Symptoms of hyperglycemia develop slowly over several days or weeks. Patients with dka or hhs present with hyperglycemia and dehydration and frequently appear quite ill physically. Hyperglycemic crises in cancer patients american diabetes. Diabetic ketoacidosis dka and hyperglycemic hyperosmolar state hhs are diabetic emergencies that cause high morbidity and mortality.
The discovery of insulin in 1921 changed the life expectancy of patients with diabetes. Hyperglycemic crises in diabetes university of kansas. Diabetic ketoacidosis and the hyperosmolar hyperglycemic state are the most serious acute metabolic complications of diabetes. Treatment of diabetic ketoacidosis dkahyperglycemic hyperosmolar state hhs. Increasing evidence indicates that the hyperglycemia in patients with hyperglycemic crises is associated with a. There was a decline in mortality from 2000 to 2014 across all age groups and both sexes with largest absolute decrease among persons aged. Occurs most commonly in older patients with type 2 diabetes.
It can also occur in patients with other types of diabetes. Hyperosmolar hyperglycemic state american family physician. Evidencebased management of hyperglycemic emergencies in. Hyperglycemia doesnt cause symptoms until glucose values are significantly elevated usually above 180 to 200 milligrams per deciliter mgdl, or 10 to 11 millimoles per liter mmoll. Acute interventions are required to manage hypovolemia, acidemia, hyperglycemia, electrolyte abnormalities, and precipitating causes. Treatment of diabetic ketoacidosis dka hyperglycemic hyperosmolar state hhs. Table 1 comparison of diabetic ketoacidosis to hyperosmolar hyperglycemic state variables diabetic. Hyperglycemic crises in urban blacks jama internal medicine. Geraci3 1division of endocrinology, department of medicine, university of mississippi school of medicine. The most common trigger for a hyperglycemic crisis is an infection, such as strep throat, pneumonia, an infected foot ulcer, an intestinal virus, or a urinary tract infection.
Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Mental status and ph and serum bicarbonate levels help clinicians determine the extent of disease severity, classifying patients as having mild, moderate, or severe dka table 4. About 10% of patients with type 1 diabetes treated with. In 2010, among adults aged 20 years or older, hyperglycemic crisis caused 2,361 deaths. Typically, dka presents in type i diabetics while hhs presents in type ii diabetics.
Diabetic ketoacidosis and the hyperglycemic hyperosmolar state are potentially fatal hy perglycemic crises that occur as acute complications of uncontrolled diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome management emergency medicine. Hyperglycemia in diabetes symptoms and causes mayo clinic. In their consensus statement on hyperglycemic crises in adult patients with diabetes, kitabchi et al.
Table 1 outlines the diagnostic criteria for dka and hhs. Hyperglycemia polyuria,polydipsia, weakness ecfvcontraction acidosis airhunger,nausea, vomitingandabdominal pain alteredsensorium kussmaulrespiration, acetoneodouredbreath alteredsensorium precipitating condition seelistofconditionsintable2 canjdiabetes422018s109s114 contents lists available at sciencedirect canadianjournalofdiabetes. Diabetic ketoacidosis dka and hyperglycemic hyperosmolar state hhs are. Diagnosis and management of hyperglycemic emergencies niyutchai chaithongdi 1, jose s. Overview of the diabetic ketoacidosis dka hyperglycemic. Thirty years of personal experience in hyperglycemic crises. Guidelines and position statements from medical organisations are widely used by clinicians to guide the care of their patients. Umpierrez and others published hyperglycemic crises. The mortality rate from dka in children ranges from 0. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome hhs are life threatening complications that occur in patients with diabetes.
Criteria for resolution of ketoacidosis include a blood glucose hyperglycemia, and electrolyte abnormalities table 5. May 17, 2015 hyperglycaemic hyperosmolar state hhs is a medical emergency, which differs from diabetic ketoacidosis dka and requires a different approach. The incidence of dka and the economic burden of its treatment continue to rise, but its associated mortality rate which was uniformly high has diminished remarkably over the. Pdf hyperglycemic crises and their complications in children. Hyperosmolar hyperglycemic state criteria bmj best practice.
For the pediatric patient who presents with a hyperglycemic crisis, the following aspects of. Hyperglycemic crises in adult patients with diabetes diabetes care 2009 jul. Jul 31, 2011 a lecture on the recognition, pathogenesis, and treatment of diabetic ketoacidosis and the hyperosmolar hyperglycemic state. Hyperglycemic crises in adult patients with diabetes. Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management is key to the successful resolution of dka and hhs. Pdf overview of cerebral edema during correction of. Novel advances in the management of hyperglycemic crises uk versus usa ketan k. Ketoacidosis and hyperosmolar hyperglycemia are the two most serious acute metabolic complications of diabetes, even if managed properly. Lasting mortality risk increase with hyperglycemic crises.
Hyperglycemic emergencies in adults diabetes guidelines. Hhs are the two most serious acute metabolic complications of diabetes. Guidelines for management of diabetic ketoacidosis. Geraci 3 1 division of endocrinology, department of medicine, university of mississippi school of medicine. This practice improvement project was formulated to determine accuracy rate in differentiating between two hyperglycemic crises diabetes ketoacidosis dka and hyperosmolar hyperglycemic nonketotic syndrome hhnks in a clinical population of individuals who manifested hyperglycemia and diabetes mellitus dm. National data shows a decline in death related to both hyperglycemic crises. The longer blood sugar levels stay high, the more serious the symptoms become. The hyperglycemic emergencies, diabetic ketoacidosis dka and hyperglycemic hyperosmolar state hhs are potentially fatal complications of uncontrolled diabetes mellitus. It has been shown that hyperglycemic emergencies predispose to inflammatory and procoagulant states.
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. They are found to occur simultaneously in up to of cases overlap syndrome of hyperosmolar ketoacidosis. For the diagnosis of ketoacidosis, the ada guidelines. The mortality rate in patients with diabetic ketoacidosis dka is hyperglycemic state hhs still remains high. Diabetic ketoacidosis dka and the hyperosmolar hyperglycemic state hhs are the two most serious acute metabolic complications of diabetes. Hyperglycemic crisis is a metabolic emergency associated with uncontrolled diabetes mellitus that may result in significant morbidity or death. Treatment of diabetic ketoacidosis dkahyperglycemic. Diabetic ketoacidosis dka and the hyperosmolar hyperglycemic state. The mortality rate from hhs is significantly higher than for dka. The authors report no actual or potential conflict of interest in relation to this article. Risk factors for hyperglycemic crisis ushersmith et al. Treatment of hyperglycemic crises is complex, typically involves use of highrisk medications such as intravenous iv insulin, and is commonly complicated by hypoglycemia 1, 2.
Hyperglcemic crises hyperglycemia medical specialties. Diabetic ketoacidosis dka and hyperosmolar hyperglycemic state hhs, also known as hyperosmotic hyperglycemic nonketotic state hhnk are two of the most serious acute complications of diabetes. In both syndromes, there is insufficient insulin levels to transport. Dka is responsible for more than 500,000 hospital days per year 1,2 at an estimated annual direct medical expense and indirect cost of 2. Hyperglycemic crises often require critical care management and are associated with signi. This article is published with open access at abstract. Increasing evidence indicates that the hyperglycemia in patients with hyperglycemic crises is associated with a severe inflammatory state characterized by an elevation of proinflammatory cytokines tumor necrosis factor.
Fisher, md 1 d iabetic ketoacidosis dka and the hyperosmolar hyperglycemic state hhsarethetwomostseriousacute. 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. The mortality rate for dka and hyperglycemic crises has been falling over the years figure 1b. Mar 31, 2017 guidelines and position statements from medical organisations are widely used by clinicians to guide the care of their patients. Diabetic ketoacidosis dka and hyperglycemic hyperosmolar state hhs are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. A persons breath may develop a specific fruity smell. Contributes to less than 1% of all diabetesrelated admissions. Use of the va and stanford namelogos is only to indicate my academic. Correction of hypertonicity constitutes one of the main aims and challenges of managing hyperglycemic crises. Joint british diabetes jbds societies inpatient care group. Solutes distributed in total body water, such as urea, ethanol, methanol, or propyl alcohol, increase osmolality but do not. They are part of the spectrum of hyperglycemia, and each represents an extreme in the spectrum.
Patients with dka and hhs should be treated with continuous intravenous insulin until the hyperglycemic crisis is resolved. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Iv fluid resuscitation, iv insulin, and iv potassium. A lecture on the recognition, pathogenesis, and treatment of diabetic ketoacidosis and the hyperosmolar hyperglycemic state. Dka is more common in young people with type 1 diabetes and hhs in adult and elderly patients with type 2 diabetes. Overview of cerebral edema during correction of hyperglycemic crises article pdf available in american journal of case reports 19. Jul 31, 2011 a lecture on the recognition, pathogenesis, and management of diabetic ketoacidosis and the hyperosmolar hyperglycemic state. Critical components of the hyperglycemic crises management include coordinating fluid. A lecture on the recognition, pathogenesis, and management of diabetic ketoacidosis and the hyperosmolar hyperglycemic state. The hospital admission and mortality rates of patients with diabetic emergencies, such as diabetic ketoacidosis dka and hyperglycemic hyperosmolar nonketotic syndrome hhns, are higher in black patients than in white patients with diabetes. In 2010, among adults aged 20 years or older, hyperglycemic crisis caused 2,361 deaths in the u. Pdf management of hyperglycemic crises in patients with diabetes. Jul 11, 2016 severe hyperglycemic conditions, known as diabetic ketoacidosis dka and hyperosmolar hyperglycemic state hhs, involve very serious imbalances in blood chemistry and usually require that a person be hospitalized until normal blood chemistry is restored.
Diabetic ketoacidosis and hyperglycemic hyperosmolar state asped. Hyperglycemic crises often require critical care management and are associated with significant health care costs, morbidity, and mortality. The terms hyperglycemic hyperosmolar nonketotic coma and hyperglycemic hyperosmolar nonketotic state have been replaced with the term hyperglycemic hyperosmolar state hhs to reflect the. Management of hyperosmolar hyperglycaemic state in adults. Three of the five therapies to manage dka and hhs are mandatory. Glucose level intervention recheck glucose decreased by 250 mgdl double infusion rate 1 hour post change decreased by 50100 mgdl and remains 250 mgdl. Diabetic ketoacidosis dka and hyperosmolar hyperglycemic state hhs are diabetes. Diabetic ketoacidosis and hyperglycemic hyperosmolar. Hyperglycemic crises in diabetes american diabetes association k etoacidosis and hyperosmolar hyperglycemia are the two most serious acute metabolic complications of diabetes, even if managed properly. Largescale studies to determine optimal management of dka and hhs are lacking. Research design and methods we analyzed data from 1 january 2006 through 30 september 2015 from the nationwide emergency department sample and. Diabetic ketoacidosis dka is a common, serious, and preventable complication of type 1 diabetes, with a mortality of 35%. Hyperglcemic crises free download as powerpoint presentation.
Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome. Serum sodium concentration and tonicity in hyperglycemic. Novel advances in the management of hyperglycemic crises uk versus usa. May 17, 2018 diabetic ketoacidosis dka and hyperglycemic hyperosmolar state hhs are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. Diabetic ketoacidosis dka and hyperglycemic hyperosmolar state hhs cause major morbidity and significant mortality in patients with diabetes mellitus. Serum hypertonicity as an exclusive consequence of development of hyperglycemia. Hyperglycemic crises in adult patients with diabetes abbas e. The 2009 american diabetes association ada position statement on hyperglycaemic emergencies in adult patients with diabetes details the management of diabetic ketoacidosis dka and hyperosmolar hyperglycaemia state. Diagnosis and management of hyperglycemic emergencies niyutchai chaithongdi1, jose s.
Thrombotic conditions such as disseminated intravascular coagulation contribute to the morbidity and mortality in hyperglycemic crises. Diabetic ketoacidosis dka and hyperosmolar hyperglycemic state hhs are similar but distinct diabetic emergencies that are frequently encountered in the ed. Mar 31, 2017 diabetic ketoacidosis dka and hyperglycemic hyperosmolar state hhs are diabetic emergencies that cause high morbidity and mortality. Diabetic ketoacidosis dka is a potentially lifethreatening complication of diabetes mellitus. Pdf hyperglycemic crises in adult patients with diabetes. Other triggers include stroke, heart attack, trauma, alcohol abuse, certain drugs such as corticosteroids and certain blood pressure medicines, and the skipping or. Hyperosmolar hyperglycemic state is a relatively common, lifethreatening endocrine emergency that is reported in all age groups,1 but it most frequently affects older patients with type 2 diabetes. Because they can occur in anyone with diabetes, everyone should know what causes them. Trends in emergency department visits and inpatient. Severe symptomatic hypophosphatemia with thrombocytopenia in a child with diabetic ketoacidosis. Diabetic ketoacidosis and hyperosmolar hyperglycemic.
Diabetic ketoacidosis dka and hyperglycemic hyperosmolar state hhs are the most serious and lifethreatening hyperglycemic emergencies in diabetes. Hyperglycemic crises in adult patients with diabetes ncbi. Hyperosmolar hyperglycemic state is a lifethreatening emergency manifested by. Management of hyperglycemic crises medical clinics. Hyperglycemic crisis diabetic ketoacidosis and hyperosmotic hyperglycemic nonketotic state daniel j hellrung do phd daniel. There were 1,211 patients who had a first admission with confirmed hyperglycemic crises criteria, 465 38% had isolated dka, 421 35% had isolated hhs, and 325 27% had combined. The present article summarizes the recent guidance on. These disorders can occur in both type 1 and type 2 diabetes. The mortality rate in patients with diabetic ketoacidosis dka. Expedited diagnosis and management of inpatient hyperosmolar. Hyperglycemic crises in adult patients with diabetes diabetes care. Hyperglycemic crises and their complications in children. Mortality of hyperglycemic crisis dka is the most common cause of death in children and adolescents with type 1 diabetes.
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