Description
Patients with both type 1 and type 2 diabetes mellitus may experience acute metabolic consequences such as diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS). Effective management, thorough clinical and biochemical examination, and prompt diagnosis are essential for the successful treatment of DKA and HHS. Coordinating fluid resuscitation, insulin therapy, electrolyte replacement, and constant patient monitoring while using the available laboratory tests to forecast the resolution of the hyperglycemic crisis are essential parts of managing hyperglycemic crises. To lower the risks of complications, it's critical to comprehend and promptly recognise potential unusual scenarios including DKA or HHS presentation in the comatose state, the potential for mixed acid-base disorders to obscure the diagnosis of DKA, and the risk of cerebral edema during therapy.
Résumé
- Hyperglycemia, referring to high blood sugar levels, is defined as exceeding 100 mg/dL, with normal levels between 80-100 mg/dL. Diabetes, categorized as acute or chronic, includes Type 1 (absolute insulin deficiency) and Type 2 (insulin resistance). Case reports aid in understanding diabetes and hyperglycemia emergencies.
- Initial treatment steps involve volume correction and potassium adjustments, starting with IV fluids and insulin. The amount of fluid to start with is important as deficit can be between 3 to 6 liters. Pre-renal acute kidney injury often occurs due to dehydration.
- The pathophysiology of diabetic ketoacidosis (DKA) involves insulin deficiency, increased glucose production, and mobilization of fat and muscle, leading to ketogenesis. In contrast, hyperosmolar non-ketotic coma (HONK) may involve normal insulin levels with counter-regulatory hormones inhibiting insulin action, resulting in severe hyperglycemia and osmotic diuresis.
- DKA is frequently seen in type 1 diabetes, particularly in younger women, while HONK is more prevalent in elderly individuals with type 2 diabetes. Management of DKA requires history taking (insulin use, missed doses), physical exams (dehydration signs), and lab tests (CBC, blood sugar, ABG, HVA1C).
- Fluid resuscitation is crucial, guided by clinical response, and should use normal saline initially, transitioning to balanced crystalloids to maintain intravascular volume. Insulin therapy, a cornerstone of management, reduces glucose and ketone production with an initial bolus of 0.1 unit/kg, followed by continuous infusion at 0.1 unit/kg/hour. Potassium levels require close monitoring due to potential shifts.
- Monitoring electrolyte levels are important, the target should be for bringing potassium up to 4 to 4.5 miliequivalent/liter and correcting any deficit. Normalizing the anion gap, rather than relying solely on ketone measurements, is crucial for assessing resuscitation adequacy. By carbonate therapy should be instituted only if pH is less than 6.9 with slow correction of sodium.
- Mortality is higher in elderly patients with DKA due to pre-existing organ dysfunction. Complications include cerebral edema. Hyperosmolar non-ketotic coma is common in type 2 diabetes.
Exemple de certificat
À propos des intervenants
Dr Aklesh Tandekar
Spécialiste en soins intensifs, MD, EDIC, IDCCM, FIMSA, DA, FCPS, FISCCM, hôpitaux Apollo, Mumbai.
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