A new position statement - on Hyperglycemic Crisis in Patients with Diabetes Mellitus - was included with the ADA's annual release of Clinical Practice Recommendations in January 2001. According to the ADA, diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia (HHS) are the two most serious acute metabolic complications of diabetes. Mortality for DKA is under 5% at experienced centers but remains around 15% for HHS.
The most common cause is infection, but these conditions may also occur following a stroke, heart attack, trauma, or pancreatitis. They may also occur in individuals who abuse alcohol, take drugs that affect carbohydrate metabolism, or fail to take their prescribed insulin.
Successful treatment requires correcting dehydration, hyperglycemia, and electrolyte imbalances. Frequent patient monitoring is essential. Recommendations for treatment are:
- Start insulin therapy via continuous IV infusion (unless it is a mild episode of DKA).
- Initiate fluid therapy to expand volume and restore kidney circulation.
- Assess the need for bicarbonate therapy to prevent severe acidosis; do not use if pH is 7.0 or greater.
- Phosphate replacement may be used in patients with cardiac dysfunction, anemia, respiratory depression, and those with a low serum phosphate concentration.
- Gradually correct glucose and osmolality and use isotonic or hypotonic saline judiciously, depending on the patient's serum sodium levels and hemodynamic status, to avoid cerebral edema.
In order to avoid DKA and HHS, patients are advised to communicate with their healthcare providers during an episode of illness and never to discontinue taking their insulin.
Source: ADA, Hyperglycemic crises in patients with diabetes mellitus, Position statement, January 2001.