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Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are 2 hyperglycemic crises frequently encountered in emergency departments.
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DKA, characterized by hyperglycemia, ketonemia, and anion gap metabolic acidosis, results from absolute or relative insulin deficiency and counterregulatory hormone excess.
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HHS, characterized by hyperglycemia, hyperosmolarity, and profound dehydration without significant ketoacidosis, results from prolonged poor glycemic control and inadequate
Current Diagnosis and Treatment of Hyperglycemic Emergencies
Section snippets
Key points
Epidemiology
The prevalence and financial burden of diabetes are tremendous and rising. Approximately 10% of the US population lives with diabetes, and approximately 2 million Americans are diagnosed with diabetes yearly.1 It is projected that by the year 2050, up to 1 in 3 American adults will be diabetic.2 An estimated 10% of health care dollars are spent treating diabetes and its complications, and 20% of health care dollars are spent caring for diabetics overall; in 2012, the direct medical costs of
Pathophysiology
DKA and HHS are both characterized by hyperglycemia, which stems from insulin resistance or deficiency of insulin secretion from the pancreas. In DKA, the driving force is insulin insufficiency and a subsequent increase in insulin counterregulatory hormones (ICRHs), which prevents the body from metabolizing carbohydrates.10, 11 Insulin normally stimulates the transference of glucose from the bloodstream into tissues of the body, where it is needed for energy, glycogen storage, and lipogenesis.
Treatment
Successful treatment of DKA and HHS involves the correction of hypovolemia, hyperglycemia, ketoacid production, and electrolyte abnormalities and treating any precipitating illnesses. The fluid, electrolyte, and insulin regimens for initial emergency department resuscitation of DKA and HHS share many commonalities.
Complications
Many complications of treatment are evident only later during an ICU stay yet may result from early inappropriate management. Most complications in DKA and HHS are due to either the predisposing or associated condition or the treatment of the hyperglycemia itself. The most common complications are hypoglycemia and hypokalemia. Less common, yet significant, complications include cerebral edema, volume overload, and acute respiratory distress syndrome (ARDS). Emergency providers must be
Disposition
Most patients with a diagnosis of DKA or HHS require admission to a hospital for treatment, observation, and resolution of the underlying cause or modification to an appropriate medication regimen.
All patients benefit from frequent clinical and laboratory reassessment while in an emergency department for adequate urine output, electrolyte correction, and the absence of fluid overload. Emergency practitioners should anticipate that the fluid, metabolic, and electrolyte deficits be gradually
Summary
Diabetes is an increasingly prevalent chronic illness and, along with DKA and HHS, is associated with significant morbidity, mortality, and cost. Both DKA and HHS are complicated hyperglycemic states characterized by dehydration and electrolyte disturbances. The treatment of both conditions must be tailored to individual patients and relies on aggressive fluid resuscitation, strictly monitored insulin replacement, and electrolyte management, while correcting the underlying causes and monitoring
Acknowledgments
Thanks to Morgan Walker, MSN, for her assistance in article editing.
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