Med Clin North Am. May;(3) doi: / Management of Hyperglycemic Crises: Diabetic Ketoacidosis and. For the diagnosis of ketoacidosis, the ADA guidelines recommend that .. Hyperglycemic crises in adult patients with diabetes. Diabetes. Introduction. Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic nal crisis, trauma and, possibly, continuous subcutaneous insulin infusion (CSII).
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An electrocardiogram, hyperglycwmic X-ray, and urine, sputum, or blood cultures should also be obtained. The UK guideline also incorporates the new evidence to show that the continued use of long-acting basal insulin helps to prevent the rebound hyperglycemia seen when the intravenous insulin is stopped [ 31 ].
Hyperglycemia The hyperglycemia in DKA is the result of three events: This is an important point as persistent decrease in plasma HCO3- concentration should not be interpreted as a sign of continuous DKA if ketosis and hyperglycemia are resolving.
Manitol infusion and mechanical ventilation are suggested for treatment of cerebral edema There are several potential implications of these differences. The pathogenesis of HHS is not as well understood as that of DKA, but a greater degree of dehydration due to osmotic diuresis and differences in insulin availability distinguish it from DKA 4 The Journal of pediatrics ; Potassium Despite total-body potassium depletion, mild-to-moderate hyperkalemia is common in patients with hyperglycemic crises.
Crit Care Med ; Am J Med ; Clin Endocrinol Metab ; The concept of low-dose intravenous insulin was established in the late s and early s by teams on both sides of the Atlantic. Accumulation of ketoacids results in an increased anion gap metabolic acidosis.
Studies on serum osmolality and mental alteration have established a positive linear relationship between osmolality and ava obtundation 9 Hhyperglycemic cerebral oedema does not occur regularly during treatment for diabetic ketoacidosis.
The need of such a method, when using intravenous infusion of insulin, is not clear, as there is no prospective randomized study to establish efficacy of bolus or priming dose before infusion of insulin. Other pitfalls include artificial elevation of serum creatinine due to interference from ketone bodies when a colorimetric method is used Cerebral edema, a frequently fatal complication of DKA, occurs in 0. FFA, free fatty acid. A follow up study demonstrated that a priming or loading dose given uyperglycemic one half by IV route and another half by intramuscular route was as effective as one dose given intravenously in lowering the level of ketone bodies in the first hour Insulin secretion in diabetes mellitus.
Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State.
Patients with known diabetes may be given insulin at the dosage they were receiving before the onset of DKA so long as it was controlling glucose properly. Rarely, DKA patients may present with significant hypokalemia.
Not all patients with ketoacidosis have DKA. The UK championed the use of insulin infusions of between 1. For example, DKA patients with concomitant fever or sepsis may have additional respiratory alkalosis manifesting by lower than expected PCO2.
This is included to recognize that DKA may be partially treated prior to presentation at the hospital.
Hyperglycemic Crises in Adult Patients With Diabetes
Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors. The differences in the guidelines are with choice of fluid with respect to sodium concentrations and timing of insulin initiation.
Significant resources are spent on the cost of hospitalization. UK Aa The UK guideline recommends adjustment of insulin infusion depending on the rate of fall of glucose 3. An increasing number of DKA cases without precipitating cause have been reported in children, adolescents, and adult subjects with type 2 diabetes.
Criwes recent report states that active cocaine use is an independent risk factor for recurrent DKA Neurologic manifestations of diabetic comas: Further areas of research also include prospective trial of whether different hyperglycrmic of DKA require different treatments and whether this affects outcomes. An electrocardiogram, blood, urine or sputum cultures and chest X-ray should also be performed, if indicated. The process of HHS usually evolves over several days to weeks, whereas the evolution of the acute DKA episode rcises type 1 diabetes or even in type 2 diabetes tends to be much shorter.
Prior to the discovery and isolation of insulin in by Banting and Best, type 1 diabetes was universally fatal within a few months of initial diagnosis.
Both guidelines recommend careful monitoring of serum osmolality in order to avoid complications of rapid overcorrection.