Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state - Diabetic Hyperglycemia Diagnosis and Tests

Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state
2003
Jean-Louis Chiasson, Nahla Aris-Jilwan, Raphaël Bélanger, Sylvie Bertrand, Hugues Beauregard, Jean-Marie Ékoé, Hélène Fournier and Jana Havrankova
CMAJ

From the Division of Endocrinology–Metabolism, Centre hospitalier de l'Université de Montréal, and the Department of Medicine, Université de Montréal, Montréal, Que.

Correspondence to: Dr. Jean-Louis Chiasson, Research Centre, Centre hospitalier de l'Université de Montréal, Rm. 8-202, Masson Pavilion, 3850 St-Urbain St., Montreal QC H2W 1T7; fax 514 412-7208; jean.louis.chiasson@umontreal.ca

Abstract

DIABETIC KETOACIDOSIS AND THE HYPERGLYCEMIC hyperosmolar state are the most serious complications of diabetic decompensation and remain associated with excess mortality. Insulin deficiency is the main underlying abnormality. Associated with elevated levels of counterregulatory hormones, insulin deficiency can trigger hepatic glucose production and reduced glucose uptake, resulting in hyperglycemia, and can also stimulate lipolysis and ketogenesis, resulting in ketoacidosis. Both hyperglycemia and hyperketonemia will induce osmotic diuresis, which leads to dehydration. Clinical diagnosis is based on the finding of dehydration along with high capillary glucose levels with or without ketones in the urine or plasma. The diagnosis is confirmed by the blood pH, serum bicarbonate level and serum osmolality. Treatment consists of adequate correction of the dehydration, hyperglycemia, ketoacidosis and electrolyte deficits.

Diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) appear as 2 extremes in the spectrum of diabetic decompensation.1 They remain the most serious acute metabolic complications of diabetes mellitus and are still associated with excess mortality. Because the approach to the diagnosis and treatment of these hyperglycemic crises are similar, we have opted to address them together.

The incidence of DKA is between 4.6 and 8.0 per 1000 person-years among patients with diabetes, whereas that of HHS is less than 1 per 1000 person-years.2 Based on the estimated diabetic population in Canada,3 we can anticipate that 5000–10 000 patients will be admitted to hospital because of DKA every year and 500–1000 patients because of HHS. The estimated mortality rate for DKA is between 4% and 10%, whereas the rate for HHS varies from 10% to 50%, the range most likely owing to underlying illnesses.2

Pathogenesis

In both DKA and HHS, the underlying metabolic abnormality results from the combination of absolute or relative insulin deficiency and increased amounts of counterregulatory hormones.

© 2003 Canadian Medical Association or its licensors

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