidosis--Ringer's lactate versus normal saline: a randomized controlled trial

OBJECTIVE

To determine if Ringer's lactate is superior to 0.9% sodium chloride solution for resolution of acidosis in the management of diabetic ketoacidosis (DKA).

DESIGN

Parallel double blind randomized controlled trial.

METHODS

Patients presenting with DKA at Kalafong and Steve Biko Academic hospitals were recruited for inclusion in this study if they were >18 years of age, had a venous pH >6.9 and ≤7.2, a blood glucose of >13 mmol/l and had urine ketones of ≥2+. All patients had to be alert enough to give informed consent and should have received <1 l of resuscitation fluid prior to enrolment.

RESULTS

Fifty-seven patients were randomly allocated, 29 were allocated to receive 0.9% sodium chloride solution and 28 to receive Ringer's lactate (of which 27 were included in the analysis in each group). An adjusted Cox proportional hazards analysis was done to compare the time to normalization of pH between the 0.9% sodium chloride solution and Ringer's lactate groups. The hazard ratio (Ringer's compared with 0.9% sodium chloride solution) for time to venous pH normalization (pH = 7.32) was 1.863 (95% CI 0.937-3.705, P = 0.076). The median time to reach a pH of 7.32 for the 0.9% sodium chloride solution group was 683 min (95% CI 378-988) (IQR: 435-1095 min) and for Ringer's lactate solution 540 min (95% CI 184-896, P = 0.251). The unadjusted time to lower blood glucose to 14 mmol/l was significantly longer in the Ringer's lactate solution group (410 min, IQR: 240-540) than the 0.9% sodium chloride solution group (300 min, IQR: 235-420, P = 0.044). No difference could be demonstrated between the Ringer's lactate and 0.9% sodium chloride solution groups in the time to resolution of DKA (based on the ADA criteria) (unadjusted: P = 0.934, adjusted: P = 0.758)

CONCLUSION

This study failed to indicate benefit from using Ringer's lactate solution compared to 0.9% sodium chloride solution regarding time to normalization of pH in patients with DKA. The time to reach a blood glucose level of 14 mmol/l took significantly longer with the Ringer's lactate solution.

Do obese children with diabetic ketoacidosis have type 1 or type 2 diabetes?

OBJECTIVE

Many obese children with unprovoked diabetic ketoacidosis (DKA) display clinical features of type 2 diabetes during follow up. We describe the clinical presentation, autoimmune markers and the long-term course of obese and lean children with DKA.

RESEARCH DESIGN AND METHODS

We reviewed the medical records on the initial acute hospitalization and outpatient follow-up care of 21 newly diagnosed obese and 20 lean children with unprovoked DKA at Emory University affiliated children's hospitals between 1/2003 and 12/2006.

RESULTS

Obese children with DKA were older and predominantly male, had acanthosis nigricans, and had lower prevalence of autoantibodies to islet cells and glutamic acid decarboxylase than lean children. Half of the obese, but none of the lean children with DKA achieve near-normoglycemia remission and discontinued insulin therapy during follow-up. Time to achieve remission was 2.2±2.3 months. There were no differences on clinical presentation between obese children who achieved near-normoglycemia remission versus those who did not. The addition of metformin to insulin therapy shortly after resolution of DKA resulted in lower hemoglobin A1c (HbA1c) levels, higher rates of near-normoglycemia remission, and lower frequency of DKA recurrence. Near-normoglycemia remission, however, was of short duration and the majority of obese patients required reinstitution of insulin treatment within 15 months of follow-up.

CONCLUSION

In contrast to lean children with DKA, many obese children with unprovoked DKA display clinical and immunologic features of type 2 diabetes during follow-up. The addition of metformin to insulin therapy shortly after resolution of DKA improves glycemic control, facilitates achieving near-normoglycemia remission and prevents DKA recurrence in obese children with DKA.

Hyperglycemic emergencies in Indian patients with diabetes mellitus on pilgrimage to Amarnathji yatra

BACKGROUND

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) represent two distinct metabolic derangements manifested by insulin deficiency and severe hyperglycemia, with estimated mortality rates of 2.5-9%. In patients with type 2 diabetes mellitus (DM) controlled by diet or oral agents, DKA does not occur unless there is significant severe stress such as severe sepsis, major surgery, trauma, etc. We observed many such emergencies occurring in pilgrims.

OBJECTIVE

We analyzed the data of 13 patients with DM admitted in our endocrine department with hyperglycemic emergencies during 2 years of the annual pilgrimage (yatra) to Amarnathji.

MATERIALS AND METHODS

We reviewed and analyzed the case records of 13 yatris with DM who were referred and admitted in our hospital with hyperglycemic emergencies during the yatra season (July-August) of 2006 and 2007.

RESULTS

Eleven of 13 had DKA and 1 each had HHS and hypoglycemia. After initial clinical assessment and blood sampling for blood counts, electrolytes, blood gases, urinalysis, chest radiography, and electrocardiography, these cases were managed with standard protocol published by American Diabetes Association (ADA) for the management of DKA and HHS. Average blood glucose was 466 mg/dl and nine subjects had moderate to severe ketonuria. All the cases, except one, were in stable condition at the time of discharge.

CONCLUSION

High altitude, strenuous exertion of going uphill, withdrawal of insulin or oral hypoglycemic drugs, starvation, sepsis, and alcohol intake were recorded as predisposing factors. Therefore, there is an immense need for institution of a special health education program to all the yatris before taking the endeavor.

Evidence-based management of hyperglycemic emergencies in diabetes mellitus

The hyperglycemic emergencies, diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are potentially fatal complications of uncontrolled diabetes mellitus. The incidence of DKA and the economic burden of its treatment continue to rise, but its associated mortality rate which was uniformly high has diminished remarkably over the years. This Improvement in outcome is largely due to better understanding of the pathogenesis of hyperglycemic emergencies and the application of evidence-based guidelines in the treatment of patients. In this article, we present a critical review of the evidence behind the recommendations that have resulted in the improved prognosis of patients with hyperglycemic crises. A succinct discussion of the pathophysiology and important etiological factors in DKA and HHS are provided as a prerequisite for understanding the rationale for the effective therapeutic maneuvers employed in these acute severe metabolic conditions. The evidence for the role of preventive measures in DKA and HHS is also discussed. The unanswered questions and future research needs are also highlighted.

Managing diabetic ketoacidosis in non-intensive care unit setting: Role of insulin analogs

Aim:

To compare the efficacy and safety of rapid acting insulin analog lispro given subcutaneously with that of standard low-dose intravenous regular insulin infusion protocolin patients with mild to moderate diabetic ketoacidosis.

Materials and Methods:

In this prospective, randomized and open trial, 50 consecutive patients of mild to moderate diabetic ketoacidosis were randomly assigned to two groups. The patients in group 1 were treated with intravenous regular insulin infusion and admitted in intensive care unit. The patients in group 2 were treated with subcutaneous insulin lispro 2 hourly and managed in the emergency medical ward. Response to therapy was assessed by duration of treatment and amount of insulin administered until resolution of hyperglycemia and ketoacidosis, total length of hospital stay, and number of hypoglycemic events in the two study groups.

Results:

The baseline clinical and biochemical parameters were similar between the two groups. There were no differences in the mean duration of treatment and amount of insulin required for correction of hyperglycemia and ketoacidosis. There was no mortality and no difference in the length of hospital stay between the two groups. The length of stay and amount of insulin required for correction of hyperglycemia was greater in patients who had infection as the precipitating cause than those with poor compliance. The hypoglycemic events were higher in the regular insulin group (2 vs1) than in the lispro group.

Conclusion:

Patients with uncomplicated diabetic ketoacidosis can be managed in the medical wards with appropriate supervision and careful monitoring. Rapid acting insulin analog lispro is a safe and effective alternative to intravenous regular insulin for this subset of patients.

Gender-related differences in clinical characteristics and outcomes in patients with diabetic ketoacidosis

BACKGROUND

Diabetic ketoacidosis (DKA) is 1 of the most common and serious complications of diabetes, and is a significant cause of morbidity and mortality. There is a paucity of data regarding gender-related differences in clinical characteristics and outcomes of patients hospitalized for DKA.

OBJECTIVE

The purpose of this study was to assess whether gender plays a role in clinical characteristics and outcome of DKA.

METHODS

We performed a retrospective cohort study of patients hospitalized with DKA between January 1, 2003 and January 1, 2010. The outcomes of male and female patients were compared. The primary outcome was in-hospital all-cause mortality. The secondary outcomes were 30-day all-cause mortality and rate of complications: sepsis, respiratory failure, multiple organ failure, stroke, and myocardial infarction.

RESULTS

Eighty-nine men and 131 women with DKA were included in the study. Male patients had higher rates of chronic renal failure compared with women (16.9% vs 3.1%; P = 0.001), whereas more women than men received oral hypoglycemic therapy (19.8% vs 9.0%; P = 0.046); women also had higher glycosated hemoglobin levels before admission (11.9% [1.7%] vs 9.9% [2.2%]; P = 0.025). The in-hospital mortality rate was not significantly different for both genders (4.5% in the male group vs 3.8% in the female group; P = 1.0). We did not find significant differences between the 2 groups in the 30-day mortality rate (4.5% vs 6.1%; P = 0.7) or the rate of complications (5.6% vs 6.9%; P = 0.9). Advanced age, mechanical ventilation, and bedridden state were independent predictors of 30-day mortality.

CONCLUSIONS

In our study we did not find statistically significant differences in the in-hospital mortality, 30-day all-cause mortality, or rate of complications between men and women hospitalized with DKA. However, women with poorly controlled type 2 diabetes mellitus receiving oral hypoglycemic therapy required particular attention and might benefit from earlier introduction and intensification of insulin therapy to avoid DKA.