Management of diabetic ketoacidosis and hyperglycemic hyperosmolar state in adults

ABSTRACT

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) are two acute complications of diabetes associated with high mortality rate if not efficiently and effectively treated. Both entities are characterized by insulinopenia, hyperglycemia and dehydration. DKA and HHS are two serious complications of diabetes associated with significant mortality and a high healthcare costs. The overall DKA mortality in the US is less than 1%, but a rate higher than 5% is reported in the elderly and in patients with concomitant life-threatening illnesses. Mortality in patients with HHS is reported between 5% and 16%, which is about 10 times higher than the mortality in patients with DKA. Objectives of management include restoration circulatory volume and tissue perfusion, resolution of hyperglycemia, correction of electrolyte imbalance and increased ketogenesis.

KEYWORDS:

• Ketoacidosis
• hyperglycemia hyperosmolar state
• diabetic ketoacidosis
• hospital
• inpatient care

Financial & competing interests disclosure

G.E. Umpierrez is supported in part by research grants from the American Diabetes Association (1-14-LLY-36), PHS grant UL1 RR025008 from the Clinical Translational Science Award Program (M01 RR-00039), National Institute of Health, National Center for Research Resources and has received unrestricted research support for inpatient studies (to Emory University) from Novo Nordisk, Boehringer Ingelheim and Merck and has received consulting fees and/or honoraria for membership in advisory boards from Novo Nordisk, Glytec, Sanofi, Merck, and Boehringer Ingelheim. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are characterized by insulinopenia, hyperglycemia and dehydration. Clinically, they differ by the presence of increased ketones bodies and severity of metabolic acidosis.

• The overall DKA mortality in the US is <1%, but a rate >5% is reported in the elderly and in patients with concomitant life-threatening illnesses.

• Mortality in patients with HHS is reported between 5 and 16%, which is about 10 times higher than the mortality in patients with DKA.

• Treatment of DKA represents a substantial economic burden. The estimated hospital cost for patients with hyperglycemic crises exceeds $2 billion per year.

• In the U. S., the most common precipitating cause are poor adherence to therapy (insulin omission), infection and newly diagnosed diabetes. In contrast, in third-world countries, infections and access of care are the most prevalent precipitating causes.

• Objectives of management include restoration circulatory volume and tissue perfusion, resolution of hyperglycemia, correction of electrolyte imbalance and increased ketogenesis.

• Most patients with DKA can be safely managed in observational and step-down units, without requiring admission in an intensive care unit (ICU).

• With improved outpatient treatment and follow-up programs and better adherence to self-care, about 50–75% of DKA admissions could be avoided.