Severe hypernatremia in soft drink ketoacidosis and hyperglycemic hyperosmolar state at the onset of type 2 diabetes mellitus: a case series of three adolescents

Quantifying the Deficits of Body Water and Monovalent Cations in Hyperglycemic Emergencies

Background/Objectives: Hyperglycemic emergencies cause significant losses of body water, sodium, and potassium. This report presents a method for computing the actual losses of water and monovalent cations in these emergencies. Methods: We developed formulas for computing the losses of water and monovalent cations as a function of the presenting serum sodium and glucose levels, the sum of the concentrations of sodium plus potassium in the lost fluids, and body water at the time of hyperglycemia presentation as measured by bioimpedance or in the initial euglycemic state as estimated by anthropometric formulas. The formulas for computing the losses from hyperglycemia were tested in examples of hyperglycemic episodes. Results: The formulas were tested in two patient groups, those with or without known weight loss during the development of hyperglycemia. In the first group, these formulas were applied to estimate the losses of body water and monovalent cations in (a) a previously published case of a boy with diabetic ketoacidosis and known weight loss who, during treatment not addressing his water deficit, developed severe hypernatremia and (b) a comparison of water loss computed by this new method with the reported average fluid gained during treatment of the hyperglycemic hyperosmolar state in a published study. In the second group, the formulas were applied in hypothetical subjects with varying levels of initial body water, serum sodium, and glucose at the time of hyperglycemia and sums of sodium and potassium concentrations in the lost fluids. Conclusions: Losses of body water and monovalent cations, which determine the severity of dehydration and hypovolemia, vary significantly between patients with hyperglycemic emergencies presenting with the same serum glucose and sodium concentrations. These losses can be calculated using estimated or measured body water values. Prospective studies are needed to test this proof-of-concept report.

Hypernatremia in Hyperglycemia: Clinical Features and Relationship to Fractional Changes in Body Water and Monovalent Cations during Its Development

In hyperglycemia, the serum sodium concentration ([Na]S) receives influences from (a) the fluid exit from the intracellular compartment and thirst, which cause [Na]S decreases; (b) osmotic diuresis with sums of the urinary sodium plus potassium concentration lower than the baseline euglycemic [Na]S, which results in a [Na]S increase; and (c), in some cases, gains or losses of fluid, sodium, and potassium through the gastrointestinal tract, the respiratory tract, and the skin. Hyperglycemic patients with hypernatremia have large deficits of body water and usually hypovolemia and develop severe clinical manifestations and significant mortality. To assist with the correction of both the severe dehydration and the hypovolemia, we developed formulas computing the fractional losses of the body water and monovalent cations in hyperglycemia. The formulas estimate varying losses between patients with the same serum glucose concentration ([Glu]S) and [Na]S but with different sums of monovalent cation concentrations in the lost fluids. Among subjects with the same [Glu]S and [Na]S, those with higher monovalent cation concentrations in the fluids lost have higher fractional losses of body water. The sum of the monovalent cation concentrations in the lost fluids should be considered when computing the volume and composition of the fluid replacement for hyperglycemic syndromes.

Severe hypernatremia in hyperglycemic conditions; managing it effectively: A case report

BACKGROUND

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are common acute complications of diabetes mellitus with a high risk of mortality. When combined with hypernatremia, the complications can be even worse. Hypernatremia is a rarely associated with DKA and HHS as both are usually accompanied by normal sodium or hyponatremia. As a result, a structured and systematic treatment approach is critical. We discuss the therapeutic approach and implications of this uncommon presentation.

CASE SUMMARY

A 62-year-old man with no known past medical history presented to emergency department with altered mental status. Initial work up in emergency room showed severe hyperglycemia with a glucose level of 1093 mg/dL and severe hypernatremia with a serum sodium level of 169 mEq/L. He was admitted to the intensive care unit (ICU) and was started on insulin drip as per DKA protocol. Within 12 h of ICU admission, blood sugar was 300 mg/dL. But his mental status didn’t show much improvement. He was dehydrated and had a corrected serum sodium level of > 190 mEq/L. As a result, dextrose 5% in water and ringer's lactate were started. He was also given free water via an nasogastric (NG) tube and IV Desmopressin to improve his free water deficit, which improved his serum sodium to 140 mEq/L.

CONCLUSION

The combination of DKA, HHS and hypernatremia is rare and extremely challenging to manage, but the most challenging part of this condition is selecting the correct type of fluids to treat these conditions. Our case illustrates that desmopressin and free water administration via the NG route can be helpful in this situation.

Meta-Analysis of the Effect of Nursing Intervention on Children with Type 2 Diabetes

Objective

To systematically evaluate the effect of nursing intervention on children with type 2 diabetes.

Methods

The randomized controlled trials (RCTs) on nursing intervention in children with type 2 diabetes in CNKI, VIP, WanFang, Chinese Biomedical Database (CBM), PubMed, The Cochrane Library, Embase, and Science were searched by the computer until July 2022. Two evaluators reviewed the articles, selected the information, and assessed their quality according to the inclusion criteria and exclusion criteria and then carried out meta-analysis with RevMan 5.3.

Results

A total of 5 RCT studies were kept, including 319 patients with type 2 diabetes (≤21 years old), where 162 patients were in the nursing group and 157 patients were in the control group. Meta-analysis revealed that, compared with routine nursing, nursing intervention could effectively control children's fasting blood glucose (FBG) (MD = -1.68, 95% CI (-2.19, -1.17), P < 0.00001), 2 h postprandial blood glucose (2hPG) (MD = -4.01, 95% CI (-4.70, -3.33), P < 0.00001), fasting insulin (FINS) (MD = -7.42, 95% CI (-10.63, -4.20), P < 0.00001), 2 h postprandial insulin (2hINS) (MD = -58.18, 95% CI (-103.24, -13.11), P = 0.01), triglycerides (TG) (MD = -0.41, 95% CI (-0.56, -0.25), P < 0.00001), and systolic blood pressure (SBP) (MD = -8.85, 95% CI (-14.67, -3.03), P = 0.003) and effectively maintain patients' blood glucose at a normal level (MD = -8.85, 95% CI (-14.67, -3.03), P = 0.003), where all the differences were statistically significant.

Conclusion

The existing evidence showed that nursing intervention has a significant effect in controlling normal blood glucose and improving insulin utilization in children with type 2 diabetes, which can effectively improve the therapeutic effect on children.