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Zarse E, Knoll MM, Halpin K, Thompson M, Williams DD, Tallon EM, Kallanagowdar G, Tsai S. Recognizing Complications in Youth With Diabetes Admitted With Diabetic Ketoacidosis Versus Hyperglycemic Hyperosmolar State. J Pediatr Health Care 2024; 38:761-768. [PMID: 38888521 DOI: 10.1016/j.pedhc.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/16/2023] [Accepted: 12/15/2023] [Indexed: 06/20/2024]
Abstract
INTRODUCTION We compare in-hospital complications in youth with isolated diabetic ketoacidosis (DKA) to youth with hyperosmolarity. METHOD We reviewed medical records of youth (1-20 years) admitted over two years with DKA, hyperglycemic hyperosmolar state (HHS), and hyperosmolar DKA. We evaluated outcomes, including hospital length of stay, altered mental status (AMS), and acute kidney injury (AKI). RESULTS Of 369 admissions, 334 had isolated DKA, 32 had hyperosmolar DKA, and three had isolated HHS. Hyperosmolar youth had longer length of stay, larger initial fluid boluses, more frequent pediatric intensive care unit admissions, and increased risk of AKI and AMS. The odds of AKI were positively associated with serum osmolality and negatively associated with new-onset diabetes mellitus (DM) compared with established DM. CONCLUSIONS In youth with DM, hyperosmolarity increases acute complications compared with isolated DKA. Larger-scale studies are needed to identify ways to prevent acute complications in youth experiencing hyperglycemic emergencies.
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Everett EM, Copeland T, Wisk LE, Chao LC. Risk Factors for Hyperosmolar Hyperglycemic State in Pediatric Type 2 Diabetes. Pediatr Diabetes 2023; 2023:1318136. [PMID: 37614411 PMCID: PMC10445777 DOI: 10.1155/2023/1318136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
Background There is a paucity of data on the risk factors for the hyperosmolar hyperglycemic state (HHS) compared with diabetic ketoacidosis (DKA) in pediatric type 2 diabetes (T2D). Methods We used the national Kids' Inpatient Database to identify pediatric admissions for DKA and HHS among those with T2D in the years 2006, 2009, 2012, and 2019. Admissions were identified using ICD codes. Those aged <9yo were excluded. We used descriptive statistics to summarize baseline characteristics and Chi-squared test and logistic regression to evaluate factors associated with admission for HHS compared with DKA in unadjusted and adjusted models. Results We found 8,961 admissions for hyperglycemic emergencies in youth with T2D, of which 6% were due to HHS and 94% were for DKA. These admissions occurred mostly in youth 17-20 years old (64%) who were non-White (Black 31%, Hispanic 20%), with public insurance (49%) and from the lowest income quartile (42%). In adjusted models, there were increased odds for HHS compared to DKA in males (OR 1.77, 95% CI 1.42-2.21) and those of Black race compared to those of White race (OR 1.81, 95% CI 1.34-2.44). Admissions for HHS had 11.3-fold higher odds for major or extreme severity of illness and 5.0-fold higher odds for mortality. Conclusion While DKA represents the most admissions for hyperglycemic emergencies among pediatric T2D, those admitted for HHS had higher severity of illness and mortality. Male gender and Black race were associated with HHS admission compared to DKA. Additional studies are needed to understand the drivers of these risk factors.
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Affiliation(s)
- Estelle M. Everett
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Timothy Copeland
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Lauren E. Wisk
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Lily C. Chao
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Injeyan M, Baron S, Lauzier B, Gaillard‐Le Roux B, Denis M. Hyperglycaemic hyperosmolar state and cerebral thrombophlebitis in paediatrics: A case report. Endocrinol Diabetes Metab 2023; 6:e389. [PMID: 36722309 PMCID: PMC10000624 DOI: 10.1002/edm2.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/12/2022] [Accepted: 10/16/2022] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Hyperglycaemic hyperosmolar state (HHS) is a known complication of type 2 diabetes mellitus; however, carbonated carbohydrate fluid intake may precipitate a more severe presentation of type 1 diabetes mellitus with hyperosmolar state. The management of these patients is not easy and can lead to severe complications such as cerebral venous thrombosis. METHODS We present the case of a 21-month-old boy admitted for consciousness disorders revealing a hyperglycaemic hyperosmolar state on a new-onset type 1 diabetes and who developed cerebral venous thrombosis. RESULTS AND CONCLUSION Emergency physicians should be aware of HHS in order to start the appropriate treatment as early as possible and to monitor the potential associated acute complications. This case highlights the importance of decreasing very gradually the osmolarity in order to avoid cerebral complications. Cerebral venous thrombosis in HHS paediatric patients is rarely described, and it is important to recognize that not all episodes of acute neurological deterioration in HHS or diabetic ketoacidosis are caused by cerebral oedema.
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Affiliation(s)
- Maud Injeyan
- Department of PediatricsCHU de NantesNantesFrance
| | - Sabine Baron
- Department of PediatricsCHU de NantesNantesFrance
- Department of Pediatric EndocrinologyCHU de NantesNantesFrance
| | - Benjamin Lauzier
- Pediatric Intensive Care UnitCHU de NantesNantesFrance
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thoraxNantesFrance
| | | | - Manon Denis
- Pediatric Intensive Care UnitCHU de NantesNantesFrance
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thoraxNantesFrance
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Lee S, Yoo S, Yoon JY, Cheon CK, Kim YA. Pediatric management challenges of hyperglycemic hyperosmolar state: case series of Korean adolescents with type 2 diabetes. Ann Pediatr Endocrinol Metab 2023; 28:61-66. [PMID: 35038836 PMCID: PMC10073033 DOI: 10.6065/apem.2142108.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/22/2021] [Indexed: 11/20/2022] Open
Abstract
The hyperglycemic hyperosmolar state (HHS) is considered the most fatal complication of type 2 diabetes mellitus (DM). The number of case reports describing pediatric HHS has increased recently in parallel with obesity and the prevalence of type 2 DM in pediatric patients. In this study, we investigated the patient characteristics and outcomes of HHS in 9 adolescents with obesity and type 2 DM. Almost all patients exhibited mixed clinical features of HHS and diabetic ketoacidosis (DKA), including characteristics such as hyperosmolality and ketoacidosis. These features made definitive diagnosis difficult; 5 out of 9 patients were initially diagnosed with DKA and were treated accordingly. Patients who were initially diagnosed with HHS received a more vigorous and appropriate fluid replacement than other patients did. No patients died, although 3 exhibited complications, such as arrhythmia, acute kidney injury requiring renal replacement therapy, rhabdomyolysis, and acute pancreatitis. Hyperosmolality with consequent severe dehydration is considered a significant factor contributing to the outcomes of patients with HHS. Therefore, early recognition of hyperosmolality is crucial for an appropriate diagnosis and adequate fluid rehydration to restore perfusion in the early period of treatment to improve patient outcomes for this rare but serious emerging condition in pediatric patients.
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Affiliation(s)
- Sumin Lee
- Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea
| | - Sukdong Yoo
- Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea
| | - Ju Young Yoon
- Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea
| | - Chong Kun Cheon
- Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Tech nology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Young A Kim
- Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Tech nology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Hassan EM, Mushtaq H, Mahmoud EE, Chhibber S, Saleem S, Issa A, Nitesh J, Jama AB, Khedr A, Boike S, Mir M, Attallah N, Surani S, Khan SA. Overlap of diabetic ketoacidosis and hyperosmolar hyperglycemic state. World J Clin Cases 2022; 10:11702-11711. [PMID: 36405291 PMCID: PMC9669841 DOI: 10.12998/wjcc.v10.i32.11702] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/14/2022] [Accepted: 09/27/2022] [Indexed: 11/08/2022] Open
Abstract
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia state (HHS) are two life-threatening metabolic complications of diabetes that significantly increase mortality and morbidity. Despite major advances, reaching a uniform consensus regarding the diagnostic criteria and treatment of both conditions has been challenging. A significant overlap between these two extremes of the hyperglycemic crisis spectrum poses an additional hurdle. It has well been noted that a complete biochemical and clinical patient evaluation with timely diagnosis and treatment is vital for symptom resolution. Worldwide, there is a lack of large-scale studies that help define how hyperglycemic crises should be managed. This article will provide a comprehensive review of the pathophysiology, diagnosis, and management of DKA-HHS overlap.
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Affiliation(s)
- Esraa Mamdouh Hassan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Hisham Mushtaq
- Medicine, St. Vincent's Medical Center, Bridgeport, CT 06606, United States
| | - Esraa Elaraby Mahmoud
- Medicine, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Sherley Chhibber
- Medicine, Mercy Catholic Medical Center, Darby, PA 19025, United States
| | - Shoaib Saleem
- Medicine, Mayo Hospital, Lahore 54000, Punjab, Pakistan
| | - Ahmed Issa
- Medicine, Medical University of the Americas, Nevis, West Indies
| | - Jain Nitesh
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Abbas B Jama
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Anwar Khedr
- Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Sydney Boike
- Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Mikael Mir
- Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Noura Attallah
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Salim Surani
- Medicine & Pharmacology, Texas A&M University Health Science Center, College Station, TX 77843, United States
- Anesthesiolgy, Mayo Clinic, Rochester, MN 55905, United States
| | - Syed A Khan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
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Glaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, Wolfsdorf JI, Codner E. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022; 23:835-856. [PMID: 36250645 DOI: 10.1111/pedi.13406] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/01/2023] Open
Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Austria Medical University of Graz, Graz, Austria
| | - Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Valentino Cherubini
- Department of Women's and Children's Health, G. Salesi Hospital, Ancona, Italy
| | - Sylvia Estrada
- Department of Pediatrics, Division of Endocrinology and Metabolism, University of the Philippines, College of Medicine, Manila, Philippines
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Parra Villasmil MG, Patel S, Tansey M, Badheka A, Chegondi M. A Rare Presentation of New-Onset Type 1 Diabetes Mellitus in a Developmentally Delayed Child With an Overlap of Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Cureus 2022; 14:e28983. [PMID: 36237743 PMCID: PMC9548379 DOI: 10.7759/cureus.28983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2022] [Indexed: 12/03/2022] Open
Abstract
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are serious complications associated with diabetes mellitus (DM). HHS is a common diagnosis in adults but rare in children. DKA is a usual presentation for new-onset type 1 DM, although HHS is rarely a manifestation of new-onset type 1 DM. Diagnosis and management of HHS are challenging in pediatric patients, especially if they present with a mixed picture of HHS and DKA. We report an adolescent female with a new onset of type 1 DM presented as mixed DKA and HHS. Treatment included meticulous management of fluids and continuous insulin drip with the resolution of acidosis within 24 hours and hyperosmolar state at 96 hours of admission. Early differentiation of these two entities and meticulous fluid management improves the outcome and decreases the risk of complications such as cerebral edema, renal failure, and thrombosis, among others.
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Brar PC, Tell S, Mehta S, Franklin B. Hyperosmolar diabetic ketoacidosis-- review of literature and the shifting paradigm in evaluation and management. Diabetes Metab Syndr 2021; 15:102313. [PMID: 34731818 DOI: 10.1016/j.dsx.2021.102313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 09/22/2021] [Accepted: 10/10/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hyperosmolar diabetic ketoacidosis (H-DKA), a distinct clinical entity, is the overlap of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). AIM We describe the clinical presentation, metabolic aberrations, and associated morbidity/mortality of these cases with H-DKA. We highlight the problem areas of medical care which require particular attention when caring for pediatric diabetes patients presenting with H-DKA. METHODS In our study we reviewed the literature back to 1963 and retrieved twenty-four cases meeting the criteria of H-DKA: glucose >600 mg/dL, pH < 7.3, bicarbonate <15 mEq/L, and serum osmolality >320 mOsm/kg, while adding three cases from our institution. RESULTS Average age of presentation of H-DKA was 10.2 years ± 4.5 years in females and 13.3 years ± 4 years in males, HbA1c was 13%. Biochemical parameters were consistent with severe dehydration: serum osmolality = 394.8±55 mOsm/kg, BUN = 48±22 mg/dL, creatinine = 2.81±1.03 mg/dL. Acute kidney injury, present in 12 cases, was the most frequent end-organ complication. CONCLUSION Multi-organ involvement with AKI, rhabdomyolysis, pancreatitis, neurological and cardiac issues such as arrhythmias, are common in H-DKA. Aggressive fluid management, insulin therapy and supportive care can prevent acute and long term adverse outcomes in children and adolescents.
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Affiliation(s)
- Preneet Cheema Brar
- Division of Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, New York, USA.
| | - Shoshana Tell
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado Anschutz Medical Campus & Children's Hospital Colorado, Aurora, CO, USA
| | - Shilpa Mehta
- Division of Pediatric Endocrinology and Diabetes, New York Medical College, Hawthorne, NY, USA
| | - Bonita Franklin
- Division of Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, New York, USA
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Mohn A, Polidori N, Castorani V, Comegna L, Giannini C, Chiarelli F, Blasetti A. Hyperglycaemic hyperosmolar state in an obese prepubertal girl with type 2 diabetes: case report and critical approach to diagnosis and therapy. Ital J Pediatr 2021; 47:38. [PMID: 33602256 PMCID: PMC7891158 DOI: 10.1186/s13052-021-00983-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 02/02/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Isolated Hyperosmolar Hyperglycaemic Syndrome (HHS) is a life-threatening condition characterized by elevated serum glucose concentrations and hyperosmolality without significant ketosis. It is often described in obese adults with unknown Type 2 Diabetes (T2D), rarely in youth. In childhood the most common cause of metabolic glucose related derangement is Diabetic Ketoacidosis (DKA) in Type 1 Diabetes (T1D). Interestingly, both components can be combined with each other, thus the prevalent condition needs to be recognised implying a different therapeutic approach. Case presentation In this case, we report a prepubertal Caucasian obese girl admitted for two episodes of combined HHS/DKA in order to elucidate her clinical course taking into account the current pediatric recommendations based on adult guidelines for HHS. Conclusions The treatment of HHS and even more of HHS/DKA in youth is still controversial as no specific guidelines for children are available especially during the prepubertal age. The description of our case might be helpful and offer relevant points for future consensus.
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Affiliation(s)
- Angelika Mohn
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy.
| | - Nella Polidori
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy
| | - Valeria Castorani
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy
| | - Laura Comegna
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy
| | - Cosimo Giannini
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy
| | - Francesco Chiarelli
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy
| | - Annalisa Blasetti
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy
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Maduemem KE, Adesanya O, Anuruegbe OO, Rafiq A. Hyperglycaemic hyperosmolar state: first presentation of type 1 diabetes mellitus in an adolescent with complex medical needs. BMJ Case Rep 2021; 14:14/2/e237793. [PMID: 33542015 PMCID: PMC7868183 DOI: 10.1136/bcr-2020-237793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This is a case of hyperglycaemic hyperosmolar state (HHS) as first presentation of type 1 diabetes mellitus in a 14-year-old girl with background complex medical needs. She presented with marked hyperglycaemia (56 mmol/L) without significant ketonaemia (2.6 mmol/L) and serum hyperosmolality (426 mOsm/kg). Managing her profound hypernatraemic (>180 mmol/L) dehydration was challenging but resulted in good outcome. Paediatric patients with HHS will likely be treated with the diabetes ketoacidosis (DKA) protocol because of perceived rarity of HHS leading to inadequate rehydration and risk of vascular collapse. Hence, emphasis on the differences in the management protocols of DKA and HHS is paramount. Prompt recognition and adequate management are crucial to avert complications. The undesirable rate of decline of hypernatraemia due to the use of hypotonic fluid was captured in this case. We describe the pivotal role of liberal fluid therapy with non-hypotonic fluids.
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Affiliation(s)
- Kene Ebuka Maduemem
- College of Medicine and Veterinary Medicine, University of Edinburgh Division of Medical and Radiological Sciences, Edinburgh, Edinburgh, UK,Paediatrics, Northampton General Hospital NHS Trust, Northampton, Northamptonshire, UK
| | - Omotayo Adesanya
- Paediatrics, Northampton General Hospital NHS Trust, Northampton, Northamptonshire, UK
| | - Obinna O Anuruegbe
- Paediatrics, Northampton General Hospital NHS Trust, Northampton, Northamptonshire, UK
| | - Anjum Rafiq
- Paediatrics, Northampton General Hospital NHS Trust, Northampton, Northamptonshire, UK
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11
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Ing TS, Ganta K, Bhave G, Lew SQ, Agaba EI, Argyropoulos C, Tzamaloukas AH. The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications. Front Med (Lausanne) 2020; 7:477. [PMID: 32984372 PMCID: PMC7479837 DOI: 10.3389/fmed.2020.00477] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/15/2020] [Indexed: 12/15/2022] Open
Abstract
In hyperglycemia, hypertonicity results from solute (glucose) gain and loss of water in excess of sodium plus potassium through osmotic diuresis. Patients with stage 5 chronic kidney disease (CKD) and hyperglycemia have minimal or no osmotic diuresis; patients with preserved renal function and diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) have often large osmotic diuresis. Hypertonicity from glucose gain is reversed with normalization of serum glucose ([Glu]); hypertonicity due to osmotic diuresis requires infusion of hypotonic solutions. Prediction of the serum sodium after [Glu] normalization (the corrected [Na]) estimates the part of hypertonicity caused by osmotic diuresis. Theoretical methods calculating the corrected [Na] and clinical reports allowing its calculation were reviewed. Corrected [Na] was computed separately in reports of DKA, HHS and hyperglycemia in CKD stage 5. The theoretical prediction of [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu] in most clinical settings, except in extreme hyperglycemia or profound hypervolemia, was supported by studies of hyperglycemia in CKD stage 5 treated only with insulin. Mean corrected [Na] was 139.0 mmol/L in 772 hyperglycemic episodes in CKD stage 5 patients. In patients with preserved renal function, mean corrected [Na] was within the eunatremic range (141.1 mmol/L) in 7,812 DKA cases, and in the range of severe hypernatremia (160.8 mmol/L) in 755 cases of HHS. However, in DKA corrected [Na] was in the hypernatremic range in several reports and rose during treatment with adverse neurological consequences in other reports. The corrected [Na], computed as [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu], provides a reasonable estimate of the degree of hypertonicity due to losses of hypotonic fluids through osmotic diuresis at presentation of DKH or HHS and should guide the tonicity of replacement solutions. However, the corrected [Na] may change during treatment because of ongoing fluid losses and should be monitored during treatment.
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Affiliation(s)
- Todd S Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, United States
| | - Kavitha Ganta
- Medicine Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Gautam Bhave
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Susie Q Lew
- Department of Medicine, George Washington University School of Medicine, Washington, DC, United States
| | | | - Christos Argyropoulos
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Antonios H Tzamaloukas
- Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM, United States
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12
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Schmitt J, Rahman AKMF, Ashraf A. Concurrent diabetic ketoacidosis with hyperosmolality and/or severe hyperglycemia in youth with type 2 diabetes. Endocrinol Diabetes Metab 2020; 3:e00160. [PMID: 32704574 PMCID: PMC7375104 DOI: 10.1002/edm2.160] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Prevalence of diabetic ketoacidosis (DKA) complicated by severe hyperglycaemia and hyperosmolality and its outcomes in youth with type 2 diabetes (T2DM) are not well-described. Our aim is to determine the frequency and clinical outcomes of isolated DKA, DKA with severe hyperglycaemia (DKA + SHG) and DKA with hyperglycaemia and hyperosmolality (DKA + HH) in youth with T2DM admitted for acute hyperglycaemic crisis. METHODS Through retrospective medical record review, patients with T2DM were identified and categorized into isolated DKA, DKA + SHG (DKA + glucose ≥33.3 mmol/L) and DKA + HH (DKA + glucose ≥33.3 mmol/L + osmolality ≥320 mmol/kg). RESULTS Forty-eight admissions in 43 patients ages 9-18 were included: 28 (58%) had isolated DKA, six (13%) had DKA + SHG and 14 (29%) had DKA + HH. Subgroups' demographics and medical history were similar. Seventeen patients (35%) had acute kidney injury (AKI). Odds of AKI were higher in DKA + SHG and DKA + HH relative to isolated DKA (P = .015 and .002 respectively). Frequency of altered mental status (AMS) was similar among groups. Three patients (6%) had concurrent soft-tissue infections at presentation with no differences among subgroup. Three patients (6%) had other medical complications. These occurred only in patients with AKI and DKA + SHG or AKI and DKA + HH. CONCLUSIONS In youth with T2DM, severe hyperglycaemia ± hyperosmolality frequently complicates DKA. Youth with DKA and features of hyperglycaemic hyperosmolar syndrome, including isolated severe hyperglycaemia, have increased odds of AKI.
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Affiliation(s)
- Jessica Schmitt
- Department of PediatricsUniversity of Alabama at BirminghamBirminghamALUSA
| | - AKM. Fazlur Rahman
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamALUSA
| | - Ambika Ashraf
- Department of PediatricsUniversity of Alabama at BirminghamBirminghamALUSA
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13
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Unresponsive: A Case of Hyperglycemia and Altered Mental Status. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2019. [DOI: 10.1016/j.cpem.2019.100726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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14
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Kharode I, Coppedge E, Antal Z. Care of Children and Adolescents with Diabetes Mellitus and Hyperglycemia in the Inpatient Setting. Curr Diab Rep 2019; 19:85. [PMID: 31440933 DOI: 10.1007/s11892-019-1205-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW Children and adolescents with acute hyperglycemia and diabetes mellitus frequently have acute, potentially life-threatening presentations which require high-acuity care in an inpatient and often intensive care setting. This review discusses the evaluation and care of hyperglycemia and diabetes mellitus in hospitalized children in both critical and non-critical care settings, highlighting important differences in their care relative to adults. RECENT FINDINGS Diabetic ketoacidosis remains highly prevalent at diagnosis among children with type 1 diabetes, and hyperglycemic hyperosmolar state is increasingly prevalent among children with type 2 diabetes. Recent clinical trials have investigated the potential benefits of various types of intravenous fluids and their rates of administration as well as the risks and benefits of intensive glucose control in critically ill children. The Endocrine Society has developed guidelines focused on managing hyperglycemic hyperosmolar state, outlining important aspects of care shown to decrease morbidity and mortality. In the non-critical illness setting, intensive therapy on newly diagnosed diabetes is increasingly recommended at the outset. With the increasing incidence of diabetes mellitus in children and adolescents, recent studies addressing acute diabetes emergencies help inform best practices for care of hospitalized children with hyperglycemia and diabetes.
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Affiliation(s)
- Ishita Kharode
- Division of Pediatric Endocrinology, Richmond University Medical Center, 355 Bard Avenue, Staten Island, NY, 10310, USA
| | - Emily Coppedge
- Weill Cornell Medicine, Division of Pediatric Endocrinology, NY Presbyterian Hospital, 505 East 70 Street, New York, NY, 10021, USA
| | - Zoltan Antal
- Weill Cornell Medicine, Division of Pediatric Endocrinology, NY Presbyterian Hospital, 505 East 70 Street, New York, NY, 10021, USA.
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15
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Reddy A, Finley L, Horrall S. Hyperosmolar hyperglycemic syndrome in a young boy. Proc (Bayl Univ Med Cent) 2019; 32:627-628. [PMID: 31656445 DOI: 10.1080/08998280.2019.1646598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 07/10/2019] [Accepted: 07/18/2019] [Indexed: 01/11/2023] Open
Abstract
We describe a 6-year-old boy who presented to the emergency department with the complaint of nausea and vomiting with diarrhea. Workup revealed a glucose level of 1904 mg/dL, and hyperglycemic hyperosmolar syndrome was diagnosed. Hyperglycemic hyperosmolar syndrome is very rare in the pediatric population, but recent published reports suggest that the incidence of this disorder may be increasing.
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Affiliation(s)
- Archana Reddy
- College of Medicine, Texas A&M Health Science CenterTempleTexas
| | - Leland Finley
- Department of Emergency Medicine, Baylor Scott & White Medical Center-TempleTempleTexas
| | - Shawn Horrall
- Department of Emergency Medicine, Baylor Scott & White Medical Center-TempleTempleTexas
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16
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 364] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Abstract
We present the case of a 16-year-old boy who presented with fatigue, polyuria, and polydipsia while on chemotherapy for his relapsed acute lymphoblastic leukemia (ALL). Blood gas examination confirmed the diagnosis of hyperosmolar hyperglycemic state. The etiology for his hyperglycemia was most likely a result of oral glucocorticoid therapy combined with asparaginase therapy-both are a cornerstone of induction chemotherapy for ALL. The patient was aggressively rehydrated with saline, and medications were administered to correct his hyperkalemia. He was then slowly brought to euglycemia with a continuous infusion of insulin. Although hyperosmolar hyperglycemic state is rare during the treatment of ALL, frontline providers should be aware of this diagnosis because of the significant risk of hypovolemic shock and death if correction of hyperglycemia occurs prior to complete fluid resuscitation.
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18
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Tang Q, Li Z, Huang D, Wang C, Jiang X, Cheng C, Chen Y. Continuous renal replacement therapy-the new treatment of seriously hyperglycemia. Am J Emerg Med 2016; 34:2469.e3-2469.e4. [PMID: 27390090 DOI: 10.1016/j.ajem.2016.06.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 06/13/2016] [Indexed: 01/26/2023] Open
Affiliation(s)
- Qian Tang
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.
| | - Zhiyong Li
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Huang
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Chengpan Wang
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Xianshu Jiang
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Changqin Cheng
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Yanmei Chen
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
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19
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Price A, Losek J, Jackson B. Hyperglycaemic hyperosmolar syndrome in children: Patient characteristics, diagnostic delays and associated complications. J Paediatr Child Health 2016; 52:80-4. [PMID: 26228354 DOI: 10.1111/jpc.12980] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2015] [Indexed: 11/28/2022]
Abstract
AIMS The aim of this study was to describe the demographical and clinical characteristics, diagnostic difficulties, and morbidity and mortality in children with hyperglycaemic hyperosmolar syndrome (HHS). METHODS Retrospective cross-section descriptive study of children (<18 years of age) at an urban, tertiary, academic Children's Hospital diagnosed with HHS from January 2002 to December 2011. RESULTS Six patients met inclusion criteria for the diagnosis of HHS. Age ranged from 6 to 16 years with 4 (67%) patients younger than 13 years. Four (67%) patients were women and 5 (83%) were African-American. Body mass index (BMI)-for-age percentile was >97% in four (67%) patients. Three (60%) of five patients seen as outpatients were misdiagnosed, two cases were seen twice before an accurate diagnosis of HHS was made. There was one (17%) death. Complications included three patients with acute renal failure, one patient with seizures, and one patient with rhabdomyolysis and compartment syndrome leading to below the knee amputation. Malignant hyperthermia and ventricular arrhythmias occurred in the patient who expired. Three of the five patients who had autoantibody tests had positive results and were diagnosed with type 1 diabetes mellitus. CONCLUSIONS Characteristics of children with HSS are variable for age, gender and BMI-for-age percentile and not predominately limited to obese male adolescent African-American. Delay in diagnosis is common and morbidity and mortality in paediatric HHS are significant. The subsequent diagnosis of patients presenting with HHS includes type 1 and 2 diabetes mellitus.
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Affiliation(s)
- Amanda Price
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Joseph Losek
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Benjamin Jackson
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, United States
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20
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Li W, Gong C, Wu D, Liu M. Two case reports of severe pediatric hyperosmolar hyperglycemia and diabetic ketoacidosis accompanied with rhabdomyolysis and acute renal failure. J Pediatr Endocrinol Metab 2014; 27:1227-31. [PMID: 25051275 DOI: 10.1515/jpem-2014-0131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 06/10/2014] [Indexed: 01/01/2023]
Abstract
OBJECTIVE This report describes two adolescent males in China who suffered from type 2 diabetes mellitus (T2DM) and hyperglycemic hyperosmolar syndrome (HHS) complicated by rhabdomyolysis (RM). After sufficient fluid administration, both patients recovered. DESIGN Case report. RESULTS These two obese patients suffered from T2DM, DKA and HHS. Because of insufficient fluid administration, these patients became aggravated and suffered from RM. After aggressive fluid resuscitation and insulin injection, the conditions of the two patients improved. Insulin administration was ceased after approximately 1 month of subcutaneous injections. The two patients attained good glucose control with diet management. CONCLUSIONS HHS is one of the most severe complications of T2DM. RM is a sign that the condition of a patient with HHS may worsen. Although management strategies are undefined, effective fluid infusion was shown to be helpful. Thus, the early signs of HHS and RM should be recognized so as to avoid severe complications.
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Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care 2014; 37:3124-31. [PMID: 25342831 PMCID: PMC4207202 DOI: 10.2337/dc14-0984] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The hyperosmolar hyperglycemic state (HHS) is the most serious acute hyperglycemic emergency in patients with type 2 diabetes. von Frerichs and Dreschfeld described the first cases of HHS in the 1880s in patients with an "unusual diabetic coma" characterized by severe hyperglycemia and glycosuria in the absence of Kussmaul breathing, with a fruity breath odor or positive acetone test in the urine. Current diagnostic HHS criteria include a plasma glucose level >600 mg/dL and increased effective plasma osmolality >320 mOsm/kg in the absence of ketoacidosis. The incidence of HHS is estimated to be <1% of hospital admissions of patients with diabetes. The reported mortality is between 10 and 20%, which is about 10 times higher than the mortality rate in patients with diabetic ketoacidosis (DKA). Despite the severity of this condition, no prospective, randomized studies have determined best treatment strategies in patients with HHS, and its management has largely been extrapolated from studies of patients with DKA. There are many unresolved questions that need to be addressed in prospective clinical trials regarding the pathogenesis and treatment of pediatric and adult patients with HHS.
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Affiliation(s)
- Francisco J Pasquel
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
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22
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Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WWR, Mungai LNW, Rosenbloom AL, Sperling MA, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014; 15 Suppl 20:154-79. [PMID: 25041509 DOI: 10.1111/pedi.12165] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 12/16/2022] Open
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23
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Mulder L, Onur O, Kleis L, Borders H, Cemeroglu AP. Atypical neurologic presentations of new onset type 1 diabetes mellitus in pediatric age group: a report of five unusual cases and review of the literature. J Pediatr Endocrinol Metab 2014; 27:749-56. [PMID: 24526607 DOI: 10.1515/jpem-2013-0312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 12/27/2013] [Indexed: 11/15/2022]
Abstract
Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases in childhood and is caused by insulin deficiency resulting from the autoimmune destruction of insulin producing beta cells of the pancreas. Most children in the US with new onset T1DM present with the classic signs and symptoms of hyperglycemia and 30% with diabetic ketoacidosis (DKA). Neurologic manifestations are relatively rare and mostly include lethargy, decreased level of consciousness, and coma as a result of DKA. In this article, five cases of new onset T1DM with exceedingly rare or unreported neurologic manifestations in the pediatric age group are presented, along with a review of the literature.
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24
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Arora R, Chiwane S, Hartwig E, Kannikeswaran N. A child with altered sensorium, hyperglycemia, and elevated troponins. J Emerg Med 2013; 46:184-90. [PMID: 23880446 DOI: 10.1016/j.jemermed.2013.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Revised: 01/23/2013] [Accepted: 05/01/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are potentially life-threatening complications of diabetes mellitus. Although DKA and HHS share similar features, they are distinct clinical entities requiring different treatment measures. OBJECTIVE This case illustrates that the clinical distinction between these two entities can be difficult at times, especially in children who can present with an overlapping picture. CASE REPORT We report an interesting case of a 12-year-old whose initial presentation of diabetes was a mixed picture of hyperosmolar DKA and HHS coma complicated by myocardial strain and acute renal insufficiency. The myocardial strain resolved completely with resolution of the metabolic abnormalities. CONCLUSIONS Emergency physicians should be cognizant of varied presentations of hyperglycemic emergencies in children to initiate appropriate management for better outcomes.
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Affiliation(s)
- Rajan Arora
- Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Saurabh Chiwane
- Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Earl Hartwig
- Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Nirupama Kannikeswaran
- Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
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25
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Bagdure D, Rewers A, Campagna E, Sills MR. Epidemiology of hyperglycemic hyperosmolar syndrome in children hospitalized in USA. Pediatr Diabetes 2013; 14:18-24. [PMID: 22925225 DOI: 10.1111/j.1399-5448.2012.00897.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 05/17/2012] [Accepted: 06/01/2012] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Previous studies of hyperglycemic hyperosmolar syndrome (HHS) in children are limited to case series or single-institution reviews, which describe HHS primarily in children with type 2 diabetes mellitus. OBJECTIVE To estimate the incidence and describe the epidemiologic characteristics of HHS among children in USA. SUBJECTS All discharges in the Kids' Inpatient Database - a triennial, nationwide, stratified probability sample of hospital discharges for years 1997-2009 - with age 0-18 yr and a diagnosis of HHS. METHODS Using sample weights, we calculated the incidence and population rate of hospitalization with a diagnosis of HHS. RESULTS Our sample included 1074 HHS hospitalizations; of these, 42.9% were 16-18 yr, 70.6% had type 1 diabetes (T1D), and 53.0% had major or extreme severity of illness. The median length of stay was 2.6 d, 2.7% of hospitalizations ended in death, and median hospital charge was $10 882. When comparing HHS hospitalizations by diabetes type, the proportion with T1D fell steadily with age, from 89.1% among children 0-9 yr, to 65.1% in 16-18 yr olds. Patients with T1D had a shorter length of stay by 0.9 d, and had a lower median charge by $5311. There was no difference in mortality by diabetes type. Population rates for HHS hospitalization rose 52.4% from 2.1 to 3.2 per 1 000 000 children from 1997 to 2009. CONCLUSION Hospitalizations for a diagnosis of HHS have high morbidity and are increasing in incidence since 1997. In contrast to prior reports, we found a substantial percentage of HHS hospitalizations occurred among children with T1D.
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Affiliation(s)
- Dayanand Bagdure
- Department of Pediatrics, University of Maryland School of Medicine, Division of Pediatric Critical Care Medicine, Baltimore, MD 21201, USA.
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26
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Hyperglycemic hyperosmolar syndrome in the pediatric patient: a case report and review of the literature. Pediatr Emerg Care 2012; 28:699-702. [PMID: 22766588 DOI: 10.1097/pec.0b013e31825d23c9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
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Abstract
Diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus (DM), occurs more commonly in children with type 1 DM than type 2 DM. Hyperglycemia, metabolic acidosis, ketonemia, dehydration and various electrolyte abnormalities result from a relative or absolute deficiency of insulin with or without an excess of counter-regulatory hormones. Management requires careful replacement of fluid and electrolyte deficits, intravenous administration of insulin, and close monitoring of clinical and biochemical parameters directed towards timely detection of complications, including hypokalemia, hypoglycemia and cerebral edema. Cerebral edema may be life threatening and is managed with fluid restriction, administration of mannitol and ventilatory support as required. Factors precipitating the episode of DKA should be identified and rectified. Following resolution of ketoacidosis, intravenous insulin is transitioned to subcutaneous route, titrating dose to achieve normoglycemia.
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28
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Abstract
The object of this review is to provide the definitions, frequency, risk factors, pathophysiology, diagnostic considerations, and management recommendations for diabetic ketoacidosis (DKA) in children and adolescents, and to convey current knowledge of the causes of permanent disability or mortality from complications of DKA or its management, particularly the most common complication, cerebral edema (CE). DKA frequency at the time of diagnosis of pediatric diabetes is 10%-70%, varying with the availability of healthcare and the incidence of type 1 diabetes (T1D) in the community. Recurrent DKA rates are also dependent on medical services and socioeconomic circumstances. Management should be in centers with experience and where vital signs, neurologic status, and biochemistry can be monitored with sufficient frequency to prevent complications or, in the case of CE, to intervene rapidly with mannitol or hypertonic saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours; an initial bolus of 10-20 mL/kg 0.9% saline is followed by 0.45% saline calculated to supply maintenance and replace 5%-10% dehydration. Potassium (K) must be replaced early and sufficiently. Bicarbonate administration is contraindicated. The prevention of DKA at onset of diabetes requires an informed community and high index of suspicion; prevention of recurrent DKA, which is almost always due to insulin omission, necessitates a committed team effort.
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29
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Hyperglycemic hyperosmolar syndrome in children: pathophysiological considerations and suggested guidelines for treatment. J Pediatr 2011; 158:9-14, 14.e1-2. [PMID: 21035820 DOI: 10.1016/j.jpeds.2010.09.048] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 07/23/2010] [Accepted: 09/20/2010] [Indexed: 12/31/2022]
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30
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Abstract
The object of this review is to provide the definitions, frequency, risk factors, pathophysiology, diagnostic considerations, and management recommendations for diabetic ketoacidosis (DKA) in children and adolescents, and to convey current knowledge of the causes of permanent disability or mortality from complications of DKA or its management, particularly the most common complication, cerebral edema (CE). DKA frequency at the time of diagnosis of pediatric diabetes is 10%-70%, varying with the availability of healthcare and the incidence of type 1 diabetes (T1D) in the community. Recurrent DKA rates are also dependent on medical services and socioeconomic circumstances. Management should be in centers with experience and where vital signs, neurologic status, and biochemistry can be monitored with sufficient frequency to prevent complications or, in the case of CE, to intervene rapidly with mannitol or hypertonic saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours; an initial bolus of 10-20 mL/kg 0.9% saline is followed by 0.45% saline calculated to supply maintenance and replace 5%-10% dehydration. Potassium (K) must be replaced early and sufficiently. Bicarbonate administration is contraindicated. The prevention of DKA at onset of diabetes requires an informed community and high index of suspicion; prevention of recurrent DKA, which is almost always due to insulin omission, necessitates a committed team effort.
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Affiliation(s)
- Arlan L Rosenbloom
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA,
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31
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Aggressive fluid resuscitation in severe pediatric hyperglycemic hyperosmolar syndrome: a case report. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:379063. [PMID: 20339503 PMCID: PMC2842888 DOI: 10.1155/2010/379063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 01/26/2010] [Indexed: 02/02/2023]
Abstract
Objective. This report describes a severe case of hyperglycemic hyperosmolar syndrome
complicated by rhabdomyolysis, acute kidney injury, hyperthermia, and hypovolemic
shock, with management centred upon fluid administration.
Design. Case report.
Setting. Pediatric intensive care unit in university teaching hospital.
Patients. 12 years old adolescent female presenting with hyperglycemic hyperosmolar
syndrome with a new diagnosis of type 2 diabetes mellitus.
Intervention. Aggressive fluid resuscitation and insulin.
Main results. The patient had a good outcome, discharged home on hospital day 6.
Conclusions. Hyperglycemic hyperosmolar syndrome is associated with a number of
complications. Management strategies are undefined, given the rarity of its presentation,
and further studies are warranted.
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32
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Rosenbloom AL. Hyperglycemic hyperosmolar state: an emerging pediatric problem. J Pediatr 2010; 156:180-4. [PMID: 20105637 DOI: 10.1016/j.jpeds.2009.11.057] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Revised: 10/12/2009] [Accepted: 11/19/2009] [Indexed: 01/14/2023]
Affiliation(s)
- Arlan L Rosenbloom
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, USA.
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33
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Murthy S, Sharara-Chami R. Aggressive Fluid Resuscitation in Severe Pediatric Hyperglycemic Hyperosmolar Syndrome: A Case Report. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-379063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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34
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Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee W, Rosenbloom A, Sperling M, Hanas R. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes 2009; 10 Suppl 12:118-33. [PMID: 19754623 DOI: 10.1111/j.1399-5448.2009.00569.x] [Citation(s) in RCA: 172] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Joseph Wolfsdorf
- Division of Endocrinology, Children's Hospital Boston, MA 02115, USA.
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