Hyperglycemic Crisis

Diabetes Ketoacidosis (DKA) Hyperglycemic Hyperosmolar State (HHS)

Ext.Sorawit Boonyathee

1) Hyperglycemia > 250 mg/dL

2) Metabolic Acidosis (High Anion gap > 12 mEq/L)

HCO3 < 15 mEq/L or

Arterial pH < 7.3

3) Ketonemia (moderately positive) or Ketonuria

แนวทางการวินิจฉัย DKA

1) Hyperglycemia > 600 mg/dL

2) Effective Serum Osmolarity > 320 mOsm/kg

แนวทางการวินิจฉัย HHS

Acute Illness

Infection (30 – 40 %)

Omission of Insulin (15 – 20 %)

New-Onset Diabetes (20 – 25 %)

Cerebrovascular accident

Myocardial Infarction

Acute pancreatitis

Other medical illness

Drugs

Interferon - alpha

Clozapine Cocaine Lithium

Olanzapine Orlistat

Protease inhibitor Terbutaline

Precipitating Factor : DKA

Acute Illness

• Infection

• Cerebrovascular accident

• Myocardial infarction

• Acute pancreatitis

• Pulmonary embolus

• Peritoneal dialysis

• Renal failure

• Intestinal obstruction

• Subdural hematoma

• Previously undiagnosed

diabetes

Drugs

• Calcium channel blockers

• Chlopromazine

• Cimetidime

• Immunosuppressive agents

• Phenytoin

• Propanolol

• Steroids

• Thiazides diuretics

• Total parenteral nutrition

Endocrine

• Acromegaly

• Thyrotoxicosis

• Cushing’s

syndrome

Precipitating Factor : HHS

Diagnosis Criteria

Mild Moderate Severe HHS

Plasma glucose

> 250 mg/dL > 600 mg/dL

Arterial pH 7.25 – 7.30 7.00 – 7.25 < 7.00 > 7.30

Serum HCO3

(mEq/L) 15 – 18 10 – 15 < 10 > 15

Degree of DKA

Diagnosis Criteria Mild Moderate Severe HHS

Urine Ketone Positive Small

Serum Ketone Positive Small

Effective Serum Osmolarity

Variable > 320

mOsm/kg

Degree of DKA (Cont.)

Diagnosis Criteria

Mild Moderate Severe HHS

Anion Gap > 10 > 12 > 12 < 12

Mental Status Alert Alert / Drowsy

Stupor / Coma

Stupor / Coma

Degree of DKA (Cont.)

แนวทางการรักษา

Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetic Association. Diabetes Care. 2009;32:1335-1343.

plasma glucose < 11.1 mmol/L (200 mg/dL) (at this point, insulin can be decreased by 50%)

serum bicarbonate > 18 mmol/L (18 mEq/L) venous pH > 7.3 anion gap < 10

Criteria for Resolution : DKA

Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29:2739-2748.

plasma glucose < 12.2 to 16.7 mmol/L

(< 250 - 300 mg/dL)

plasma effective osmolality < 315 mmol/kg

(< 315 mOsm/kg)

Improvement in hemodynamic and mental status

Criteria for Resolution : HHS

Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29:2739-2748.