Hyperglycemic Emergencies in Adults

      Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) should be suspected in ill patients with diabetes. If either DKA or HHS is diagnosed, precipitating factors must be sought and treated.
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      References

        • Hamblin P.S.
        • Topliss D.J.
        • Chosich N.
        • et al.
        Deaths associated with diabetic ketoacidosis and hyperosmolar coma, 1973-1988.
        Med J Aust. 1989; 151: 439-444
        • Holman R.C.
        • Herron C.A.
        • Sinnock P.
        Epidemiologic characteristics of mortality from diabetes with acidosis or coma, United States, 1970-78.
        Am J Public Health. 1983; 73: 1169-1173
        • Wachtel T.J.
        • Tetu-Mouradjian L.M.
        • Goldman D.L.
        • et al.
        Hyperosmolarity and acidosis in diabetes mellitus: a three year experience in Rhode Island.
        J Gen Med. 1991; 6: 495-502
        • Malone M.L.
        • Gennis B.
        • Goodwin J.S.
        Characteristics of diabetic ketoacidosis in older versus younger adults.
        J Am Geriatr Soc. 1992; 40: 1100-1104
        • Laffel L.M.
        • Wentzell K.
        • Loughlin C.
        • et al.
        Sick day management using blood 3-hydroxybutyrate (3-OHB) compared with urine ketone monitoring reduces hospital visits in young people with T1DM: a randomized clinical trial.
        Diabet Med. 2006; 23: 278-284
        • Kitabchi A.E.
        • Umpierrez G.E.
        • Murphy M.B.
        • et al.
        Management of hyperglycemic crises in patients with diabetes.
        Diabetes Care. 2001; 24: 131-153
        • Malatesha G.
        • Singh N.K.
        • Bharija A.
        • et al.
        Comparison of arterial and venous pH, bicarbonate, PCO2 in initial emergency department assessment.
        Emerg Med J. 2007; 24: 569-571
        • Brandenburg M.A.
        • Dire D.J.
        Comparison of arterial and venous blood gas values in the initial emergency department evaluation of patients with diabetic ketoacidosis.
        Ann Emerg Med. 1998; 31: 459-465
        • Ma O.J.
        • Rush M.D.
        • Godfrey M.M.
        • Gaddis G.
        Arterial blood gas results rarely influence emergency physician management of patients with suspected diabetic ketoacidosis academic.
        Emerg Med. 2003; 10: 836-841
        • Charles R.A.
        • Bee Y.M.
        • Eng P.H.
        • Goh S.Y.
        Point-of-care blood ketone testing: screening for diabetic ketoacidosis at the emergency department.
        Singapore Med J. 2007; 48: 986-989
        • Naunheim R.
        • Jang T.J.
        • Banet G.
        • et al.
        Point-of-care test identifies diabetic ketoacidosis at triage.
        Acad Emerg Med. 2006; 13: 683-685
        • Sefedini E.
        • Prasek M.
        • Metelko Z.
        • et al.
        Use of capillary beta-hydroxybutyrate for the diagnosis of diabetic ketoacidosis at emergency room: Our one-year experience.
        Diabetol Croat. 2008; 37: 73-78
        • MacKay L.
        • Lyall M.J.
        • Delaney S.
        • et al.
        Are blood ketones a better predictor than urine ketones of acid base balance in diabetic ketoacidosis?.
        Pract Diabetes Int. 2010; 27: 396-399
        • Bektas F.
        • Eray O.
        • Sari R.
        • Akbas H.
        Point of care blood ketone testing of diabetic patients in the emergency department.
        Endocr Res. 2004; 30: 395-402
        • Harris S.
        • Ng R.
        • Syed H.
        • Hillson R.
        Near patient blood ketone measurements and their utility in predicting diabetic ketoacidosis.
        Diabet Med. 2004; 22: 221-224
        • Chiasson J.L.
        • Aris-Jilwan N.
        • Belanger R.
        • et al.
        Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state.
        CMAJ. 2003; 168: 859-866
        • Lebovitz H.E.
        Diabetic ketoacidosis.
        Lancet. 1995; 345: 767-772
        • Munro J.F.
        • Campbell I.W.
        • McCuish A.C.
        • et al.
        Euglycemic diabetic ketoacidosis.
        BMJ. 1973; 2: 578-580
        • Guo R.X.
        • Yang L.Z.
        • Li L.X.
        • Zhao X.P.
        Diabetic ketoacidosis in pregnancy tends to occur at lower blood glucose levels: case-control study and a case report of euglycemic diabetic ketoacidosis in pregnancy.
        J Obstet Gynaecol Res. 2008; 34: 324-330
        • Oliver R.
        • Jagadeesan P.
        • Howard R.J.
        • Nikookam K.
        Euglycaemic diabetic ketoacidosis in pregnancy: an unusual presentation.
        J Obstet Gynaecol. 2007; 27: 308
        • Chico A.
        • Saigi I.
        • Garcia-Patterson A.
        • et al.
        Glycemic control and perinatal outcomes of pregnancies complicated by type 1 diabetes: Influence of continuous subcutaneous insulin infusion and lispro insulin.
        Diabetes Technol Ther. 2010; 12: 937-945
        • May M.E.
        • Young C.
        • King J.
        Resource utilization in treatment of diabetic ketoacidosis in adults.
        Am J Med Sci. 1993; 306: 287-294
        • Levetan C.S.
        • Jablonski K.A.
        • Passaro M.D.
        • et al.
        Effect of physician specialty on outcomes in diabetic ketoacidosis.
        Diabetes Care. 1999; 22: 1790-1795
        • Bull S.V.
        • Douglas I.S.
        • Foster M.
        • Albert R.K.
        Mandatory protocol for treating adult patients with diabetic ketoacidosis decreases intensive care unit and hospital lengths of stay: results of a nonrandomized trial.
        Crit Care Med. 2007; 35: 41-46
        • Waller S.L.
        • Delaney S.
        • Strachan M.W.
        Does an integrated care pathway enhance the management of diabetic ketoacidosis?.
        Diabet Med. 2007; 24: 359-363
        • Devalia B.
        Adherence to protocol during the acute management of diabetic ketoacidosis: would specialist involvement lead to better outcomes?.
        Int J Clin Pract. 2010; 64: 1580-1582
        • Salahuddin M.
        • Anwar M.N.
        Study on effectiveness of guidelines and high dependency unit management on diabetic ketoacidosis patients.
        J Postgrad Med Inst. 2009; 23: 120-123
        • Kreisberg R.A.
        Diabetic ketoacidosis: new concepts and trends in pathogenesis and treatment.
        Ann Intern Med. 1978; 88: 681-695
        • Ennis E.D.
        • Stahl E.J.
        • Kreisberg R.A.
        The hyperosmolar hyperglycemic syndrome.
        Diabetes Rev. 1994; 2: 115-126
        • Mahoney C.P.
        • Vlcek B.W.
        • DelAguila M.
        Risk factors for developing brain herniation during diabetic ketoacidosis.
        Pediatr Neurol. 1999; 2: 721-727
        • Rosenbloom A.L.
        Intracerebral crises during treatment of diabetic ketoacidosis.
        Diabetes Care. 1990; 13: 22-33
        • Adrogue H.J.
        • Barrero J.
        • Eknoyan G.
        Salutary effects of modest fluid replacement in the treatment of adults with diabetic ketoacidosis.
        JAMA. 1989; 262: 2108-2113
        • Fein I.A.
        • Rackow E.C.
        • Sprung C.L.
        • et al.
        Relation of colloid osmotic pressure to arterial hypoxemia and cerebral edema during crystalloid volume loading of patients with diabetic ketoacidosis.
        Ann Intern Med. 1982; 96: 570-575
        • Owen O.E.
        • Licht J.H.
        • Sapir D.G.
        Renal function and effects of partial rehydration during diabetic ketoacidosis.
        Diabetes. 1981; 30: 510-518
        • Kitabchi A.E.
        • Ayyagari V.
        • Guerra S.M.
        • et al.
        The efficacy of low dose versus conventional therapy of insulin for treatment of diabetic ketoacidosis.
        Ann Intern Med. 1976; 84: 633-638
        • Heber D.
        • Molitch M.E.
        • Sperling M.A.
        Low-dose continuous insulin therapy for diabetic ketoacidosis. Prospective comparison with “conventional” insulin therapy.
        Arch Intern Med. 1977; 137: 1377-1380
        • Butkiewicz E.K.
        • Leibson C.L.
        • O'Brien P.C.
        • et al.
        Insulin therapy for diabetic ketoacidosis. Bolus insulin injection versus continuous insulin infusion.
        Diabetes Care. 1995; 18: 1187-1190
        • Kitabchi A.E.
        • Murphy M.B.
        • Spencer J.
        • et al.
        Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis?.
        Diabetes Care. 2008; 31: 2081-2085
        • Fort P.
        • Waters S.M.
        • Lifshitz F.
        Low-dose insulin infusion in the treatment of diabetic ketoacidosis: bolus versus no bolus.
        J Pediatr. 1980; 96: 36-40
        • Lindsay R.
        • Bolte R.G.
        The use of an insulin bolus in low-dose insulin infusion for pediatric diabetic ketoacidosis.
        Pediatr Emerg Care. 1989; 5: 77-79
        • Della Manna T.
        • Steinmetz L.
        • Campos P.R.
        • et al.
        Subcutaneous use of a fast-acting insulin analog: an alternative treatment for pediatric patients with diabetic ketoacidosis.
        Diabetes Care. 2005; 28: 1856-1861
        • Umpierrez G.E.
        • Latif K.
        • Stoever J.
        • et al.
        Efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for the treatment of patients with diabetic ketoacidosis.
        Am J Med. 2004; 117: 291-296
        • Umpierrez G.E.
        • Cuervo R.
        • Karabell A.
        • et al.
        Treatment of diabetic ketoacidosis with subcutaneous insulin aspart.
        Diabetes Care. 2004; 27: 1873-1888
        • Wiggam M.I.
        • O'Kane M.J.
        • Harper R.
        • et al.
        Treatment of diabetic ketoacidosis using normalization of blood 3-hydroxybutyrate concentration as the endpoint of emergency management.
        Diabetes Care. 1997; 20: 1347-1352
        • Waldhäusl W.
        • Kleinberger G.
        • Korn A.
        • et al.
        Severe hyperglycemia: effects of rehydration on endocrine derangements and blood glucose concentration.
        Diabetes. 1979; 28: 577-584
        • Gerich J.E.
        • Martin M.M.
        • Recant L.L.
        Clinical and metabolic characteristics of hyperosmolar nonketotic coma.
        Diabetes. 1971; 20: 228-238
        • Morris L.R.
        • Murphy M.B.
        • Kitabchi A.E.
        Bicarbonate therapy in severe diabetic ketoacidosis.
        Ann Intern Med. 1986; 105: 836-840
        • Gamba G.
        • Oseguera J.
        • Castrejon M.
        • et al.
        Bicarbonate therapy in severe diabetic ketoacidosis: a double blind, randomized placebo controlled trial.
        Rev Invest Clin. 1991; 43: 234-248
        • Hale P.J.
        • Crase J.
        • Nattrass M.
        Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis.
        Br Med J Clin Res Ed. 1984; 289: 1035-1038
        • Soler N.G.
        • Bennet M.A.
        • Dixon K.
        • et al.
        Potassium balance during treatment of diabetic ketoacidosis with special reference to the use of bicarbonate.
        Lancet. 1972; 2: 665-667
        • Carlotti A.P.
        • Bohn D.
        • Mallie J.P.
        • et al.
        Tonicity balance, and not electrolyte-free water calculations, more accurately guides therapy for acute changes in natremia.
        Intensive Care Med. 2001; 27: 921-924
        • O'Malley G.
        • Moran C.
        • Draman M.S.
        • et al.
        Central pontine myelinolysis complicating treatment of the hyperglycaemic hyperosmolar state.
        Ann Clin Biochem. 2008; 45: 440-443
        • Keller U.
        • Berger W.
        Prevention of hypophosphatemia by phosphate infusion during treatment of diabetic ketoacidosis and hyperosmolar coma.
        Diabetes. 1980; 29: 87-95
        • Wilson H.K.
        • Keuer S.P.
        • Lea A.S.
        • et al.
        Phosphate therapy in diabetic ketoacidosis.
        Arch Intern Med. 1982; 142: 517-520
        • Fisher J.N.
        • Kitabchi A.E.
        A randomized study of phosphate therapy in the treatment of diabetic ketoacidosis.
        J Clin Endocrinol Metab. 1983; 57: 177-180
        • Singhal P.C.
        • Abromovici M.
        • Ayer S.
        • et al.
        Determinants of rhabdomyolysis in the diabetic state.
        Am J Nephrol. 1991; 11: 447-450
        • Bellazzini M.A.
        • Meyer T.
        Pseudo-myocardial infarction in diabetic ketoacidosis with hyperkalemia.
        J Emerg Med. 2010; 39: e139-e141
        • Petrov D.
        • Petrov M.
        Widening of the QRS complex due to severe hyperkalemia as an acute complication of diabetic ketoacidosis.
        J Emerg Med. 2008; 34: 459-461
        • Geddes J.
        • Deans K.A.
        • Cormack A.
        • et al.
        Cardiac troponin I concentrations in people presenting with diabetic ketoacidosis.
        Ann Clin Biochem. 2007; 44: 391-393
        • Talapatra I.
        • Tymms D.J.
        Diabetic ketoacidosis precipitated by subacute (De Quervain's) thyroiditis.
        Pract Diabetes Int. 2006; 23: 76-77
        • Booth G.L.
        • Fang J.
        Acute complications of diabetes.
        in: Hux J.E. Booth G.L. Slaughter P.M. Diabetes in Ontario: An ICES Practice Atlas. Institute for Clinical Evaluative Sciences, Toronto, ON2003: 2.19-2.50 (Available at:) (Accessed May 1, 2012)
        • Bagg W.
        • Sathu A.
        • Streat S.
        • et al.
        Diabetic ketoacidosis in adults at Auckland Hospital, 1988-1996.
        Aust N Z J Med. 1998; 28: 604-608
        • Umpierrez G.E.
        • Kelly J.P.
        • Navarrete J.E.
        • et al.
        Hyperglycemic crises in urban blacks.
        Arch Intern Med. 1997; 157: 669-675
        • Musey V.C.
        • Lee J.K.
        • Crawford R.
        • et al.
        Diabetes in urban African-Americans. I. Cessation of insulin therapy is the major precipitating cause of diabetic ketoacidosis.
        Diabetes Care. 1995; 18: 483-489
        • Wachtel T.J.
        • Silliman R.A.
        • Lamberton P.
        Predisposing factors for the diabetic hyperosmolar state.
        Arch Intern Med. 1987; 147: 499-501