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Online Letters: Comments and Responses

Hyperglycemic Crises in Adult Patients With Diabetes: A Consensus Statement From the American Diabetes Association

Response to Rosival

  1. Abbas E. Kitabchi, PHD, MD1,
  2. Guillermo E. Umpierrez, MD2,
  3. Mary B. Murphy, RN, MBA, CDE1 and
  4. Robert A. Kreisberg, MD3
  1. 1Division of Endocrinology, Diabetes, and Metabolism, University of Tennessee Health Science Center, Memphis, Tennessee
  2. 2Clinical Research Center and Diabetes Unit, Grady Memorial Hospital/Emory University School of Medicine, Atlanta, Goergia
  3. 3University of South Alabama, Baptist Health System, Birmingham, Alabama
  1. Address correspondence to Dr. Abbas E. Kitabchi, Director, Division of Endocrinology, Diabetes, and Metabolism, University of Tennessee Health Science Center, 956 Court Ave., Suite D334, Memphis, TN 38163. E-mail: akitabchi{at}utmem.edu
Diabetes Care 2007 Jul; 30(7): e76-e76. https://doi.org/10.2337/dc07-0694
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Response to Rosival

In response to the comments by Dr. Rosival (1), we point out that impaired mental status is present in 52% of adult patients with diabetic ketoacidosis (DKA) and 74% of patients with hyperglycemic hyperosmolar syndrome (HHS) (2). Although most patients are lethargic or stuporous on arrival, 13% of admissions for DKA and 23% for HHS present with loss of consciousness. In previous reports (3–6), we evaluated the relationship between the initial biochemical data and level of consciousness in adult patients with DKA (4). In 1980, we reported that age, admission plasma glucose, bicarbonate, blood urea nitrogen, and osmolality correlated with the level of consciousness; however, arterial pH and serum ketone bodies did not (4). Coma was uncommon in patients younger than 40 years old, and in both groups it was most frequent in patients aged >65 years. Furthermore, in a subsequent study of 132 patients with DKA, we found a significant correlation between serum osmolality and level of consciousness. A serum osmolality >320 mOsm/kg was observed in stuporous or comatose patients, while an osmolality <320 mOsm/kg was observed in alert patients with DKA (5). More recently, in 144 consecutive patients with DKA and 23 subjects with HHS, we reported that loss of consciousness correlated better with serum osmolality than with severity of metabolic acidosis. In patients with DKA, the mean ± SEM serum osmolality and arterial pH was 311 ± 3 mmol/kg and 7.18 in noncomatose patients and 345 ± 4 mmol/kg and 7.03 in comatose patients, respectively (P < 0.01 for both). Furthermore, in the absence of significant metabolic acidosis in patients with HHS, we observed a positive correlation between level of consciousness and serum osmolality (2).

Dr. Rosival reports a contradiction between our findings, which are summarized in the recent ADA consensus statement in adult subjects (6), and a recent retrospective study in 225 children with DKA (7). In this cohort, either pH or bicarbonate measurements were available on admission in 218 episodes: pH in 174, plasma bicarbonate in 212, and both measurements in 168. Only four of these patients presented with loss of consciousness. In this report, the admission consciousness level was related to the degree of acidosis rather than to blood glucose, sodium, or osmolality level. Level of consciousness also appeared to be related to age, with younger children more likely to have a reduced consciousness level.

It is not clear what explains the differences between admission levels of consciousness and admission biochemical data in adults and children with DKA. We believe that duration of DKA may be an important factor. Thus, in children, the duration of DKA may be shorter than in adults, limiting their exposure to acute hyperglycemia. Therefore, the degree of acidosis may play a more prominent role in the level of consciousness in children with DKA.

Footnotes

  • DIABETES CARE

References

  1. ↵
    Rosival V: Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association (Letter). Diabetes Care 30:e75, 2007. DOI:10.2337/dc07-0511
    OpenUrlFREE Full Text
  2. ↵
    Umpierrez GE, Kelly JP, Navarrete JE, Casals MM, Kitabchi AE: Hyperglycemic crises in urban blacks. Arch Intern Med 157:669–675, 1997
    OpenUrlCrossRefPubMedWeb of Science
  3. ↵
    Kitabchi AE, Umpierrez GE, Murphy MB, Kriesberg RA: Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association (Consensus Statement). Diabetes Care 29:2739–2748, 2006
    OpenUrlFREE Full Text
  4. ↵
    Kitabchi AE, Ayyagari V, Guerra SM: The efficacy of low-dose versus conventional therapy of insulin for treatment of diabetec ketoacidosis. Ann Intern Med 84:663–638, 1976
    OpenUrl
  5. ↵
    Morris LR, Kitabchi AE: Efficacy of low-dose insulin therapy for severely obtunded patients in diabetic ketoacidosis. Diabetes Care 3:53–56, 1980
    OpenUrlAbstract/FREE Full Text
  6. ↵
    Kitabchi AE, Fisher JN: Insulin therapy of diabetic ketoacidosis: physiologic versus pharmacologic doses of insulin and their routes of administration. In Handbook of Diabetes Mellitus. Brownlee M, Ed. New York, Garland ATPM Press, 1981, p. 95–149
  7. ↵
    Edge JA, Roy Y, Bergomi A, Murphy NP, Ford-Adams ME, Ongg KK, Dunger DB: Conscious level in children with diabetic ketoacidosis is related to severity of acidosis and not to blood glucose concentration. Pediatr Diabetes 7:11–15, 2006
    OpenUrlPubMedWeb of Science
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Hyperglycemic Crises in Adult Patients With Diabetes: A Consensus Statement From the American Diabetes Association
Abbas E. Kitabchi, Guillermo E. Umpierrez, Mary B. Murphy, Robert A. Kreisberg
Diabetes Care Jul 2007, 30 (7) e76; DOI: 10.2337/dc07-0694

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Hyperglycemic Crises in Adult Patients With Diabetes: A Consensus Statement From the American Diabetes Association
Abbas E. Kitabchi, Guillermo E. Umpierrez, Mary B. Murphy, Robert A. Kreisberg
Diabetes Care Jul 2007, 30 (7) e76; DOI: 10.2337/dc07-0694
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