Skip to main content
SpringerLink
Log in

Diabetes in the Critically Ill Patient: DKA, HHS, and Beyond

  • Chapter
  • First Online:
Diabetes Management in Hospitalized Patients

Part of the book series: Contemporary Endocrinology ((COE))

  • 290 Accesses

Abstract

Hyperglycemia is a common occurrence in critically ill patients, carrying a risk of increased adverse events. It can manifest itself as the primary cause of admission, such as in diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), or as a secondary diagnosis in patients with or without preexisting diabetes. The management of hyperglycemic emergencies such as DKA or HHS can be quite complex, requiring an interplay of fluid, electrolyte, and insulin replacement. The consensus targets for blood glucose control in the critical care setting coalesce on the range between 140 and 180 mg/dL, with insulin as the preferred modality of treatment. Little data is available on the management of hyperglycemia in special populations such as patients with renal failure or congestive heart failure.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 169.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 219.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(1):16–38. https://doi.org/10.1210/jc.2011-2098.

    Article  CAS  PubMed  Google Scholar 

  2. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32(6):1119–31. https://doi.org/10.2337/dc09-9029.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003;78(12):1471–8. https://doi.org/10.4065/78.12.1471.

    Article  PubMed  Google Scholar 

  4. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335. https://doi.org/10.2337/dc09-9032.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Dungan KM, Braithwaite SS, Preiser J. Stress hyperglycaemia. Lancet. 2009;373(9677):1798. https://doi.org/10.1016/s0140-6736(09)60553-5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Farsani SF, Brodovicz K, Soleymanlou N, Marquard J, Wissinger E, Maiese BA. Incidence and prevalence of diabetic ketoacidosis (DKA) among adults with type 1 diabetes mellitus (T1D): a systematic literature review. BMJ Open. 2017;7(7):e016587. https://doi.org/10.1136/bmjopen-2017-016587.

    Article  PubMed Central  Google Scholar 

  7. Umpierrez GE. Hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Cham: Springer International Publishing; 2020. p. 595–614.

    Google Scholar 

  8. Draznin B, Aroda VR, Bakris G, et al. 16. Diabetes care in the hospital: standards of medical care in diabetes—2022. Diabetes Care. 2022;45(Suppl 1):S244–53. https://doi.org/10.2337/dc22-S016.

    Article  Google Scholar 

  9. Saperstein Y, Park J, McFarlane SI. Closing the mortality gap in diabetic ketoacidosis and hyperosmolar hyperglycemic state: implications of a clinical decision support app. Int J Clin Endocrinol Metab. 2018;4(1):8–11. https://doi.org/10.17352/ijcem.000031.

    Article  Google Scholar 

  10. Dhatariya KK. Defining and characterising diabetic ketoacidosis in adults. Diabetes Res Clin Pract. 2019;155:107797.

    Article  CAS  PubMed  Google Scholar 

  11. Douros A, Lix LM, Fralick M, et al. Sodium-glucose cotransporter-2 inhibitors and the risk for diabetic ketoacidosis: a multicenter cohort study. Ann Intern Med. 2020;173(6):417–25. https://doi.org/10.7326/M20-0289.

    Article  PubMed  Google Scholar 

  12. Li L, Andrews EB, Li X, et al. Incidence of diabetic ketoacidosis and its trends in patients with type 1 diabetes mellitus identified using a U.S. claims database, 2007–2019. J Diabetes Complicat. 2021;35(7):107932.

    Article  CAS  Google Scholar 

  13. Dabelea D, Rewers A, Stafford JM, et al. Trends in the prevalence of ketoacidosis at diabetes diagnosis: the SEARCH for diabetes in youth study. Pediatrics. 2014;133(4):938. https://doi.org/10.1542/peds.2013-2795.

    Article  Google Scholar 

  14. Benoit SR, Zhang Y, Geiss LS, Gregg EW, Albright A. Trends in diabetic ketoacidosis hospitalizations and in-hospital mortality—United States, 2000–2014. MMWR Morb Mortal Wkly Rep. 2018;67(12):362–5. https://doi.org/10.15585/mmwr.mm6712a3.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Taborsky GJ. The physiology of glucagon. J Diabetes Sci Technol. 2010;4(6):1338. https://doi.org/10.1177/193229681000400607.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Jones BJ, Tan T, Bloom SR. Minireview: glucagon in stress and energy homeostasis. Endocrinology. 2012;153(3):1049–54. https://doi.org/10.1210/en.2011-1979.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Adeva-Andany MM, Funcasta-Calderon R, Fernandez-Fernandez C, Castro-Quintela E, Carneiro-Freire N. Metabolic effects of glucagon in humans. J Clin Transl Endocrinol. 2018;15:45–53. https://doi.org/10.1016/j.jcte.2018.12.005.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Dizon S, Keely EJ, Malcolm J, Arnaout A. Insights into the recognition and management of SGLT2-inhibitor-associated ketoacidosis: it’s not just euglycemic diabetic ketoacidosis. Can J Diabetes. 2017;41(5):499–503.

    Article  PubMed  Google Scholar 

  19. Saponaro C, Pattou F, Bonner C. SGLT2 inhibition and glucagon secretion in humans. Diabetes Metab. 2018;44(5):383–5.

    Article  CAS  PubMed  Google Scholar 

  20. Ogawa W, Sakaguchi K. Euglycemic diabetic ketoacidosis induced by SGLT2 inhibitors: possible mechanism and contributing factors. J Diabetes Investig. 2016;7(2):135–8. https://doi.org/10.1111/jdi.12401.

    Article  CAS  PubMed  Google Scholar 

  21. Rosenstock J, Ferrannini E. Euglycemic diabetic ketoacidosis: a predictable, detectable, and preventable safety concern with SGLT2 inhibitors. Diabetes Care. 2015;38(9):1638–42. https://doi.org/10.2337/dc15-1380.

    Article  CAS  PubMed  Google Scholar 

  22. Umpierrez GE, Kitabchi AE. Diabetic ketoacidosis: risk factors and management strategies. Treat Endocrinol. 2003;2(2):95–108. https://doi.org/10.2165/00024677-200302020-00003.

    Article  PubMed  Google Scholar 

  23. Qari FA. Precipitating factors for diabetic ketoacidosis. Saudi Med J. 2002;23(2):173–6.

    PubMed  Google Scholar 

  24. Gosmanov AR, Gosmanova EO, Kitabchi AE. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state. MDText.com, Inc.; 2000.

    Google Scholar 

  25. Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in diabetes. Diabetes Care. 2004;27(suppl 1):s94–s102. https://doi.org/10.2337/diacare.27.2007.S94.

    Article  PubMed  Google Scholar 

  26. Karoli R, Fatima J, Salman T, Sandhu S, Shankar R. Managing diabetic ketoacidosis in non-intensive care unit setting: role of insulin analogs. Indian J Pharmacol. 2011;43(4):398–401. https://doi.org/10.4103/0253-7613.83109.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Umpierrez GE, Cuervo R, Karabell A, Latif K, Freire AX, Kitabchi AE. Treatment of diabetic ketoacidosis with subcutaneous insulin aspart. Diabetes Care. 2004;27(8):1873–8. https://doi.org/10.2337/diacare.27.8.1873.

    Article  CAS  PubMed  Google Scholar 

  28. Andrade-Castellanos CA, Colunga-Lozano LE, Delgado-Figueroa N, Gonzalez-Padilla DA, Andrade-Castellanos CA. Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. Cochrane Database Syst Rev. 2016;2016(1):CD011281. https://doi.org/10.1002/14651858.CD011281.pub2.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Viallon A, Zeni F, Lafond P, et al. Does bicarbonate therapy improve the management of severe diabetic ketoacidosis? Crit Care Med. 1999;27(12):2690–3. https://doi.org/10.1097/00003246-199912000-00014.

    Article  CAS  PubMed  Google Scholar 

  30. Tran TTT, Pease A, Wood AJ, et al. Review of evidence for adult diabetic ketoacidosis management protocols. Front Endocrinol. 2017;8:106. https://doi.org/10.3389/fendo.2017.00106.

    Article  Google Scholar 

  31. Swanson CM, Potter DJ, Kongable GL, Cook CB. Update on inpatient glycemic control in hospitals in the United States. Endocr Pract. 2011;17(6):853–61. https://doi.org/10.4158/EP11042.OR.

    Article  PubMed  Google Scholar 

  32. Newcomer JW. Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs. 2005;19(1):1–93. https://doi.org/10.2165/00023210-200519001-00001.

    Article  CAS  PubMed  Google Scholar 

  33. Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care. 2014;37(11):3124–31. https://doi.org/10.2337/dc14-0984.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Odak M, Douedi S, Upadhyaya V, Fadhel M, Cosentino J. Focal neurological seizure due to hyperglycemic hyperosmolar non-ketotic syndrome in undiagnosed diabetes mellitus. Cureus. 2020;12(8):e9909. https://doi.org/10.7759/cureus.9909.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Slovis CM, Mork VGC, Slovis RJ, Bain RP. Diabetic ketoacidosis and infection: leukocyte count and differential as early predictors of serious infection. Am J Emerg Med. 1987;5(1):1–5. https://doi.org/10.1016/0735-6757(87)90280-4.

    Article  CAS  PubMed  Google Scholar 

  36. Huang C, Kuo E. Mechanism of hypokalemia in magnesium deficiency. J Am Soc Nephrol. 2007;18(10):2649–52. https://doi.org/10.1681/ASN.2007070792.

    Article  CAS  PubMed  Google Scholar 

  37. Gangu K, Basida SD, Vijayan A, Avula S, Bobba A. Outcomes of diabetic ketoacidosis in adults with end-stage kidney disease: retrospective study based on a national database. Cureus. 2022;14(5):e24782. https://doi.org/10.7759/cureus.24782.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Seddik AA, Bashier A, Alhadari AK, et al. Challenges in management of diabetic ketoacidosis in hemodialysis patients, case presentation and review of literature. Diabetes Metab Syndr Clin Res Rev. 2019;13(4):2481–7. https://doi.org/10.1016/j.dsx.2019.06.022.

    Article  Google Scholar 

  39. Islam T, Sherani K, Surani S, Vakil A. Guidelines and controversies in the management of diabetic ketoacidosis—a mini-review. World J Diabetes. 2018;9(12):226–9. https://doi.org/10.4239/wjd.v9.i12.226.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19):1359–67. https://doi.org/10.1056/NEJMoa011300.

    Article  PubMed  Google Scholar 

  41. Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283–97. https://doi.org/10.1056/NEJMoa0810625.

    Article  PubMed  Google Scholar 

  42. Egi M, Bellomo R, Stachowski E, et al. Blood glucose concentration and outcome of critical illness: the impact of diabetes. Crit Care Med. 2008;36(8):2249–55. https://doi.org/10.1097/CCM.0b013e318181039a.

    Article  CAS  PubMed  Google Scholar 

  43. Krikorian A, Ismail-Beigi F, Moghissi E. Comparisons of different insulin infusion protocols: a review of recent literature. Curr Opin Clin Nutr Metab Care. 2010;13(2):198–204. https://doi.org/10.1097/MCO.0b013e32833571db.

    Article  CAS  PubMed  Google Scholar 

  44. Newton CA, Smiley D, Bode BW, et al. A comparison study of continuous insulin infusion protocols in the medical intensive care unit: computer-guided vs. standard column-based algorithms. J Hosp Med. 2010;5(8):432–7. https://doi.org/10.1002/jhm.816.

    Article  PubMed  Google Scholar 

  45. Kalfon P, Giraudeau B, Ichai C, et al. Tight computerized versus conventional glucose control in the ICU: a randomized controlled trial. Intensive Care Med. 2014;40(2):171–81. https://doi.org/10.1007/s00134-013-3189-0.

    Article  CAS  PubMed  Google Scholar 

  46. Fox MA, Perry MC, Liu-DeRyke X. Insulin glargine in critically ill patients: once/day versus twice/day dosing. Pharmacotherapy. 2020;40(3):186–90. https://doi.org/10.1002/phar.2373.

    Article  CAS  PubMed  Google Scholar 

  47. Sadhu AR, Serrano IA, Xu J, et al. Continuous glucose monitoring in critically ill patients with COVID-19: results of an emergent pilot study. J Diabetes Sci Technol. 2020;14(6):1065–73. https://doi.org/10.1177/1932296820964264.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Internal Medicine, Advocate Christ Medical Center, Chicago, IL, USA

    Baani Singh & Sylvia Chlebek

  2. University of Illinois at Chicago, Chicago, IL, USA

    Armand Krikorian

Authors
  1. Baani Singh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sylvia Chlebek
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Armand Krikorian
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Armand Krikorian .

Editor information

Editors and Affiliations

  1. Division of Endocrinology, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, NY, USA

    Rifka C. Schulman-Rosenbaum

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Singh, B., Chlebek, S., Krikorian, A. (2023). Diabetes in the Critically Ill Patient: DKA, HHS, and Beyond. In: Schulman-Rosenbaum, R.C. (eds) Diabetes Management in Hospitalized Patients. Contemporary Endocrinology. Springer, Cham. https://doi.org/10.1007/978-3-031-44648-1_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-031-44648-1_5

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-44647-4

  • Online ISBN: 978-3-031-44648-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation