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Adult Hyperglycemic Crisis: A Review and Perspective

  • Hospital Management of Diabetes (G Umpierrez, Section Editor)
  • Published:
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Abstract

Hyperglycemic crisis, which includes Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State, is a common diagnosis in high acuity hospital units and admission rates continue to increase despite preventive strategies. While diabetic ketoacidosis remains a common cause of death in children and adolescents with type 1 diabetes, in adults reported mortality is variable and depends on the severity of metabolic derangement and the presence of other acute and chronic conditions. Hyperosmolar hyperglycemic state, and the overlap syndrome of hyperosmolar ketoacidosis, have a higher overall mortality though outcomes are improving. We discuss the diagnosis, epidemiology, and management strategies with particular reference to commonly encountered pitfalls in care and provide an updated perspective on the shifts in the epidemiology and novel management strategies for these important disorders.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Walker M, Marshall SM, Alberti KG. Clinical aspects of diabetic ketoacidosis. Diabetes Metab Rev. 1989;5:651–63.

    Article  PubMed  CAS  Google Scholar 

  2. • Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32:1335–43. Consensus statement from the American Diabetes Association which provides a comprehensive overview of the topic.

    Article  PubMed  CAS  Google Scholar 

  3. Kitabchi AE, Umpierrez GE, Fisher JN, Murphy MB, Stentz FB. Thirty years of personal experience in hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state. J Clin Endocrinol Metab. 2008;93:1541–52.

    Article  PubMed  CAS  Google Scholar 

  4. Umpierrez GE, Khajavi M, Kitabchi AE. Review: diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome. Am J Med Sci. 1996;311:225–33.

    Article  PubMed  CAS  Google Scholar 

  5. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:978–82.

    Article  PubMed  CAS  Google Scholar 

  6. Control CfD. Avialable at: http://www.cdc.gov/diabetes/statistics/dkafirst/fig 7.htm. x: x; 2012 [cited 2012]. Accessed 1 Aug 2012.

  7. Gordon EE, Kabadi UM. The hyperglycemic hyperosmolar syndrome. Am J Med Sci. 1976;271:252–68.

    Article  PubMed  CAS  Google Scholar 

  8. Wachtel TJ, Tetu-Mouradjian LM, Goldman DL, Ellis SE, O'Sullivan PS. Hyperosmolarity and acidosis in diabetes mellitus: a three-year experience in Rhode Island. J Gen Intern Med. 1991;6:495–502.

    Article  PubMed  CAS  Google Scholar 

  9. Faich GA, Fishbein HA, Ellis SE. The epidemiology of diabetic acidosis: a population-based study. Am J Epidemiol. 1983;117:551–8.

    PubMed  CAS  Google Scholar 

  10. Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee W, et al. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes. 2009;10 Suppl 12:118–33.

    Article  PubMed  Google Scholar 

  11. Basu A, Close CF, Jenkins D, Krentz AJ, Nattrass M, Wright AD. Persisting mortality in diabetic ketoacidosis. Diabet Med. 1993;10:282–4.

    Article  PubMed  CAS  Google Scholar 

  12. Tillman CR. Hypokalemic hypoventilation complicating severe diabetic ketoacidosis. South Med J. 1980;73:231–3.

    Article  PubMed  CAS  Google Scholar 

  13. Arora S, Cheng D, Wyler B, Menchine M. Prevalence of hypokalemia in ED patients with diabetic ketoacidosis. Am J Emerg Med. 2012;30:481–4.

    Article  PubMed  Google Scholar 

  14. Umpierrez GaS D. Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome. In: Fonseca V, editor. Clinical diabetes: Elsevier; 2006.

  15. Barski L, Nevzorov R, Rabaev E, Jotkowitz A, Harman-Boehm I, Zektser M, et al. Diabetic ketoacidosis: clinical characteristics, precipitating factors, and outcomes of care. IMAJ. 2012;14:299–303.

    PubMed  Google Scholar 

  16. Chen HF, Wang CY, Lee HY, See TT, Chen MH, Jiang JY, et al. Short-term case fatality rate and associated factors among inpatients with diabetic ketoacidosis and hyperglycemic hyperosmolar state: a hospital-based analysis over a 15-year period. Intern Med. 2010;49:729–37.

    Article  PubMed  Google Scholar 

  17. de Vries L, Oren L, Lebenthal Y, Shalitin S, Lazar L, Phillip M. Decrease in frequency of ketoacidosis at diabetes onset over the past two decades - perspectives of a paediatric tertiary care centre. Diabet Med. 2012;29(8):e170–5.

    Article  PubMed  Google Scholar 

  18. Ekpebegh CO, Longo-Mbenza B, Akinrinmade A, Blanco-Blanco E, Badri M, Levitt NS. Hyperglycaemic crisis in the Eastern Cape province of South Africa: high mortality and association of hyperosmolar ketoacidosis with a new diagnosis of diabetes. Suid-Afrikaanse Tydskrif Vir Geneeskd. 2010;100:822–6.

    CAS  Google Scholar 

  19. Negrato CA, Cobas RA, Gomes MB; Brazilian Type 1 Diabetes Study Group. Temporal changes in the diagnosis of type 1 diabetes by diabetic ketoacidosis in Brazil: a nationwide survey. Diabet Med. 2012; 29(9):1142–7.

    Google Scholar 

  20. Mauvais-Jarvis F, Sobngwi E, Porcher R, Riveline JP, Kevorkian JP, Vaisse C, et al. Ketosis-prone type 2 diabetes in patients of sub-Saharan African origin: clinical pathophysiology and natural history of beta-cell dysfunction and insulin resistance. Diabetes. 2004;53:645–53.

    Article  PubMed  CAS  Google Scholar 

  21. Balasubramanyam A, Zern JW, Hyman DJ, Pavlik V. New profiles of diabetic ketoacidosis: type 1 vs type 2 diabetes and the effect of ethnicity. Arch Intern Med. 1999;159:2317–22.

    Article  PubMed  CAS  Google Scholar 

  22. • Randall L, Begovic J, Hudson M, Smiley D, Peng L, Pitre N, et al. Recurrent diabetic ketoacidosis in inner-city minority patients: behavioral, socioeconomic, and psychosocial factors. Diabetes Care. 2011;34:1891–6. This article highlights the non biological precipitants and comorbidities that are common to recurrant DKA admissions and the challenges that accompany this issue.

    Article  PubMed  Google Scholar 

  23. Rewers A. Current concepts and controversies in prevention and treatment of diabetic ketoacidosis in children. Curr Diab Rep. 2012;12(5):524–32.

    Google Scholar 

  24. Fritsch M, Rosenbauer J, Schober E, Neu A, Placzek K, Holl RW, et al. Predictors of diabetic ketoacidosis in children and adolescents with type 1 diabetes. Experience from a large multicentre database. Pediatr Diabetes. 2011;12(4 Pt 1):307–12.

    Article  PubMed  Google Scholar 

  25. Weinert LS, Scheffel RS, Severo MD, Cioffi AP, Telo GH, Boschi A, et al. Precipitating factors of diabetic ketoacidosis at a public hospital in a middle-income country. Diabetes Res Clin Pract. 2012;96:29–34.

    Article  PubMed  Google Scholar 

  26. MacIsaac RJ, Lee LY, McNeil KJ, Tsalamandris C, Jerums G. Influence of age on the presentation and outcome of acidotic and hyperosmolar diabetic emergencies. Intern Med J. 2002;32:379–85.

    Article  PubMed  CAS  Google Scholar 

  27. Isotani H, Asaka S, Kameoka K, Furukawa K. Hyperglycemic hyperosmolar syndrome associated with severe ketosis in Japanese woman. Hormone and metabolic research = Hormon- und Stoffwechselforschung = Hormones et Metabolisme. 1997;29:360–1.

  28. Bhowmick SK, Levens KL, Rettig KR. Hyperosmolar hyperglycemic crisis: an acute life-threatening event in children and adolescents with type 2 diabetes mellitus. Endocr Pract. 2005;11:23–9.

    PubMed  Google Scholar 

  29. Nyenwe EA, Razavi LN, Kitabchi AE, Khan AN, Wan JY. Acidosis: the prime determinant of depressed sensorium in diabetic ketoacidosis. Diabetes Care. 2010;33:1837–9.

    Article  PubMed  Google Scholar 

  30. Faigel DO, Metz DC. Prevalence, etiology, and prognostic significance of upper gastrointestinal hemorrhage in diabetic ketoacidosis. Dig Dis Sci. 1996;41:1–8.

    Article  PubMed  CAS  Google Scholar 

  31. Byard RW, Zhou C. Erosive gastritis, Armanni-Ebstein phenomenon and diabetic ketoacidosis. Forensic Sci Med Pathol. 2010;6(4):304–6. Epub 2010/07/16.

    Article  PubMed  Google Scholar 

  32. Rewers A. Current concepts and controversies in prevention and treatment of diabetic ketoacidosis in children. Curr Diabetes Rep. 2012;12:524–32.

    Article  CAS  Google Scholar 

  33. Nyenwe EA, Loganathan RS, Blum S, Ezuteh DO, Erani DM, Wan JY, et al. Active use of cocaine: an independent risk factor for recurrent diabetic ketoacidosis in a city hospital. Endocr Pract. 2007;13:22–9.

    PubMed  Google Scholar 

  34. Warner EA, Greene GS, Buchsbaum MS, Cooper DS, Robinson BE. Diabetic ketoacidosis associated with cocaine use. Arch Intern Med. 1998;158:1799–802.

    Article  PubMed  CAS  Google Scholar 

  35. Rehman HU. A woman with ketoacidosis but not diabetes. BMJ. 2012;344:e1535.

    Article  PubMed  CAS  Google Scholar 

  36. Franke B, Carr D, Hatem MH. A case of euglycaemic diabetic ketoacidosis in pregnancy. Diabet Med. 2001;18:858–9.

    Article  PubMed  CAS  Google Scholar 

  37. Burge MR, Hardy KJ, Schade DS. Short-term fasting is a mechanism for the development of euglycemic ketoacidosis during periods of insulin deficiency. J Clin Endocrinol Metab. 1993;76:1192–8.

    Article  PubMed  CAS  Google Scholar 

  38. Glaser N, Kuppermann N. DKA-related cerebral edema and intravenous fluid therapy: potential pitfalls of uncontrolled retrospective studies. J Pediatr. 2008;152:145. author reply 7–9.

    PubMed  Google Scholar 

  39. Umpierrez GE, Latif K, Stoever J, Cuervo R, Park L, Freire AX, et al. Efficacy of subcutaneous insulin lispro vs continuous intravenous regular insulin for the treatment of patients with diabetic ketoacidosis. Am J Med. 2004;117:291–6.

    Article  PubMed  CAS  Google Scholar 

  40. Umpierrez GE, Cuervo R, Karabell A, Latif K, Freire AX, Kitabchi AE. Treatment of diabetic ketoacidosis with subcutaneous insulin aspart. Diabetes Care. 2004;27:1873–8.

    Article  PubMed  CAS  Google Scholar 

  41. Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32:1119–31.

    Article  PubMed  Google Scholar 

  42. Umpierrez GE, Jones S, Smiley D, Mulligan P, Keyler T, Temponi A, et al. Insulin analogs vs human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care. 2009;32:1164–9.

    Article  PubMed  CAS  Google Scholar 

  43. Kitabchi AE, Nyenwe EA. Hyperglycemic crises in diabetes mellitus: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Endocrinol Metab Clin North Am. 2006;35:725–51. viii.

    Article  PubMed  CAS  Google Scholar 

  44. Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553–91.

    Article  PubMed  Google Scholar 

  45. Aggarwal A, Rawn JD, Pendergrass ML, Garg RK. Long-acting subcutaneously administered insulin for glycemic control immediately after cardiac surgery. Endocr Pract. 2011;17:558–62.

    Article  PubMed  Google Scholar 

  46. Avanzini F, Marelli G, Donzelli W, Busi G, Carbone S, Bellato L, et al. Transition from intravenous to subcutaneous insulin: effectiveness and safety of a standardized protocol and predictors of outcome in patients with acute coronary syndrome. Diabetes Care. 2011;34:1445–50.

    Article  PubMed  CAS  Google Scholar 

  47. • Hsia E, Seggelke S, Gibbs J, Hawkins RM, Cohlmia E, Rasouli N, et al. Subcutaneous Administration of Glargine to Diabetic Patients Receiving Insulin Infusion Prevents Rebound Hyperglycemia. J Clin Endocrinol Metab. 2012;97(9):3132–7. This study brings to light a potential new approach to transition from intravenous to subcutaneous insulin therapy to ameliorate the risk of rebound hyperglycemia.

  48. Rubin DJ, Rybin D, Doros G, McDonnell ME. Weight-based, insulin dose-related hypoglycemia in hospitalized patients with diabetes. Diabetes Care. 2011;34:1723–8.

    Article  PubMed  Google Scholar 

  49. Umpierrez GE, Kelly JP, Navarrete JE, Casals MM, Kitabchi AE. Hyperglycemic crises in urban blacks. Arch Intern Med. 1997;157:669–75.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston Medical Center, Evans 201, 88 East Newton St., Boston, MA, 02118, USA

    Devin W. Steenkamp, Sara M. Alexanian & Marie E. McDonnell

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  1. Devin W. Steenkamp
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  2. Sara M. Alexanian
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  3. Marie E. McDonnell
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Correspondence to Marie E. McDonnell.

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Steenkamp, D.W., Alexanian, S.M. & McDonnell, M.E. Adult Hyperglycemic Crisis: A Review and Perspective. Curr Diab Rep 13, 130–137 (2013). https://doi.org/10.1007/s11892-012-0342-z

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