Management of Hyperglycemic Crises in Patients With Diabetes

Abstract

Abbreviations: AaO 2 , alveolar-to-arteriolar oxygen; AKA, alcoholic ketoacidosis; ARDS, adult respiratory distress syndrome; BUN, blood urea nitrogen; CPT, carnitine palmitoyl-transferase; CSF, cerebrospinal fluid; DKA, diabetic ketoacidosis; FFA, free fatty acid; HHS, hyperosmolar hyperglycemic state; IRI, immunoreactive insulin; PaO 2 , arteriolar partial pressure of oxygen; RDKA, recurrent DKA.A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Management of Hyperglycemic Crises in Patients With Diabetes T E C H N I C A L R E V I E R e v i e w s / C o m m e n t a r i e s / P o s i t i o n S t a t e m e n t s 132DIABETES CARE, VOLUME 24, NUMBER 1, JANUARY 2001Technical Review noted in newly diagnosed obese type 2 diabetic patients (5,26,31). Therefore, the concept that the presence of DKA in type 2 diabetes is a rare occurrence is incorrect.The most common types of infections are pneumonia and urinary tract infection, accounting for 30-50% of cases (Table 4). Other acute medical illnesses as precipitating causes include alcohol abuse, trauma, pulmonary embolism, and myocardial infarction, which can occur both in type 1 and 2 diabetes (6). Various drugs that alter carbohydrate metabolism, such as corticosteroids, pentamidine, sympathomimetic agents, and ␣-and ␤-adrenergic blockers, and excessive use of diuretics in the elderly may also precipitate the development of DKA and HHS.The recent increased use of continuous subcutaneous insulin infusion pumps that use small amounts of short-acting insulin has been associated with an incidence of DKA that is significantly increased over the incidence seen with conventional methods of multiple daily insulin injections, in spite of the fact that most of the mechanical problems with insulin pumps have been resolved (6,(32)(33)(34). In the Diabetes Control and Complications Trial, the incidence of DKA in patients on insulin pumps was about twofold higher than that in the multipleinjection group over a comparable time period (35). This may be due to the exclusive use of short-acting insulin in the pump, which if interrupted leaves no reservoir of insulin for blood glucose control.Psychological factors and poor compliance, leading to omission of insulin therapy, are important precipitating factors for recurrent ketoacidosis. In young female patients with type 1 diabetes, psychological problems complicated by eating disorders may be contributing factors in up to 20% of cases of recurrent ketoacidosis (36,37). Factors that may lead to insulin omission in younger patients include fear of weight gain with good metabolic control, fear of hypoglycemia, rebellion against authority, and stress related to chronic disease (36). Noncompliance with insulin therapy has been found to be the leading precipitating cause for DKA in urban African-Americans and medically indigent patients (5,26). In addition, a recent study showed that diabetic patients without health insurance or with Medicaid alone had hospitali...

Ketoacidosis as the initial clinical condition in nine patients with acromegaly: a review of 860 cases at a single institute

“…These observations are compatible with previous reports that young, male diabetic patients are more prone to developing ketoacidosis (27,28).…”

Prevalence and clinical outcome of inpatient hyperglycemia in a community pediatric hospital

“…[10][11][12][13][14][15] Three retrospective studies have demonstrated that admission hyperglycemia is also a predictor of adverse outcomes in the pediatric intensive care unit. 20,22 Srinivasan and colleagues 22 demonstrated that 86% of patients in their pediatric intensive care unit had a glucose value >126 mg/dL at some point during their stay.…”

“…[3][4][5][6][7][8][9][10][11][12] Several prospective randomized trials in patients with critical illness have shown that aggressive glycemic control improves short-and long-term mortality, multiorgan failure and systemic infection, and length of hospitalization. [13][14][15][16][17] The importance of glucose control also applies to adult patients admitted to general surgical and medical wards. 3,6,18 In such patients, we recently reported that the presence of hyperglycemia is associated with prolonged hospital stay, infection, disability after hospital discharge, and death.…”

Normas para redução da mortalidade materna

“…O PACS/PSF, que representavam 4% do total dos recursos destinados para o Atendimento Ambulatorial e para a Atenção Básica em 1998, atingiram 12% em 2000. 2 Comentário Comentário Comentário Comentário Comentário O PSF está sendo apresentado como um modelo de assistência à saúde para atingir a população brasileira carente e de alto risco. Mais da metade da população brasileira apresentava renda familiar per capita inferior a 1 salário mínimo e 76% não estavam cobertas por planos privados de saúde em 1998.…”