1
|
Khor A, Mohiuddin M. DKA/HHS insulin infusion protocol adherence and patient outcomes in Shellharbour Hospital. Intern Med J 2023; 53:2277-2282. [PMID: 37279023 DOI: 10.1111/imj.16151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/07/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS) are medical emergencies requiring prompt assessment and management to avoid complications. AIMS To examine adherence to the hospital DKA/HHS insulin infusion protocol, assess outcomes in patients admitted with DKA or HHS, and determine if improvements have been observed from a similar audit in 2016. METHODS An audit was conducted on 40 patients admitted to Shellharbour Hospital with DKA or HHS. Protocol adherence was assessed in the domains of fluid replacement, potassium replacement, use of the correct insulin infusion schedule, timing of commencement of dextrose infusion and appropriate transition to subcutaneous insulin. The outcomes assessed included length of hospital stay, duration of insulin infusion, time to euglycaemia, intensive care unit (ICU) transfer, overlap between insulin infusion and subcutaneous insulin, diabetes team review and incidence and management of hypoglycaemia. RESULTS The proportion of cases that adhered to the components of the insulin infusion protocol is as follows: fluid replacement (40%), potassium replacement (72.5%), correct insulin schedule (82.5%), appropriate commencement of intravenous dextrose (80%) and appropriate transition to subcutaneous insulin (87.5%). Appropriate overlap between insulin infusion and subcutaneous insulin occurred in 62.5% of patients. Eighty-five per cent of patients were reviewed by the diabetes team. Three per 40 patients experienced hypoglycaemia, and none of the three patients was treated as per protocol. Compared to the 2016 audit, there was a significant improvement in potassium replacement but a decrease in appropriate fluid replacement. CONCLUSION This audit highlights areas in DKA/HHS management requiring improvement. These include fluid and potassium replacement and appropriate overlap between subcutaneous insulin and insulin infusion.
Collapse
Affiliation(s)
- Amanda Khor
- Department of Medicine, Shellharbour Hospital, Illawarra, New South Wales, Australia
| | - Mohammad Mohiuddin
- Department of Medicine, Shellharbour Hospital, Illawarra, New South Wales, Australia
| |
Collapse
|
2
|
Ogata M, Yazawa M. Tonicity or serum osmolality? Comment on management of hyperosmolar hyperglycaemic state in adults: An updated guideline from the Joint British Diabetes Societies for Inpatient Care Group. Diabet Med 2023; 40:e15211. [PMID: 37634208 DOI: 10.1111/dme.15211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/23/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Masatomo Ogata
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masahiko Yazawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| |
Collapse
|
3
|
Pina H, Martins JD, Guerra S, Aragüés JM, Valadas C. The silent diabetic decompensation epidemic during the SARS-CoV2 pandemic - The role of primary care in early diagnosis and prevention of severe diabetic decompensation. Prim Care Diabetes 2023; 17:524-525. [PMID: 37353465 PMCID: PMC10266494 DOI: 10.1016/j.pcd.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/03/2023] [Indexed: 06/25/2023]
Abstract
AIM/HYPOTHESIS Efficiency in controlling chronic diseases, especially in the primary care setting, is associated with reduced rates of hospitalizations. Poorly controlled diabetes is associated with severe diabetic decompensation, such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). It is hypothesized that, in addition to the SARS-CoV2 pandemic, there was a parallel increase in decompensation of previously controlled chronic diseases, such as diabetes. In this work, the impact of the SARS-CoV2 pandemic on hospitalizations for severe diabetic decompensation in a Portuguese hospital was assessed. METHODS A retrospective study by hospital clinical file consultation was performed and a cohort of 177 patients admitted to a Portuguese hospital with a diagnosis of DKA or hyperosmolar hyperglycemic state HHS, excluding SARS-CoV2 infected patients, between 2019 and 2020 was analysed. RESULTS In the population not infected by SARS-CoV2, statistically significant differences were found in the relative number of hospitalizations (5.59 vs 3.79 hospitalizations for DKA/HHS per 1000 patients not infected with SARS-CoV2, p = 0.0093) and lethality due to DKA/HHS (0941 vs 0337 deaths from DKA/HHS per 1000 patients not infected with SARS-CoV2, p = 0.0251). This increase in hospitalizations and lethality was accompanied by a statistically significant increase in newly type 2 diabetes diagnosis in DKA/HHS hospital admissions (p = 0.0156) and by a statistically significant increase in average age of patients (56.3 ± 22.4 vs 69.1 ± 17.6, p < 0.001). DISCUSSION AND CONCLUSIONS These results show the empirical perspective that the consequences of the pandemic also had a considerable impact on the control of chronic diseases such as diabetes, with a higher percentage of hospitalizations due to severe decompensation, especially in the elderly population.
Collapse
Affiliation(s)
- Henrique Pina
- Endocrinology department, Hospital Beatriz Ângelo, Lisbon, Portugal.
| | | | - Sílvia Guerra
- Endocrinology department, Hospital Beatriz Ângelo, Lisbon, Portugal
| | | | - Cristina Valadas
- Endocrinology department, Hospital Beatriz Ângelo, Lisbon, Portugal
| |
Collapse
|
4
|
Diagnosis and Acute Management of Hyperglycemic Hyperosmolar Syndrome in Children and Adolescents. Pediatr Emerg Care 2023; 39:726-7. [PMID: 37642638 DOI: 10.1097/01.pec.0000978364.49725.d2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
|
5
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
6
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
7
|
Mustafa OG, Haq M, Dashora U, Castro E, Dhatariya KK. Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group. Diabet Med 2023; 40:e15005. [PMID: 36370077 PMCID: PMC10107355 DOI: 10.1111/dme.15005] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/18/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022]
Abstract
Hyperosmolar Hyperglycaemic State (HHS) is a medical emergency associated with high mortality. It occurs less frequently than diabetic ketoacidosis (DKA), affects those with pre-existing/new type 2 diabetes mellitus and increasingly affecting children/younger adults. Mixed DKA/HHS may occur. The JBDS HHS care pathway consists of 3 themes (clinical assessment and monitoring, interventions, assessments and prevention of harm) and 5 phases of therapy (0-60 min, 1-6, 6-12, 12-24 and 24-72 h). Clinical features of HHS include marked hypovolaemia, osmolality ≥320 mOsm/kg using [(2×Na+ ) + glucose+urea], marked hyperglycaemia ≥30 mmol/L, without significant ketonaemia (≤3.0 mmol/L), without significant acidosis (pH >7.3) and bicarbonate ≥15 mmol/L. Aims of the therapy are to improve clinical status/replace fluid losses by 24 h, gradual decline in osmolality (3.0-8.0 mOsm/kg/h to minimise the risk of neurological complications), blood glucose 10-15 mmol/L in the first 24 h, prevent hypoglycaemia/hypokalaemia and prevent harm (VTE, osmotic demyelination, fluid overload, foot ulceration). Underlying precipitants must be identified and treated. Interventions include: (1) intravenous (IV) 0.9% sodium chloride to restore circulating volume (fluid losses 100-220 ml/kg, caution in elderly), (2) fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement unless there is ketonaemia (FRIII should be commenced at the same time as IV fluids). (3) glucose infusion (5% or 10%) should be started once glucose <14 mmol/L and (4) potassium replacement according to potassium levels. HHS resolution criteria are: osmolality <300 mOsm/kg, hypovolaemia corrected (urine output ≥0.5 ml/kg/h), cognitive status returned to pre-morbid state and blood glucose <15 mmol/L.
Collapse
Affiliation(s)
- Omar G. Mustafa
- Department of diabetesKing's College Hospital NHS Foundation TrustLondonUK
- King's College LondonLondonUK
| | - Masud Haq
- Maidstone and Tunbridge Wells NHS TrustTunbridge WellsUK
| | - Umesh Dashora
- Conquest Hospital, Easdt Sussex Healthcare NHS TrustThe Ridge St Leonards on SeaUK
| | - Erwin Castro
- Conquest Hospital, Easdt Sussex Healthcare NHS TrustThe Ridge St Leonards on SeaUK
| | - Ketan K. Dhatariya
- Elsie Bertram Diabetes CentreNorfolk and Norwich University Hospitals NHS Foundation TrustNorwichUK
- Norwich Medicine SchoolUniversity of East AngliaNorwichUK
| | | |
Collapse
|
8
|
McCoy RG, Herrin J, Galindo RJ, Swarna KS, Umpierrez GE, Golden SH, O’Connor PJ. Rates of Hypoglycemic and Hyperglycemic Emergencies Among U.S. Adults With Diabetes, 2011-2020. Diabetes Care 2023; 46:e69-e71. [PMID: 36520618 PMCID: PMC9887609 DOI: 10.2337/dc22-1673] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Rozalina G. McCoy
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Rodolfo J. Galindo
- Division of Endocrinology, Department of Medicine, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
| | - Kavya Sindhu Swarna
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- OptumLabs, Eden Prairie, MN
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Department of Medicine, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD
- Office of Diversity, Inclusion, and Health Equity, Johns Hopkins Medicine, Baltimore, MD
| | - Patrick J. O’Connor
- Center for Chronic Care Innovation, HealthPartners Institute, Minneapolis, MN
| |
Collapse
|
9
|
Miyamura K, Nawa N, Nishimura H, Fushimi K, Fujiwara T. Association between heat exposure and hospitalization for diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia in Japan. Environ Int 2022; 167:107410. [PMID: 35868079 DOI: 10.1016/j.envint.2022.107410] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 07/03/2022] [Accepted: 07/11/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND An increase in extreme heat events has been reported along with global warming. Heat exposure in ambient temperature is associated with all-cause diabetes mortality and all-cause hospitalization in diabetic patients. However, the association between heat exposure and hospitalization for hyperglycemic emergencies, such as diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS), and hypoglycemia is unclear. The objective of our study is to clarify the impact of heat exposure on the hospitalization for DKA, HHS, and hypoglycemia. METHODS Data of daily hospitalizations for hyperglycemic emergencies (i.e., DKA or HHS) and hypoglycemia was extracted from a nationwide administrative database in Japan and linked with temperature in each prefecture in Japan during 2012-2019. We applied distributed lag non-linear model to evaluate the non-linear and lagged effects of heat exposure on hospitalization for hyperglycemic emergencies. RESULTS The pooled relative risk for hyperglycemic emergencies of heat effect (the 90th percentile of temperature with reference to the 75th percentile of temperature) and extreme heat effect (the 99th percentile of temperature with reference to the 75th percentile of temperature) over 0-3 lag days was 1.27 (95 %CI: 1.16-1.39) and 1.64 (95 %CI: 1.38-1.93), respectively. The pooled relative risk for heat effect on hospitalization for hypoglycemia and extreme heat effect over 0-3 lag days was 1.33 (95 %CI: 1.17-1.52) and 1.65 (95 %CI: 1.29-2.10), respectively. These associations were consistent by type of hyperglycemic emergencies and type of diabetes and were generally consistent by regions. DISCUSSION Heat exposure was associated with hospitalizations for DKA, HHS and hypoglycemia. These results may be useful to guide preventive actions for the risk of fatal hyperglycemic emergencies and hypoglycemia.
Collapse
Affiliation(s)
- Keitaro Miyamura
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobutoshi Nawa
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hisaaki Nishimura
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Information Section, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeo Fujiwara
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan.
| |
Collapse
|
10
|
Blank SP, Blank RM, Campbell L. What Is the Optimal Speed of correction of the Hyperosmolar Hyperglycemic State in Diabetic Ketoacidosis? An Observational Cohort Study of U.S. Intensive Care Patients. Endocr Pract 2022; 28:875-883. [PMID: 35688365 DOI: 10.1016/j.eprac.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/28/2022] [Accepted: 06/01/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The international guidelines for the treatment of diabetic ketoacidosis (DKA) advise against rapid changes in osmolarity and glucose; however, the optimal rates of correction are unknown. We aimed to evaluate the rates of change in tonicity and glucose level in intensive care patients with DKA and their relationship with mortality and altered mental status. METHODS This is an observational cohort study using 2 publicly available databases of U.S. intensive care patients (Medical Information Mart for Intensive Care-IV and Electronic Intensive Care Unit), evaluating adults with DKA and associated hyperosmolarity (baseline Osm ≥300 mOsm/L). The primary outcome was hospital mortality. The secondary neurologic outcome used a composite of diagnosed cerebral edema or Glasgow Coma Scale score of ≤12. Multivariable regression models were used to control for confounding factors. RESULTS On adjusted analysis, patients who underwent the most rapid correction of up to approximately 3 mmol/L/hour in tonicity had reduced mortality (n = 2307; odds ratio [OR], 0.21; overall P < .001) and adverse neurologic outcomes (OR, 0.44; P < .001). Faster correction of glucose levels up to 5 mmol/L/hour (90 mg/dL/hour) was associated with improvements in mortality (n = 2361; OR, 0.24; P = .020) and adverse neurologic events (OR, 0.52; P = .046). The number of patients corrected significantly faster than these rates was low. A maximal hourly rate of correction between 2 and 5 mmol/L for tonicity was associated with the lowest mortality rate on adjusted analysis. CONCLUSION Based on large-volume observational data, relatively rapid correction of tonicity and glucose level was associated with lower mortality and more favorable neurologic outcomes. Avoiding a maximum hourly rate of correction of tonicity >5 mmol/L may be advisable.
Collapse
Affiliation(s)
- Sebastiaan P Blank
- Intensive Care Unit, Royal Darwin Hospital, Tiwi, Northern Territory, Australia.
| | - Ruth M Blank
- Royal Darwin Hospital, Tiwi, Darwin, Northern Territory, Australia
| | - Lewis Campbell
- Intensive Care Unit, Royal Darwin Hospital, Tiwi, Northern Territory, Australia; Flinders University, Adelaide, Australia; Menzies School of Health Research, Royal Darwin Hospital Campus, Tiwi, Northern Territory, Australia
| |
Collapse
|
11
|
Au A, Toolis M. Hyperosmolar Hyperglycaemic State (HHS) complicated by life-threatening large vessel occlusive arterial thrombosis - A mini case series and important reminder for clinicians. Diabetes Metab Syndr 2022; 16:102515. [PMID: 35660934 DOI: 10.1016/j.dsx.2022.102515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/15/2022] [Accepted: 05/18/2022] [Indexed: 11/20/2022]
Abstract
Hyperosmolar Hyperglycaemic State (HHS) is a known life-threatening complication of Type 2 Diabetes Mellitus (T2DM). As the incidence of T2DM continues to grow, it is important to remember some of its lesser-known complications. HHS has been described in the literature to result in small vessel thrombosis, leading to coronary or cerebral arterial thrombosis, resulting in acute myocardial infarction or cerebrovascular accidents. The underlying pathology of this relates to the prothrombotic and hyperviscous state caused by HHS. On our review of the literature, however, we are unable to find a consistent description or HHS complicated by large vessel thrombotic occlusion. The authors of this paper present a mini case series describing two cases of HHS which were complicated by life or limb-threatening large vessel occlusive arterial thrombosis. This is particularly unique as we have otherwise only been able to identify single case reports in the existing literature from other authors. The purpose of this case discussion is to highlight this rare complication of HHS and to encourage clinicians to remember that HHS is not just a physiological or biochemical derangement, can also lead to true surgical emergencies requiring immediate treatment.
Collapse
Affiliation(s)
- Amos Au
- Surgical Registrar, Monash Health, Victoria, Australia.
| | - Michael Toolis
- Intensive Care Consultant, Monash Health, Victoria, Australia.
| |
Collapse
|
12
|
Bur J, Favre G, Mehlig A, Goede JS. [Acquired Stomatocytosis in Hyperosmolar Hyperglycemic Derangement]. Praxis (Bern 1994) 2022; 111:299-303. [PMID: 35414255 DOI: 10.1024/1661-8157/a003815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Acquired Stomatocytosis in Hyperosmolar Hyperglycemic Derangement Abstract. In the context of a suicidally motivated suspension of insulin therapy, a massive hyperosmolar hyperglycemic derailment occurred in pancreoprivic diabetes mellitus most likely due to aethyltoxicity. In the blood picture differentiation stomatocytes could be detected, the development of which will be discussed in more detail below.
Collapse
Affiliation(s)
- Jan Bur
- Allgemeine Innere Medizin, Kantonsspital Baselland, Liestal, Schweiz
| | - Geneviève Favre
- Allgemeine Innere Medizin und Hämatologie FMH, Kantonsspital Baselland, Liestal, Schweiz
| | - Annekathrin Mehlig
- Allgemeine Innere Medizin und Intensivmedizin FMH, Merian Iselin Klinik, Basel, Schweiz
| | - Jeroen S Goede
- Departement Medizin, Medizinische Onkologie und Hämatologie, Kantonsspital Winterthur, Winterthur, Schweiz
| |
Collapse
|
13
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
14
|
Nilsson K, Werner J. [Hyperosmolar Hyperglycemic State (HHS) with extreme hyperglycemia and hyperglycemia-induced hyponatremia in a patient with previously known diabetes mellitus type 2]. Lakartidningen 2021; 118:20167. [PMID: 33778936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This case report covers a patient presenting unconscious to the emergency department with a serum glucose level of 125.6 mmol/L and an associated hyperglycemia-induced hyponatremia with a sodium level of 101 mmol/L. The glucose level is, to our knowledge, one of the most extreme values described in medical literature. Glucose and sodium levels were normalized following treatment with intravenous fluids, mainly Ringer's lactate solution and insulin infusion with an initial rate of 0,5 IU/kg/h. The patient needed ten days of hospital care, including five days at the intensive care unit. Shortly after discharge the patient had a complete recovery. However, the extreme values led to difficulties regarding correction rates, choice of treatment and monitoring, which is further discussed in the article.
Collapse
Affiliation(s)
- Konrad Nilsson
- doktorand, ST-läkare, VO internmedicin, Visby lasarett; institutionen för medicinska vetenskaper, Uppsala universitet
| | | |
Collapse
|
15
|
Wu XY, She DM, Wang F, Guo G, Li R, Fang P, Li L, Zhou Y, Zhang KQ, Xue Y. Clinical profiles, outcomes and risk factors among type 2 diabetic inpatients with diabetic ketoacidosis and hyperglycemic hyperosmolar state: a hospital-based analysis over a 6-year period. BMC Endocr Disord 2020; 20:182. [PMID: 33317485 PMCID: PMC7734851 DOI: 10.1186/s12902-020-00659-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/25/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the two most common hyperglycemic emergencies (HEs) associated with diabetes mellitus. Individuals with HEs can present with combined features of DKA and HHS. The objective of this study is to assess the clinical characteristics, therapeutic outcomes, and associated predisposing factors of type 2 diabetic patients with isolated or combined HEs in China. METHODS We performed a retrospective analysis of 158 patients with type 2 diabetes (T2DM), complicated with DKA, HHS, or DKA combined with HHS (DKA-HHS) in Shanghai Tongji Hospital, China from 2010 to 2015. Admission clinical features, therapeutic approaches and treatment outcomes of those patients were extracted and analyzed. RESULTS Of the 158 patients with T2DM, 65 (41.1%) patients were DKA, 74 (46.8%) were HHS, and 19 (12.0%) were DKA-HHS. The most common precipitants were infections (111, 70.3%), newly diagnosed diabetes (28,17.7%) and non-compliance to medications (9, 5.7%). DKA patients were divided into mild, moderate and severe group, based on arterial blood gas. Spearman correlation analysis revealed that C-reaction protein (CRP) was positively correlated with severity of DKA, whereas age and fasting C peptide were inversely correlated with severity of DKA (P < 0.05). The mortality was 10.8% (17/158) in total and 21.6% (16/74) in the HHS group, 5.9% (1/17) in DKA-HHS. Spearman correlation analysis indicated that death in patients with HHS was positively correlated to effective plasma osmolality (EPO), renal function indicators and hepatic enzymes, while inversely associated with the continuous subcutaneous insulin infusion (CSII) therapy. Logistic regression analysis suggested that elevated blood urea nitrogen (BUN) on admission was an independent predisposing factor of mortality in HHS, while CSII might be a protective factor for patients with HHS. Furthermore, the receiver-operating characteristic (ROC) curve analysis indicated that BUN had the largest area under the ROC curves for predicting death in patients with HHS. CONCLUSIONS Our findings showed elevated CRP and decreased fasting C-peptide might serve as indicator for severe DKA. Elevated BUN might be an independent predictor of mortality in patients with HHS, whereas CSII might be a protective factor against death in HHS.
Collapse
Affiliation(s)
- Xiao-yan Wu
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
- Shanghai Hongkou District Liangcheng New Village Street Community Health Service Center, 200434, Shanghai, China
| | - Dun-min She
- Department of Endocrinology and Metabolism, Northern Jiangsu People’s Hospital, Yangzhou, 225000 China
| | - Fang Wang
- Department of Endocrinology, People’s Hospital of Shanghai Putuo District, Shanghai, 200060 China
| | - Gang Guo
- Department of Emergency, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
| | - Ran Li
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
| | - Ping Fang
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
| | - Ling Li
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
| | - Yun Zhou
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
| | - Ke-qin Zhang
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
| | - Ying Xue
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
| |
Collapse
|
16
|
Pal R, Banerjee M, Yadav U, Bhattacharjee S. Clinical profile and outcomes in COVID-19 patients with diabetic ketoacidosis: A systematic review of literature. Diabetes Metab Syndr 2020; 14:1563-1569. [PMID: 32853901 PMCID: PMC7434433 DOI: 10.1016/j.dsx.2020.08.015] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM To conduct a systematic literature review and analyze the demographic/biochemical parameters and clinical outcomes of COVID-19 patients with diabetic ketoacidosis (DKA) and combined DKA/HHS (hyperglycemic hyperosmolar syndrome). METHODS PubMed, Scopus, Embase, and Google Scholar databases were systematically searched till August 3, 2020 to identify studies reporting COVID-19 patients with DKA and combined DKA/HHS. A total of 19 articles reporting 110 patients met the eligibility criteria. RESULTS Of the 110 patients, 91 (83%) patients had isolated DKA while 19 (17%) had DKA/HHS. The majority of the patients were male (63%) and belonged to black ethnicity (36%). The median age at presentation ranged from 45.5 to 59.0 years. Most of the patients (77%) had pre-existing type 2 diabetes mellitus. Only 10% of the patients had newly diagnosed diabetes mellitus. The median blood glucose at presentation ranged from 486.0 to 568.5 mg/dl, being higher in patients with DKA/HHS compared to isolated DKA. The volume of fluid replaced in the first 24 h was higher in patients with DKA/HHS in contrast to patients with DKA alone. The in-hospital mortality rate was 45%, with higher mortality in the DKA/HHS group than in the isolated DKA group (67% vs. 29%). pH was lower in patients who had died compared to those who were discharged. CONCLUSION DKA in COVID-19 patients portends a poor prognosis with a mortality rate approaching 50%. Differentiating isolated DKA from combined DKA/HHS is essential as the latter represents nearly one-fifth of the DKA cases and tends to have higher mortality than DKA alone.
Collapse
Affiliation(s)
- Rimesh Pal
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Mainak Banerjee
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, 700007, India
| | - Urmila Yadav
- National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sukrita Bhattacharjee
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Medical College and Hospital, Kolkata, West Bengal, 700073, India
| |
Collapse
|
17
|
Gomes C, Fonseca D, Freitas A. Seasonal variation of diabetes with hyperosmolarity hospitalizations and its characteristics in mainland Portugal. Prim Care Diabetes 2020; 14:445-447. [PMID: 31937492 DOI: 10.1016/j.pcd.2019.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 12/23/2019] [Accepted: 12/28/2019] [Indexed: 12/01/2022]
Abstract
AIMS The family physician devotes a part of his care to the surveillance of diabetic patients. Hyperosmolarity is a severe acute complication. The aim of this study was to analyse seasonal variation of type 2 diabetes with hyperosmolarity hospitalizations, regarding their occurrence, mortality, length of stay, Charlson comorbidity index and its factors. METHODS The authors analysed all hospitalizations in Portuguese Mainland public sector hospitals between 2000 and 2015 with primary diagnosis of type 2 diabetes with hyperosmolarity (ICD-9-CM codes 250.20 or 250.22), using a national administrative database. Cases were classified into four seasons according to date of admission. The authors compared the occurrence, length of stay, in-hospital mortality and Charlson comorbidity index and its factors. RESULTS A total of 6596 hospitalization episodes were included. The authors found that admissions occurred more in winter, being 23% more common. No seasonal statistically significant differences were found considering the other variables. CONCLUSIONS There is an increased occurrence of this acute metabolic complication during the winter in patients with type 2 diabetes. These results should be taken into account by the family physician when planning surveillance to this risk group.
Collapse
Affiliation(s)
- Carlos Gomes
- USF Salvador Machado, Oliveira de Azeméis, Portugal.
| | | | - Alberto Freitas
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS - Center for Health Technology and Services Research, Porto, Portugal
| |
Collapse
|
18
|
Dhatariya K, James J, Kong MF, Berrington R. Diabetes at the front door. A guideline for dealing with glucose related emergencies at the time of acute hospital admission from the Joint British Diabetes Society (JBDS) for Inpatient Care Group. Diabet Med 2020; 37:1578-1589. [PMID: 32279343 DOI: 10.1111/dme.14304] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2020] [Indexed: 12/18/2022]
Abstract
People with diabetes account for nearly one-fifth of all inpatients in English and Welsh hospitals; of these, up to 90% are admitted as an emergency. Most are admitted for a reason other than diabetes with only 8% requiring admission for a diabetes-specific cause. Healthcare professionals working in emergency departments experience numerous clinical challenges, notwithstanding the need to know whether each individual with diabetes requires urgent admission. This document has been developed and written by experts in the field, and reviewed by the parent organizations of the Joint British Diabetes Societies for Inpatient Care-Diabetes UK, the Diabetes Inpatient Specialist Nurse Group and the Association of British Clinical Diabetologists. The document aims to support staff working in emergency departments and elsewhere by offering practical advice and tools for effective, appropriate and safe triage. Each section relates to the commonest diabetic specific emergencies and algorithms can be printed off to enable ease of access and use.
Collapse
Affiliation(s)
- K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - J James
- Department of Diabetes, University Hospitals Leicester NHS Trust, Leicester, UK
| | - M-F Kong
- Department of Diabetes, University Hospitals Leicester NHS Trust, Leicester, UK
| | - R Berrington
- Department of Diabetes, University Hospitals Leicester NHS Trust, Leicester, UK
| |
Collapse
|
19
|
Penela-Sánchez D, Cardona-Hernández R, Almario-Hernández AF. Hyperosmolar hyperglycemic syndrome in pediatric patients. Emergencias 2020; 31:295-296. [PMID: 31347819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Daniel Penela-Sánchez
- Servicio de Pediatría, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - Roque Cardona-Hernández
- Sección de Endocrinología, Unidad de Diabetes, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | | |
Collapse
|
20
|
Benoit SR, Hora I, Pasquel FJ, Gregg EW, Albright AL, Imperatore G. Trends in Emergency Department Visits and Inpatient Admissions for Hyperglycemic Crises in Adults With Diabetes in the U.S., 2006-2015. Diabetes Care 2020; 43:1057-1064. [PMID: 32161050 PMCID: PMC7171947 DOI: 10.2337/dc19-2449] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 02/20/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To report U.S. national population-based rates and trends in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) among adults, in both the emergency department (ED) and inpatient settings. RESEARCH DESIGN AND METHODS We analyzed data from 1 January 2006 through 30 September 2015 from the Nationwide Emergency Department Sample and National Inpatient Sample to characterize ED visits and inpatient admissions with DKA and HHS. We used corresponding year cross-sectional survey data from the National Health Interview Survey to estimate the number of adults ≥18 years with diagnosed diabetes to calculate population-based rates for DKA and HHS in both ED and inpatient settings. Linear trends from 2009 to 2015 were assessed using Joinpoint software. RESULTS In 2014, there were a total of 184,255 and 27,532 events for DKA and HHS, respectively. The majority of DKA events occurred in young adults aged 18-44 years (61.7%) and in adults with type 1 diabetes (70.6%), while HHS events were more prominent in middle-aged adults 45-64 years (47.5%) and in adults with type 2 diabetes (88.1%). Approximately 40% of the hyperglycemic events were in lower-income populations. Overall, event rates for DKA significantly increased from 2009 to 2015 in both ED (annual percentage change [APC] 13.5%) and inpatient settings (APC 8.3%). A similar trend was seen for HHS (APC 16.5% in ED and 6.3% in inpatient). The increase was in all age-groups and in both men and women. CONCLUSIONS Causes of increased rates of hyperglycemic events are unknown. More detailed data are needed to investigate the etiology and determine prevention strategies.
Collapse
Affiliation(s)
- Stephen R Benoit
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Israel Hora
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Francisco J Pasquel
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Edward W Gregg
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ann L Albright
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Giuseppina Imperatore
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| |
Collapse
|
21
|
Gershkovich B, English SW, Doyle MA, Menon K, McIntyre L. Choice of crystalloid fluid in the treatment of hyperglycemic emergencies: a systematic review protocol. Syst Rev 2019; 8:228. [PMID: 31481108 PMCID: PMC6720374 DOI: 10.1186/s13643-019-1130-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 08/13/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are life-threatening complications of diabetes mellitus which require prompt treatment with large volume crystalloid fluid administration. A variety of crystalloid fluids is currently available for use and differs in their composition and ion concentrations. While there are potential pros and cons for different crystalloid fluids, it remains unknown if any particular fluid confers a clinical outcome benefit over others in the treatment of hyperglycemic emergencies. METHODS A systematic search of MEDLINE, Embase, and the Cochrane Library of Systematic Reviews will be conducted to identify eligible studies, which will include observational and interventional studies involving adult and pediatric patients admitted to the hospital with either DKA or HHS. The interventions will include intravenous treatment with 0.9% saline versus other buffered (Ringer's lactate, Hartmann's, etc.), and non-buffered (0.45% saline) crystalloid fluids. The primary outcome is mortality at the latest follow-up time point. Secondary outcomes will include mortality at specific time points, length of hospital stay, development of acute kidney injury, requirement for renal replacement therapy, altered level of consciousness, and the time to normalization of several serum biochemical parameters. Where appropriate, meta-analyses will be performed for the outcomes and conducted separately for adult and pediatric patient populations. DISCUSSION DKA and HHS are dangerous complications of diabetes mellitus and account for significant morbidity and mortality. Given the importance of crystalloid fluid administration in the management of these conditions, a systematic synthesis of the existing evidence base will identify potential evidence gaps and may help guide future clinical practice.
Collapse
Affiliation(s)
- Benjamin Gershkovich
- Department of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
| | - Shane W. English
- Department of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario Canada
| | - Mary-Anne Doyle
- Department of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario Canada
| | - Kusum Menon
- CHEO Research Institute, Ottawa, Ontario Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario Canada
| | - Lauralyn McIntyre
- Department of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
| |
Collapse
|
22
|
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.
Collapse
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.
| |
Collapse
|
23
|
Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ 2019; 365:l1114. [PMID: 31142480 DOI: 10.1136/bmj.l1114] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.
Collapse
Affiliation(s)
- Esra Karslioglu French
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amy C Donihi
- University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Mary T Korytkowski
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
24
|
Abstract
RATIONALE Acute kidney injury is common and correctable in patients with a hyperosmolar hyperglycemic state (HHS). Nevertheless, hyperglycemic crisis may also contribute to the development of rhabdomyolysis, which can worsen renal function and lead to high mortality in such patients. PATIENT CONCERNS Herein, we report a case of hyperosmolar hyperglycemic state-related rhabdomyolysis and acute renal failure with an excellent outcome. DIAGNOSIS A 26-year-old Asian female with underlying paranoid schizophrenia presented with newly diagnosed type 2 diabetes mellitus complicated with HHS. Her renal function deteriorated rapidly in spite of standard management for hyperglycemic crisis. Rhabdomyolysis was subsequently diagnosed according to the high levels of serum creatine kinase (CK) (37,710 U/L, normal range: 20-180 U/L) and myoglobin (5167.7 ng/mL, normal range: 14.3-65.8 ng/mL). INTERVENTIONS After treatment failure of intravenous hydration plus loop diuretic agent for rhabdomyolysis related acute renal failure, temporary hemodialysis was performed 3 times to relieve oligouria and pulmonary edema. OUTCOMES Her renal function recovered well after temporary renal replacement therapy. LESSONS Rhabdomyolysis is a complication of HHS. Delayed detection can be fatal, and timely renal replacement therapy can result in an excellent prognosis. Therefore, it is crucial for clinicians to detect and treat such patients as early as possible to avoid impairing their renal function.
Collapse
Affiliation(s)
- I-Wen Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | | |
Collapse
|
25
|
|
26
|
Baldrighi M, Sainaghi PP, Bellan M, Bartoli E, Castello LM. Hyperglycemic Hyperosmolar State: A Pragmatic Approach to Properly Manage Sodium Derangements. Curr Diabetes Rev 2018; 14:534-541. [PMID: 29557753 PMCID: PMC6237920 DOI: 10.2174/1573399814666180320091451] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/26/2018] [Accepted: 03/13/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Although hypovolemia remains the most relevant problem during acute decompensated diabetes in its clinical manifestations (diabetic ketoacidosis, DKA, and hyperglycemic hyperosmolar state, HHS), the electrolyte derangements caused by the global hydroelectrolytic imbalance usually complicate the clinical picture at presentation and may be worsened by the treatment itself. AIM This review article is focused on the management of dysnatremias during hyperglycemic hyperosmolar state with the aim of providing clinicians a useful tool to early identify the sodium derangement in order to address properly its treatment. DISCUSSION The plasma sodium concentration is modified by most of the therapeutic measures commonly required in such patients and the physician needs to consider these interactions when treating HHS. Moreover, an improper management of plasma sodium concentration (PNa+) and plasma osmolality during treatment has been associated with two rare potentially life-threatening complications (cerebral edema and osmotic demyelination syndrome). Identifying the correct composition of the fluids that need to be infused to restore volume losses is crucial to prevent complications. CONCLUSION A quantitative approach based on the comparison between the measured PNa+ (PNa+ M) and the PNa+ expected in the presence of an exclusive water shift (PNa+ G) may provide more thorough information about the true hydroelectrolytic status of the patient and may therefore, guide the physician in the initial management of HHS. On the basis of data derived from our previous studies, we propose a 7-step algorithm to compute an accurate estimate of PNa+ G.
Collapse
Affiliation(s)
| | | | | | | | - Luigi M. Castello
- Address correspondence to this author at the Department of Translational Medicine, Università del Piemonte Orientale - Via Solaroli 17 28100 Novara, Italy; Tel: +39 0321 373 3097; E-mail:
| |
Collapse
|
27
|
Stoner GD. Hyperosmolar Hyperglycemic State. Am Fam Physician 2017; 96:729-736. [PMID: 29431405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Hyperosmolar hyperglycemic state is a life-threatening emergency manifested by marked elevation of blood glucose and hyperosmolarity with little or no ketosis. Although there are multiple precipitating causes, underlying infections are the most common. Other causes include certain medications, nonadherence to therapy, undiagnosed diabetes mellitus, substance abuse, and coexisting disease. In children and adolescents, hyperosmolar hyperglycemic state is often present when type 2 diabetes is diagnosed. Physical findings include profound dehydration and neurologic symptoms ranging from lethargy to coma. Treatment begins with intensive monitoring of the patient and laboratory values, especially glucose, sodium, and potassium levels. Vigorous correction of dehydration is critical, requiring an average of 9 L of 0.9% saline over 48 hours in adults. After urine output is established, potassium replacement should begin. Once dehydration is partially corrected, adults should receive an initial bolus of 0.1 units of intravenous insulin per kg of body weight, followed by a continuous infusion of 0.1 units per kg per hour (or a continuous infusion of 0.14 units per kg per hour without an initial bolus) until the blood glucose level decreases below 300 mg per dL. In children and adolescents, dehydration should be corrected at a rate of no more than 3 mOsm per hour to avoid cerebral edema. Identification and treatment of underlying and precipitating causes are necessary.
Collapse
Affiliation(s)
- Gregg D Stoner
- University of Illinois College of Medicine, Peoria, IL, USA
| |
Collapse
|
28
|
Hamelin AL, Yan JW, Stiell IG. Emergency Department Management of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State in Adults: National Survey of Attitudes and Practice. Can J Diabetes 2017; 42:229-236. [PMID: 28734951 DOI: 10.1016/j.jcjd.2017.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/11/2017] [Accepted: 05/15/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES In 2013, the Canadian Diabetes Association, now Diabetes Canada, published national clinical practice guidelines for the effective management of diabetic ketoacidosis and hyperosmolar hyperglycemic states in adults. We sought to determine emergency physician compliance rates and attitudes toward these guidelines and to identify potential barriers to their use in Canadian emergency departments. METHODS An online survey consisting of questions related to the awareness and use of the Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada was distributed to 500 randomly selected members of the Canadian Association of Emergency Physicians. Also included in the survey were 3 clinical vignettes to assess adherence rates to the guidelines. RESULTS The survey response rate was 62.2% (311 of 500). The majority of physicians reported the guidelines to be useful (83.6%); 54.6% of respondents were familiar with the guidelines, and 54.7% claimed to use them in clinical practice. The most frequently reported barrier to guideline implementation was a lack of education (56.0%). The clinical vignettes demonstrated respondent variability in fluid administration and sodium bicarbonate administration, as well as some variability in insulin and potassium administration. CONCLUSIONS Although Canadian emergency physicians were generally supportive of the guidelines, many were unaware that these guidelines existed, and barriers to their implementation were reported. These results suggest the need to improve knowledge translation strategies across Canadian emergency departments to standardize management of diabetic ketoacidosis and hyperosmolar hyperglycemic states and support the highest quality of patient care, as well as to ensure that future guidelines include management strategies applicable to the emergency department setting.
Collapse
Affiliation(s)
| | - Justin W Yan
- The Division of Emergency Medicine, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada; Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ian G Stiell
- The University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
29
|
Cho YM, Park BS, Kang MJ. A case report of hyperosmolar hyperglycemic state in a 7-year-old child: An unusual presentation of first appearance of type 1 diabetes mellitus. Medicine (Baltimore) 2017; 96:e7369. [PMID: 28640151 PMCID: PMC5484263 DOI: 10.1097/md.0000000000007369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE A hyperosmolar hyperglycemic state (HHS) is a rare presentation of a hyperglycemic crisis in children with diabetes mellitus. As this condition can be fatal and has high morbidity, early recognition and proper management are necessary for a better outcome. Here, we report a rare case of HHS as the first presentation of type 1 diabetes mellitus (T1DM) in a 7-year-old girl. PATIENT CONCERNS The patient was admitted due to polyuria and weight loss in the past few days. The initial blood glucose level was 1167mg/dL. DIAGNOSES On the basis of clinical manifestations and laboratory results, she was diagnosed with T1DM and HHS. INTERVENTIONS Treatment was started with intravenous fluid and regular insulin. OUTCOMES She was discharged without any complications related to HHS and is being followed up in the outpatient clinic with split insulin therapy. LESSONS As the incidence of T1DM is increasing, emergency physicians and pediatricians should be aware of HHS to make an early diagnosis for appropriate management, as it can be complicated in young children with T1DM.
Collapse
|
30
|
Abstract
PURPOSE OF REVIEW Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are diabetic emergencies that cause high morbidity and mortality. Their treatment differs in the UK and USA. This review delineates the differences in diagnosis and treatment between the two countries. RECENT FINDINGS Large-scale studies to determine optimal management of DKA and HHS are lacking. The diagnosis of DKA is based on disease severity in the USA, which differs from the UK. The diagnosis of HHS in the USA is based on total rather than effective osmolality. Unlike the USA, the UK has separate guidelines for DKA and HHS. Treatment of DKA and HHS also differs with respect to timing of fluid and insulin initiation. There is considerable overlap but important differences between the UK and USA guidelines for the management of DKA and HHS. Further research needs to be done to delineate a unifying diagnostic and treatment protocol.
Collapse
Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK.
- University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK.
| | - Priyathama Vellanki
- Division of Endo, Metabolism & Lipids, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
31
|
Abstract
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events. This article reviews the epidemiology, pathogenesis, diagnosis, and management of hyperglycemic emergencies.
Collapse
Affiliation(s)
- Maya Fayfman
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA
| | - Francisco J Pasquel
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA.
| |
Collapse
|
32
|
Cardoso L, Vicente N, Rodrigues D, Gomes L, Carrilho F. Controversies in the management of hyperglycaemic emergencies in adults with diabetes. Metabolism 2017; 68:43-54. [PMID: 28183452 DOI: 10.1016/j.metabol.2016.11.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/15/2016] [Accepted: 11/22/2016] [Indexed: 01/22/2023]
Abstract
Hyperglycaemic emergencies are associated with significant morbi-mortality and healthcare costs. Management consists on fluid replacement, insulin therapy, and electrolyte correction. However, some areas of patient management remain debatable. In patients without respiratory failure or haemodynamic instability, arterial and venous pH and bicarbonate measurements are comparable. Fluid choice varies upon replenishment phase and patient's condition. If patient is severely hypovolaemic, normal saline solution should be the first option. However, if patient has mild/moderate dehydration, fluid choice must take in consideration sodium concentration. Insulin therapy should be guided by β-hydroxybutyrate normalization and not by blood glucose. Variations of conventional insulin infusion protocols emerged recently. Priming dose of insulin may not be required, and fixed rate insulin infusion represents the best option to suppress hepatic glucose production, ketogenesis, and lipolysis. Concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycaemia. Simpler protocols using subcutaneous rapid-acting insulin analogues for mild/moderate diabetic ketoacidosis treatment have proven to be safe and effective, but further studies are required to confirm these results. Treatment with bicarbonate, phosphate, and low-molecular-weight heparin is still disputable, and randomized controlled trials are urgently needed to optimize patient management and decrease the morbi-mortality of hyperglycaemic emergencies.
Collapse
Affiliation(s)
- Luís Cardoso
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Nuno Vicente
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Dírcea Rodrigues
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Leonor Gomes
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Francisco Carrilho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| |
Collapse
|
33
|
Lee JH, Kim YA, Moon JH, Min SH, Song YS, Choi SH. Expressive aphasia as the manifestation of hyperglycemic crisis in type 2 diabetes. Korean J Intern Med 2016; 31:1187-1190. [PMID: 26968185 PMCID: PMC5094916 DOI: 10.3904/kjim.2014.379] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 06/10/2015] [Accepted: 06/14/2015] [Indexed: 11/27/2022] Open
Affiliation(s)
- Ji Hyun Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ye An Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Joon Ho Moon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Se Hee Min
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Young Shin Song
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Hee Choi
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Correspondence to Sung Hee Choi, M.D. Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: +82-31-787-7033 Fax: +82-31-787-4052 E-mail:
| |
Collapse
|
34
|
Lu CL, Chang HH, Chen HF, Ku LJE, Chang YH, Shen HN, Li CY. Inverse relationship between ambient temperature and admissions for diabetic ketoacidosis and hyperglycemic hyperosmolar state: A 14-year time-series analysis. Environ Int 2016; 94:642-648. [PMID: 27395337 DOI: 10.1016/j.envint.2016.06.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/14/2016] [Accepted: 06/30/2016] [Indexed: 06/06/2023]
Abstract
This study aimed to investigate the association of admissions for diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) with ambient temperature and season, respectively in patients with diabetes mellitus (DM), after excluding known co-morbidities that predispose onset of acute hyperglycemia events. This was a time series correlation analysis based on medical claims of 40,084 and 33,947 episodes of admission for DKA and HHS, respectively over a 14-year period in Taiwan. These episodes were not accompanied by co-morbidities known to trigger incidence of DKA and HHS. Monthly temperature averaged from 19 meteorological stations across Taiwan was correlated with monthly rate of admission for DKA or HHS, respectively, using the 'seasonal Autoregressive Integrated Moving Average' (seasonal ARIMA) regression method. There was an inverse relationship between ambient temperature and rates of admission for DKA (β=-0.035, p<0.001) and HHS (β=-0.016, p<0.001), despite a clear decline in rates of DKA/HHS admission in the second half of the study period. We also noted that winter was significantly associated with increased rates of both DKA (β=0.364, p<0.001) and HHS (β=0.129, p<0.05) admissions, as compared with summer. On the other hand, fall was associated with a significantly lower rate of HHS admission (β=-0.016, p<0.05). Further stratified analyses according to sex and age yield essentially similar results. It is suggested that meteorological data can be used to raise the awareness of acute hyperglycemic complication risk for both patients with diabetes and clinicians to further avoid the occurrence of DKA and HHS.
Collapse
Affiliation(s)
- Chin-Li Lu
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsin-Hui Chang
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hua-Fen Chen
- Department of Endocrinology, Far Eastern Memorial Hospital, New Taipei City, Taiwan; School of Medicine, Fujen Catholic University, New Taipei City, Taiwan
| | - Li-Jung Elizabeth Ku
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya-Hui Chang
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsiu-Nien Shen
- Department of Intensive Care Medicine, Chi Mei Medical Center, Yong-Kang District, Tainan, Taiwan.
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
| |
Collapse
|
35
|
Sanada J, Kimura T, Kaneto H. [Endocrine and Metabolic Emergencies; Points of Initial Management. Topics: VIII. Hyperglycemic emergencies]. Nihon Naika Gakkai Zasshi 2016; 105:690-697. [PMID: 27491263 DOI: 10.2169/naika.105.690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
|
36
|
Yasuda T. [Hyperglycemic hyperosmolar state]. Nihon Rinsho 2016; 74 Suppl 2:92-96. [PMID: 27266068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
|
37
|
Abstract
Diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS) and hypoglycaemia are serious complications of diabetes mellitus that require prompt recognition, diagnosis and treatment. DKA and HHS are characterized by insulinopaenia and severe hyperglycaemia; clinically, these two conditions differ only by the degree of dehydration and the severity of metabolic acidosis. The overall mortality recorded among children and adults with DKA is <1%. Mortality among patients with HHS is ~10-fold higher than that associated with DKA. The prognosis and outcome of patients with DKA or HHS are determined by the severity of dehydration, the presence of comorbidities and age >60 years. The estimated annual cost of hospital treatment for patients experiencing hyperglycaemic crises in the USA exceeds US$2 billion. Hypoglycaemia is a frequent and serious adverse effect of antidiabetic therapy that is associated with both immediate and delayed adverse clinical outcomes, as well as increased economic costs. Inpatients who develop hypoglycaemia are likely to experience a long duration of hospital stay and increased mortality. This Review describes the clinical presentation, precipitating causes, diagnosis and acute management of these diabetic emergencies, including a discussion of practical strategies for their prevention.
Collapse
Affiliation(s)
- Guillermo Umpierrez
- Division of Endocrinology and Metabolism, Emory University School of Medicine, 49 Jesse Hill Jr Drive, Atlanta, Georgia 30303, USA
| | - Mary Korytkowski
- Division of Endocrinology and Metabolism, University of Pittsburgh, 3601 Fifth Avenue, Suite 560, Pittsburgh, Pennsylvania 15213, USA
| |
Collapse
|
38
|
Abstract
The management of diabetes in older people is often challenging and poorly researched. The prevalence of cognitive impairment, chronic kidney disease and other co-existing comorbidities increase with age and have a significant impact on glycaemic control targets and treatment options. This conference examined current clinical practice, highlighted differences in the management of diabetes in the older person and suggested potential areas of future research.
Collapse
|
39
|
Abstract
An 84-year-old lady was treated for hyperosmolar hyperglycaemia with IV insulin, fluids and catheterisation for fluid balance monitoring. Trial without catheter failed as the patient complained of new-onset urinary incontinence and lack of awareness of bladder filling. In light of her breast cancer history, we excluded cauda equina. Ultrasound KUB showed an enlarged bladder. Whole-body MRI revealed a lesion in the pons which was highly suggestive of central pontine myelinolysis (CPM). Her electrolytes were normal throughout her admission; thus, the rapid fluctuation in osmolality, secondary to her hyperglycaemic state, was the likely cause of CPM. CPM has been reported secondary to hyperglycaemia; however, this is the first reported case of CPM presenting as urinary incontinence and loss of bladder sensation.
Collapse
|
40
|
Schneider S. [Letter to the editor article "hyperglycaemic crisis in patients with diabetes mellitus". reply]. Med Klin Intensivmed Notfmed 2013; 108:520. [PMID: 24175341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
|
41
|
Jensen K, Steinthorsdottir KJ, Brandt B. [In-hospital cardiac arrest due to unobserved steroid-induced hyperglycaemic hyperosmolar syndrome]. Ugeskr Laeger 2013; 175:1044-1045. [PMID: 23582128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The merging of hospital wards into highly specialized units facilitates targeted diagnostics and treatment. Often the result is favourable for the patient, but in some cases the basic conditions are overlooked. We describe a patient with inoperable oesophageal cancer who had unexplained mental confusion for three days due to an unobserved corticosteroid-induced hyperglycaemic hyperosmolar syndrome. The main differential diagnosis was cerebral metastases and a cerebral computed tomography was performed before cardiac arrest led to the right diagnosis. It is crucial to remember that unexplained deterioration in a patient with inoperable cancer can have a reversible cause.
Collapse
Affiliation(s)
- Katrine Jensen
- Thoraxkirurgisk Afdeling RT 2152, Rigshospitalet, Blegdamsvej 9, 2100 København Ø, Denmark.
| | | | | |
Collapse
|
42
|
Mul D, Meijer CR. [Hyperglycaemic crises in children and adolescents]. Ned Tijdschr Geneeskd 2013; 157:A5185. [PMID: 24326136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Recently the Paediatric Association of the Netherlands (NVK) published a new guideline on the treatment of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar syndrome (HHS) in children and adolescents. DKA comprises hyperglycaemia, ketosis and acidosis. Cerebral oedema is a feared, life-threatening complication of DKA. HHS is characterized by hyperglycaemia, hyperosmolarity, severe dehydration, and little or no ketone production. Multi-organ failure, rhabdomyolysis and thrombosis are the most common complications. The NVK guideline distinguishes between treatment of DKA and treatment of HHS, in contrast with the draft version of the Netherlands Association of Internal Medicine guideline on diabetes. To prevent cerebral oedema in children with DKA, it is necessary that both rehydration and metabolic correction are done slowly and carefully. Use of hypotonic fluids is not recommended. Correction of hyperglycaemia is of secondary importance and insulin should be started at a low dosage. Correction of intravascular hypovolaemia is the most important treatment in children with HHS. If adequate fluid replacement does not cause serum glucose levels to drop sufficiently, then administration of insulin should be considered. Fluid replacement is the initial treatment of HHS. Insulin administration should be considered when serum glucose concentrations are no longer declining adequately with fluid administration alone.
Collapse
Affiliation(s)
- Dick Mul
- Haga Ziekenhuis, locatie Juliana Kinderziekenhuis, afd. Kindergeneeskunde, Den Haag
| | | |
Collapse
|
43
|
Garcia-Pascual MDC, Kidby J. Procedures and medications to help patients control their diabetes. Emerg Nurse 2012; 20:30-35. [PMID: 23488070 DOI: 10.7748/en2012.12.20.8.30.c9481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Two of the most common acute and potentially life-threatening complications of diabetes mellitus are diabetic ketoacidosis and hyperosmolar hyperglycaemic state. Both conditions are characterised by hyperglycaemic states, but nurses should be aware of important differences so the correct condition and treatment can be identified. Treatment includes immediate referral to specialist diabetes teams and possible transfer to intensive care. This article outlines the similarities and differences in the symptoms and treatment of the conditions, and discusses prevention strategies.
Collapse
|
44
|
Blouin D. Too much of a good thing: Part 2: Management of hyperosmolar hyperglycemic syndrome. Can Fam Physician 2012; 58:1099-100. [PMID: 23064920 PMCID: PMC3470508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Danielle Blouin
- Department of Emergency Medicine, Queen's University, Kingston, Ontario
| |
Collapse
|
45
|
|
46
|
Fadini GP, de Kreutzenberg SV, Rigato M, Brocco S, Marchesan M, Tiengo A, Avogaro A. Characteristics and outcomes of the hyperglycemic hyperosmolar non-ketotic syndrome in a cohort of 51 consecutive cases at a single center. Diabetes Res Clin Pract 2011; 94:172-9. [PMID: 21752485 DOI: 10.1016/j.diabres.2011.06.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 06/13/2011] [Accepted: 06/14/2011] [Indexed: 10/18/2022]
Abstract
AIMS The hyperglycemic hyperosmolar syndrome (HHS) is a life-threatening diabetic complication. We aimed to portrait the short and long term outcome after a HHS episode and to describe features associated with increased early mortality. METHODS We collected data from consecutive HHS cases, defined based on rigorous glucose and osmolality criteria. We retrieved anthropometric measures, history of diabetes, other cardiovascular risk factors and chronic co-morbidity. Clinical and biochemical parameters were recorded at admission, after 24h and at discharge. We assessed incidence of complications, as well as short (≤ 30 days) and long term mortality. RESULTS Patients were about 80-year old. Fifty-one cases were included, characterized by severe hyperglycemia (55.5 mosm/L) and hyperosmolality (385 mosm/L). Thirty-three percent developed at least one complication. Short term mortality was 16%; lower Glasgow Coma Scale, higher plasma glucose and mild acidosis were predictive of short term mortality. The long term mortality (median follow-up 1.27 years) was not significantly different from historical mortality data after hypoglycemic coma. CONCLUSION In this study, early mortality of HHS was 16% and some clinical features at presentation were predictive of an adverse short term outcome. Long term survival after a HHS episode did not appear to be severely impaired.
Collapse
Affiliation(s)
- Gian Paolo Fadini
- Division of Metabolic Diseases, Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy.
| | | | | | | | | | | | | |
Collapse
|
47
|
Abstract
This article is aimed at providing a practical up-to-date review of the precipitating factors, diagnosis, management and secondary prevention of hyperglycemic emergencies (diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) to assist critical care physicians and hospitalists caring for these patients. Limitations of various guidelines include implementation in settings with an infrastructure different from that specified in the guidelines of a respective country, state, region or community. Appropriate individualized acute management of these conditions typically results in satisfactory clinical outcomes and may decrease the mortality rate from up to 20% in type 2 diabetics with hyperglycemic hyperosmolar state vs less than 2% in patients with DKA. DKA may be the first manifestation of type 1 diabetes and can also occur in type 2 diabetics depending on the state of insulin sufficiency/secretion. For type 1 diabetics, the transition period from adolescence to adulthood is particularly critical to prevent repetitive hospital admissions. Hyperglycemic emergencies are usually preventable but do depend on patient compliance and adherence as well as medical infrastructure. Patients of all ages should be both appropriately educated and assured continuous access to health care to prevent recurrences of these conditions.
Collapse
Affiliation(s)
- Niyutchai Chaithongdi
- Division of Endocrinology, Department of Medicine, University of Mississippi School of Medicine, Jackson, MS 39216, USA.
| | | | | | | |
Collapse
|
48
|
Tabenor E, Crouch R. Getting to the cause of a fall - An unusual case. Int Emerg Nurs 2011; 19:58-9. [PMID: 21193169 DOI: 10.1016/j.ienj.2010.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 02/03/2010] [Accepted: 02/11/2010] [Indexed: 11/18/2022]
Affiliation(s)
- Emma Tabenor
- Emergency Department, Southampton University Hospitals NHS Trust, United Kingdom
| | | |
Collapse
|
49
|
Stunkard ME, Pikul VT, Foley K. Hyperosmolar hyperglycemic syndrome with rhabdomyolysis. Clin Lab Sci 2011; 24:8-13. [PMID: 21404958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In this report we describe a patient who presented with nausea, vomiting, diarrhea, tachypnea and mental impairment. The patient had elevated serum lipase, troponin-I, creatinine kinase and myoglobin along with severe hyperglycemia (> 2000 mg/dl) and no ketouria. This patient was found to have nonketotic hyperosmolar hyperglycemia with concomitant rhabdomyolysis and myocardial infarction.
Collapse
Affiliation(s)
- Mary E Stunkard
- Department of Clinical Sciences, Northern Michigan University, Marquette, MI 49855, USA.
| | | | | |
Collapse
|
50
|
Prowle JR. A complicated hyperglycaemic emergency. Clin Med (Lond) 2010; 10:641-2. [PMID: 21416674 PMCID: PMC4951889 DOI: 10.7861/clinmedicine.10-6-641a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|