Management of Hyperglycemic Crises in Patients With Diabetes
- Abbas E. Kitabchi, PHD, MD,
- Guillermo E. Umpierrez, MD,
- Mary Beth Murphy, RN, MS, CDE, MBA,
- Eugene J. Barrett, MD, PHD,
- Robert A. Kreisberg, MD,
- John I. Malone, MD and
- Barry M. Wall, MD
- From the Division of Endocrinology (A.E.K., G.E.U., M.B.M.), University of Tennessee, and the Department of Nephrology (B.M.W.), Veterans Administration Hospital, Memphis, Tennessee; the Division of Endocrinology (E.J.B.), University of Virginia, Charlottesville, Virginia; the College of Medicine (R.A.K.), University of South Alabama, Mobile, Alabama; and the Department of Pediatrics (J.I.M.), University of South Florida, Tampa, Florida.
- Address correspondence and reprint requests to Abbas E. Kitabchi, PhD, MD, University of Tennessee, Memphis, Division of Endocrinology, 951 Court Ave., Room 335M, Memphis, TN 38163. E-mail: akitabchi{at}utmem.edu .
Article Figures & Tables
Figures
- Figure 1
—The triad of DKA (hyperglycemia, acidemia, and ketonemia) and other conditions with which the individual components are associated. From Kitabchi and Wall (19).
- Figure 2
—Proposed biochemical changes that occur during DKA leading to increased gluconeogenesis and lipolysis and decreased glycolysis. Note that lipolysis occurs mainly in adipose tissue. Other events occur primarily in the liver (except some gluconeogenesis in the kidney). Lighter arrows indicate inhibited pathways in DKA. F-6-P, fructose-6-phosphate; G-(X)-P, glucose-(X)-phosphate; HK, hexokinase; HMP, hexose monophosphate; PC, pyruvate carboxylase; PFK, phosphofructokinase; PEP, phosphoenolpyruvate; PK, pyruvate kinase; TCA, tricarboxylic acid; TG, triglycerides. From Kitabchi et al. (6).
- Figure 3
—Pathogensis of DKA and HHS.
- Figure 4
—Protocol for the management of adult patients with DKA. *DKA diagnostic criteria: blood glucose >250 mg/dl, arterial pH <7.3, bicarbonate <15 mEq/l, and moderate ketonuria or ketonemia. †After history and physical examination, obtain arterial blood gases, complete blood count with differential, urinalysis, blood glucose, BUN, electrolytes, chemistry profile, and creatinine levels STAT as well as an electrocardiogram. Obtain chest X ray and cultures as needed. ‡Serum Na should be corrected for hyperglycemia (for each 100 mg/dl glucose >100 mg/dl, add 1.6 mEq to sodium value for corrected serum sodium value).
- Figure 5
—Protocol for the management of adult patients with HHS. *Diagnostic criteria: blood glucose >600 mg/dl, arterial pH >7.3, bicarbonate >15 mEq/l, effective serum osmolality >320 mOsm/kg H2O, and mild ketonuria or ketonemia. This protocol is for patients admitted with mental status change or severe dehydration who require admission to an intensive care unit. For less severe cases, see text for management guidelines. Effective serum osmolality calculation: 2[measured Na (mEq/l)] + glucose (mg/dl)/18. †After history and physical examination, obtain arterial blood gases, complete blood count with differential, urinalysis, plasma glucose, BUN, electrolytes, chemistry profile, and creatinine levels STAT as well as an electrocardiogram. Chest X ray and cultures as needed. ‡Serum Na should be corrected for hyperglycemia (for each 100 mg/dl glucose >100 mg/dl, add 1.6 mEq to sodium value for corrected serum value).
- Figure 6
—DKA/HHS flowsheet for the documentation of clinical parameters, fluid and electrolytes, laboratory values, insulin therapy, and urinary output. From Kitabchi et al. (6).
- Figure 7
—Protocol for the management of pediatric patients (<20 years) with DKA or HHS. *DKA diagnostic criteria: blood glucose >250 mg/dl, venous pH <7.3, bicarbonate <15 mEq/l, and moderate ketonuria or ketonemia. †HHS diagnostic criteria: blood glucose >600 mg/dl, venous pH >7.3, bicarbonate >15 mEq/l, and altered mental status or severe dehydration. ‡After the initial history and physical examination, obtain blood glucose, venous blood gasses, electrolytes, BUN, creatinine, calcium, phosphorous, and urine analysis STAT. §Usually 1.5 times the 24-h maintenance requirements (∼5 ml · kg-1 · h-1) will accomplish a smooth rehydration; do not exceed two times the maintenance requirement. ∥The potassium in solution should be 1/3 KPO4 and 2/3 KCl or Kacetate.
Tables
- Table 1
- Table 2
- Table 3
- Table 4
- Table 5
- Table 6
- Table 7
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