Hyperosmolar hyperglycemic state medical therapy: Difference between revisions
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The American Diabetes Association (ADA) recommends the following therapy for hyperosmolar hyperglycemic state:<ref name="pmid2699725">{{cite journal |vauthors=Radhakrishna Pillai M, Balaram P, Bindu S, Hareendran NK, Padmanabhan TK, Nair MK |title=Interleukin 2 production in lymphocyte cultures: a rapid test for cancer-associated immunodeficiency in malignant cervical neoplasia |journal=Cancer Lett. |volume=47 |issue=3 |pages=205–10 |year=1989 |pmid=2699725 |doi= |url=}}</ref><ref name="urlDiabetes Care">{{cite web |url=http://care.diabetesjournals.org/content/32/7/1335?ijkey=34356f79daf21d51f95018c32e74e6df627e513c&keytype2=tf_ipsecsha |title=Diabetes Care |format= |work= |accessdate=}}</ref><ref name="pmid21978840">{{cite journal |vauthors=Nyenwe EA, Kitabchi AE |title=Evidence-based management of hyperglycemic emergencies in diabetes mellitus |journal=Diabetes Res. Clin. Pract. |volume=94 |issue=3 |pages=340–51 |year=2011 |pmid=21978840 |doi=10.1016/j.diabres.2011.09.012 |url=}}</ref><ref name="pmid19564476">{{cite journal| author=Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN| title=Hyperglycemic crises in adult patients with diabetes. | journal=Diabetes Care | year= 2009 | volume= 32 | issue= 7 | pages= 1335-43 | pmid=19564476 | doi=10.2337/dc09-9032 | pmc=2699725 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19564476 }} </ref> | The American Diabetes Association (ADA) recommends the following therapy for hyperosmolar hyperglycemic state:<ref name="pmid2699725">{{cite journal |vauthors=Radhakrishna Pillai M, Balaram P, Bindu S, Hareendran NK, Padmanabhan TK, Nair MK |title=Interleukin 2 production in lymphocyte cultures: a rapid test for cancer-associated immunodeficiency in malignant cervical neoplasia |journal=Cancer Lett. |volume=47 |issue=3 |pages=205–10 |year=1989 |pmid=2699725 |doi= |url=}}</ref><ref name="urlDiabetes Care">{{cite web |url=http://care.diabetesjournals.org/content/32/7/1335?ijkey=34356f79daf21d51f95018c32e74e6df627e513c&keytype2=tf_ipsecsha |title=Diabetes Care |format= |work= |accessdate=}}</ref><ref name="pmid21978840">{{cite journal |vauthors=Nyenwe EA, Kitabchi AE |title=Evidence-based management of hyperglycemic emergencies in diabetes mellitus |journal=Diabetes Res. Clin. Pract. |volume=94 |issue=3 |pages=340–51 |year=2011 |pmid=21978840 |doi=10.1016/j.diabres.2011.09.012 |url=}}</ref><ref name="pmid19564476">{{cite journal| author=Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN| title=Hyperglycemic crises in adult patients with diabetes. | journal=Diabetes Care | year= 2009 | volume= 32 | issue= 7 | pages= 1335-43 | pmid=19564476 | doi=10.2337/dc09-9032 | pmc=2699725 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19564476 }} </ref> | ||
==== Fluid therapy ==== | |||
* Initial [[Intravenous fluids|fluid therapy]] is aimed towards expansion of the [[intravascular]], [[interstitial]], and [[intracellular]] volume, all of which are reduced in [[Hyperglycemic crises resident survival guide|hyperglycemic crises]]. | |||
* [[Fluid]] restoration also leads to increased [[renal]] [[perfusion]] and improves [[renal]] function. | |||
* The following options may be used for [[fluid]] restoration: | |||
** [[Saline solution|Isotonic saline]] (0.9% [[Sodium chloride|NaCl]]) is infused at a rate of 15–20 ml/kg/h or 1–1.5 L during the first hour. It may also be [[Infusion|infused]] at a rate of 250-500 ml/h if [[serum]] [[sodium]] is low. | |||
** Subsequent choice for [[Intravenous fluids|fluid]] replacement depends on [[hemodynamics]], the volume status of the body ([[Signs and Symptoms|signs and symptoms]] of [[dehydration]]), [[serum electrolyte]] levels, and [[urinary]] output.<ref name="urlDiabetic Ketoacidosis: Evaluation and Treatment - American Family Physician">{{cite web |url=http://www.aafp.org/afp/2013/0301/p337.html |title=Diabetic Ketoacidosis: Evaluation and Treatment - American Family Physician |format= |work= |accessdate=}}</ref> | |||
** Half [[normal saline]] (0.45% [[Sodium chloride|NaCl]] ) [[Infusion|infused]] at 250–500 ml/h is beneficial if the corrected [[serum]] [[sodium]] is normal or increased.<ref name="urlDiabetic Ketoacidosis: Evaluation and Treatment - American Family Physician" /><ref name="pmid3138479">{{cite journal |vauthors=Kageyama Y, Kawamura J, Ajisawa A, Yamada T, Iikuni K |title=A case of pseudohypoparathyroidism type 1 associated with gonadotropin resistance and hypercalcitoninaemia |journal=Jpn. J. Med. |volume=27 |issue=2 |pages=207–10 |year=1988 |pmid=3138479 |doi= |url=}}</ref> | |||
* Successful progress with fluid replacement is judged by, [[blood pressure]] monitoring, measurement of [[fluid]] input/output, laboratory values, and clinical examination. | |||
* [[Intravenous fluids|Fluid]] replacement usually leads to successful treatment of volume deficit within the first 24 hours. | |||
* In patients with [[renal]] or [[cardiac]] compromise, monitoring of [[serum]] [[osmolality]] and frequent assessment of [[cardiac]], [[renal]], and [[mental status]] must be performed during [[fluid resuscitation]] to avoid [[iatrogenic]] [[fluid overload]]. | |||
* Aggressive [[rehydration]] with subsequent resolution of the [[hyperosmolar]] state has been shown to be linked to a better response to low dose [[insulin]]. | |||
* Once the [[plasma]] [[glucose]] is ∼ 300 mg/dl, 5% [[dextrose]] should be added to replacement [[Intravenous fluids|fluids]] to allow continued [[insulin]] administration. | |||
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==References== | ==References== |
Revision as of 13:56, 25 September 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Medical Therapy
Basic principles
The basic principles of hyperosmolar hyperglycemic state treatment are:
- Rapid restoration of adequate circulation and perfusion with intravenous fluids.
- Correction of plasma osmolality and plasma glucose toward normal.
- Gradual rehydration and restoration of depleted electrolytes (especially sodium and potassium), even if serum levels appear adequate.
- Insulin to lower glucose levels.
- Identifying and treating precipitating events.
- Careful monitoring to detect and treat complications.
The American Diabetes Association (ADA) recommends the following therapy for hyperosmolar hyperglycemic state:[1][2][3][4]
Fluid therapy
- Initial fluid therapy is aimed towards expansion of the intravascular, interstitial, and intracellular volume, all of which are reduced in hyperglycemic crises.
- Fluid restoration also leads to increased renal perfusion and improves renal function.
- The following options may be used for fluid restoration:
- Isotonic saline (0.9% NaCl) is infused at a rate of 15–20 ml/kg/h or 1–1.5 L during the first hour. It may also be infused at a rate of 250-500 ml/h if serum sodium is low.
- Subsequent choice for fluid replacement depends on hemodynamics, the volume status of the body (signs and symptoms of dehydration), serum electrolyte levels, and urinary output.[5]
- Half normal saline (0.45% NaCl ) infused at 250–500 ml/h is beneficial if the corrected serum sodium is normal or increased.[5][6]
- Successful progress with fluid replacement is judged by, blood pressure monitoring, measurement of fluid input/output, laboratory values, and clinical examination.
- Fluid replacement usually leads to successful treatment of volume deficit within the first 24 hours.
- In patients with renal or cardiac compromise, monitoring of serum osmolality and frequent assessment of cardiac, renal, and mental status must be performed during fluid resuscitation to avoid iatrogenic fluid overload.
- Aggressive rehydration with subsequent resolution of the hyperosmolar state has been shown to be linked to a better response to low dose insulin.
- Once the plasma glucose is ∼ 300 mg/dl, 5% dextrose should be added to replacement fluids to allow continued insulin administration.
References
- ↑ Radhakrishna Pillai M, Balaram P, Bindu S, Hareendran NK, Padmanabhan TK, Nair MK (1989). "Interleukin 2 production in lymphocyte cultures: a rapid test for cancer-associated immunodeficiency in malignant cervical neoplasia". Cancer Lett. 47 (3): 205–10. PMID 2699725.
- ↑ "Diabetes Care".
- ↑ Nyenwe EA, Kitabchi AE (2011). "Evidence-based management of hyperglycemic emergencies in diabetes mellitus". Diabetes Res. Clin. Pract. 94 (3): 340–51. doi:10.1016/j.diabres.2011.09.012. PMID 21978840.
- ↑ Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN (2009). "Hyperglycemic crises in adult patients with diabetes". Diabetes Care. 32 (7): 1335–43. doi:10.2337/dc09-9032. PMC 2699725. PMID 19564476.
- ↑ 5.0 5.1 "Diabetic Ketoacidosis: Evaluation and Treatment - American Family Physician".
- ↑ Kageyama Y, Kawamura J, Ajisawa A, Yamada T, Iikuni K (1988). "A case of pseudohypoparathyroidism type 1 associated with gonadotropin resistance and hypercalcitoninaemia". Jpn. J. Med. 27 (2): 207–10. PMID 3138479.