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02-19-2016 | Hyperglycemic hyperosmolar state | Review | Article

Diabetic emergencies — ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia

Authors: Guillermo Umpierrez, Mary Korytkowski



Diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS) and hypoglycaemia are serious complications of diabetes mellitus that require prompt recognition, diagnosis and treatment. DKA and HHS are characterized by insulinopaenia and severe hyperglycaemia; clinically, these two conditions differ only by the degree of dehydration and the severity of metabolic acidosis. The overall mortality recorded among children and adults with DKA is <1%. Mortality among patients with HHS is ~10-fold higher than that associated with DKA. The prognosis and outcome of patients with DKA or HHS are determined by the severity of dehydration, the presence of comorbidities and age >60 years. The estimated annual cost of hospital treatment for patients experiencing hyperglycaemic crises in the USA exceeds US$2 billion. Hypoglycaemia is a frequent and serious adverse effect of antidiabetic therapy that is associated with both immediate and delayed adverse clinical outcomes, as well as increased economic costs. Inpatients who develop hypoglycaemia are likely to experience a long duration of hospital stay and increased mortality. This Review describes the clinical presentation, precipitating causes, diagnosis and acute management of these diabetic emergencies, including a discussion of practical strategies for their prevention.

Nat Rev Endocrinol 2016; 12: 222–232. doi: 10.1038/nrendo.2016.15

Key points
  • Diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) are serious acute metabolic complications of diabetes mellitus, representing points along a spectrum of hyperglycaemic emergencies caused by poor glycaemic control
  • DKA comprises hyperglycaemia, hyperketonaemia and metabolic acidosis; diagnostic criteria for HHS include a plasma glucose level >33.3 mmol/l, serum osmolality >320 mmol/kg and no appreciable metabolic acidosis and ketonaemia
  • Management objectives for DKA and HHS include restoration of circulatory volume and tissue perfusion; correction of hyperglycaemia, ketogenesis and electrolyte imbalance; and identification and treatment of the precipitating event
  • Hypoglycaemia is defined as a blood glucose level <3.9 mmol/l in both the inpatient and outpatient settings
  • Severe hypoglycaemic events can negate the beneficial effects of intensive glycaemic management strategies that target near normoglycaemia among patients with diabetes mellitus
  • Patient and family education regarding the signs and symptoms of hypoglycaemia, as well as the methods available for treatment, can effectively reduce the risk of severe hypoglycaemic episodes

Diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS) and hypoglycaemia are frequent and serious complications arising among patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). In the USA, ~145,000 cases of DKA occur each year1, 2. The rate of hospitalization for HHS is lower, accounting for <1% of all diabetes- related admissions3, 4. The frequency of emergency room visits for hypoglycaemia is similar to that reported for severe hyperglycaemia1, 5. Among hospitalized individuals, hypoglycaemia is a frequent complication of ongoing treatment for hyperglycaemia, with a reported incidence of 5–28% in intensive care unit (ICU) trials (depending on the intensity of glycaemic control)6, and 1–33% in non-ICU trials using subcutaneous insulin therapy7, 8.

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