Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) are two serious acute complications of diabetes that require immediate medical attention. Patients with DKA present with hyperglycemia, ketonemia, and anion gap metabolic acidosis.
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Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome Beatrice C. Lupsa and Silvio E. Inzucchi
Précis 1. Clinical setting—Any altered state of well being in the context of significant hyperglycemia in a patient with type 1 (DKA) or advanced type 2 diabetes mellitus (DKA or HHS), particularly during acute illness, may signify one of these diabetic emergencies. 2. Diagnosis (a) History: Most patients with diabetic ketoacidosis (DKA) or with hyperosmolar hyperglycemic state (HHS) will have a history of diabetes, and a history of altered insulin dose, infection, significant medical “stress”. Antecedent symptoms of polyuria and polydipsia, lassitude, blurred vision, and mental status changes may predominate the clinical picture. With DKA, abdominal pain and tachypnea are often present. (b) Physical examination usually reveals an altered sensorium, signs of volume contraction/dehydration (tachycardia, hypotension, dry mucus membranes, “tenting” of the skin); in DKA, the odor of acetone in the breath. (c) Laboratory evaluation. The diagnostic criteria for DKA include blood glucose above 250 mg/dL, arterial pH < 7.30, serum bicarbonate < 15 mEq/l
B.C. Lupsa, M.D. (*) • S.E. Inzucchi, M.D. Section of Endocrinology, Yale University School of Medicine, Yale-New Haven Hospital, 333 Cedar Street, FMP 107, P.O. Box 208020, New Haven, CT 06520, USA e-mail: [email protected]
L. Loriaux (ed.), Endocrine Emergencies: Recognition and Treatment, Contemporary Endocrinology 74, DOI 10.1007/978-1-62703-697-9_2, © Springer Science+Business Media New York 2014
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B.C. Lupsa and S.E. Inzucchi
and moderate degree of ketonemia and/or ketonuria. Patients with HHS present with extreme hyperglycemia (blood glucose > 600 mg/dL), increased osmolality (> 320 mOsm/kg) and profound dehydration/volume contraction. The laboratory evaluation of a patient with hyperglycemic emergency should include measurement of blood glucose and hemoglobin A1c, arterial blood gases, serum electrolytes, ketones and osmolality, renal function and urinalysis. A work up for sepsis or other precipitating causes should be initiated if indicated. 3. Treatment (a) DKA 1. Fluid: Estimated fluid deficit is 5–7 liters. Correct with normal saline, 2L in the first 2 hours, the remainder over the next 22 hours. 2. Insulin: IV bolus of 0.1 U/Kg regular insulin followed by an intravenous infusion of 0.1 U/kg/h. Goal is to reduce plasma glucose by 50–75 mg/dL/h. Initial target plasma glucose is 200–250 mg/dL. Once achieved, reduce insulin rate and provide dextrose to ‘clamp’ the plasma glucose until acidosis/anion gap resolved. 3. Acid/base – pH will climb with plasma expansion and insulin administration. Use small amounts of sodium bicarbonate only for severe acidemia (pH 250 >250 (mg/dL) Arterial pH 7.25–7.30 7.00–7.24 12 Anion gapc Mental status Alert Alert/drowsy Stupor/coma a Nitroprusside reaction method b Calculation: 2 [measured Na (mEq/L)] + glucose (mg/dL)/18 c Calculation: Na− − (Cl− + HCO3−), in mEq/L
HHS >600 >7.30 >18 None — small None — small >3
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