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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Br Med J ; 3: The rate of insulin discontinuation and a history of poor compliance accounts for more than half of DKA admissions in inner-city and minority populations 974 Several cultural and socioeconomic barriers, such as low literacy rate, limited financial resources, and limited access to health care, in medically indigent patients may explain the lack of compliance and why DKA continues to occur in such high rates in inner-city patients.

The rate of decline of blood glucose concentration and the mean duration of treatment until correction of ketoacidosis were similar among patients treated with subcutaneous insulin analogs every 1 or 2 h or with intravenous regular insulin.

Ketosis-prone type 2 diabetes in patients of sub-Saharan African origin: Both documents agree that the primary treatment should be fluid replacement and that the initial fluid replacement of choice is 0.

Hyperglycemic Crises in Adult Patients With Diabetes

The cause of cerebral edema is not known with certainty. The hyperglycemia in DKA is the result of three events: Cerebral oedema during treatment of diabetic ketoacidosis: FFA, free fatty acid.

Ann Emerg Med ; Intern Med ; Therefore, in the presence of acidosis, DKA as an etiology of abdominal pain should be considered. Again, these agents may not be effective in patients with severe fluid depletion since they are given subcutaneously. The anion gap is calculated by subtracting the sum of chloride and bicarbonate concentration from the sodium concentration: To assess the severity of sodium and water deficit, serum sodium may be corrected by adding 1.


Diabet Med ; Other provoking factors include myocardial infarction, cerebrovascular accidents, pulmonary embolism, pancreatitis, alcohol and illicit drug use Table 1. The reasons for dividing DKA presentation into different levels of severity are multifactorial. Vomiting is a common clinical manifestation in DKA and leads to a loss of hydrogen ions in jyperglycemic content and the development of metabolic alkalosis.

A prospective comparison of alkaline picrate methods with an enzymatic method.

Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State.

Severe hypothermia, if present, is a poor prognostic sign Total body sodium loss can result in contraction of extracellular fluid volume and signs of intravascular volume depletion. Diabetes care ; 3: Phosphate Cruses There is no evidence hypfrglycemic phosphate therapy is necessary in treatment for better outcome of DKA The unique distinguishing factor in HHS is the absence of ketones or a low ketone production despite an insulinopenic state.

Diabetic ketoacidosis DKA and hyperglycemic hyperosmolar state HHS are diabetic emergencies cirses cause high morbidity and mortality. Characteristics and outcomes of the hyperglycemic hyperosmolar non-ketotic syndrome in a cohort of 51 consecutive cases at a single center.

Determinants of plasma potassium levels in diabetic ketoacidosis. Hyperglycemic Emergencies in Adults. These ketone bodies have been shown to affect vascular integrity and permeability, leading to edema formation Intracerebral crises during treatment of diabetic ketoacidosis.

US Perspective Because of its ability to pass freely across plasma membranes, the ADA guidelines recommend calculation of serum osmolality without the inclusion of blood urea nitrogen. Hyperosmolar nature of diabetic coma. In patients with chronic kidney disease stagethe diagnosis of DKA could be challenging due to the presence of concomitant underlying chronic metabolic acidosis or mixed acid-base disorders.

Hypoxemia may be related to the reduction in colloid osmotic pressure that leads to accumulation of water in lungs and decreased lung compliance. Agreement between arterial and central venous values for pH, bicarbonate, base excess, and lactate. N Engl J Med ; Diabetes Rev ; 2: The most recent data demonstrating a significant increase in DKA hospitalization rates in diabetic persons aged 45 years and younger 4 suggests that this group of patients may require particular attention to understand why they are more vulnerable than others to develop hyperglycemic crisis.


Close follow up is very important, as it has been shown that three-monthly visits to the endocrine clinic will reduce the number of ER admission for DKA Both statements recommend the assessment of severity at presentation.

Hyperchloremic acidosis during the recovery phase of diabetic ketosis. Ketogenesis Excess catecholamines coupled with insulinopenia promote triglyceride breakdown lipolysis to free fatty acids FFA and glycerol.

There were no differences in length of hospital stay, total amount of insulin needed for resolution of hyperglycemia or crides, or in the incidence of hypoglycemia among treatment groups.

Mannitol infusion and mechanical ventilation are used to combat cerebral edema. Occasionally, patients with HHS may present with focal neurological deficit and seizures 72 Manitol infusion and mechanical ventilation are suggested for treatment of cerebral edema Pediatr Diabetes ; 7: The use of bicarbonate in DKA is controversial 62 because most experts believe that during the treatment, as ketone bodies decrease there will be adequate bicarbonate except in severely acidotic patients.

Management of the hyperosmolar hyperglycemic syndrome. The metabolic derangements and treatment of diabetic ketoacidosis. Additionally, DKA has to be distinguished from other causes of high anion gap metabolic acidosis including lactic acidosis, advanced chronic renal failure, as well as ingestion of drugs such as salicylate, methanol and ethylene glycol.

In this condition the plasma becomes milky and lipemia retinalis may be visible in physical examination This is an important point hyperglycfmic persistent decrease in plasma HCO3- concentration should not be interpreted as a sign of continuous DKA if ketosis and hyperglycemia are resolving.