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Wagner B, Ing TS, Roumelioti ME, Sam R, Argyropoulos CP, Lew SQ, Unruh ML, Dorin RI, Degnan JH, Tzamaloukas AH. Hypernatremia in Hyperglycemia: Clinical Features and Relationship to Fractional Changes in Body Water and Monovalent Cations during Its Development. J Clin Med 2024; 13:1957. [PMID: 38610721 PMCID: PMC11012913 DOI: 10.3390/jcm13071957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/13/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
In hyperglycemia, the serum sodium concentration ([Na]S) receives influences from (a) the fluid exit from the intracellular compartment and thirst, which cause [Na]S decreases; (b) osmotic diuresis with sums of the urinary sodium plus potassium concentration lower than the baseline euglycemic [Na]S, which results in a [Na]S increase; and (c), in some cases, gains or losses of fluid, sodium, and potassium through the gastrointestinal tract, the respiratory tract, and the skin. Hyperglycemic patients with hypernatremia have large deficits of body water and usually hypovolemia and develop severe clinical manifestations and significant mortality. To assist with the correction of both the severe dehydration and the hypovolemia, we developed formulas computing the fractional losses of the body water and monovalent cations in hyperglycemia. The formulas estimate varying losses between patients with the same serum glucose concentration ([Glu]S) and [Na]S but with different sums of monovalent cation concentrations in the lost fluids. Among subjects with the same [Glu]S and [Na]S, those with higher monovalent cation concentrations in the fluids lost have higher fractional losses of body water. The sum of the monovalent cation concentrations in the lost fluids should be considered when computing the volume and composition of the fluid replacement for hyperglycemic syndromes.
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Affiliation(s)
- Brent Wagner
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87122, USA; (B.W.); (M.-E.R.); (C.P.A.)
- Kidney Institute of New Mexico, University of New Mexico Health Sciences Center, Albuquerque, NM 87122, USA
- Raymond G. Murphy Veterans Affairs Medical Center, Albuquerque, NM 87108, USA
| | - Todd S. Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, USA
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87122, USA; (B.W.); (M.-E.R.); (C.P.A.)
| | - Ramin Sam
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California in San Francisco School of Medicine, San Francisco, CA 94110, USA;
| | - Christos P. Argyropoulos
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87122, USA; (B.W.); (M.-E.R.); (C.P.A.)
| | - Susie Q. Lew
- Department of Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA;
| | - Mark L. Unruh
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87122, USA;
| | - Richard I. Dorin
- Department of Medicine, Division of Endocrinology, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico, Albuquerque, NM 87108, USA;
| | - James H. Degnan
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque, NM 87131, USA;
| | - Antonios H. Tzamaloukas
- Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM 87108, USA
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Lovegrove SS, Dubbs SB. Hyperosmolar Hyperglycemic State. Emerg Med Clin North Am 2023; 41:687-696. [PMID: 37758417 DOI: 10.1016/j.emc.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Hyperosmolar hyperglycemic state (HHS) is an underrecognized diabetic emergency with high morbidity and mortality. Many features of HHS overlap with those of diabetic ketoacidosis but key differentiators for HHS are serum osmolality greater than 320 mOsm/kg, lack of metabolic acidosis, and minimal to no presence of ketones. HHS is often triggered by an underlying illness-most commonly infection but may also be triggered by stroke, acute coronary syndrome, and other acute illnesses. Treatment guidelines recommend aggressive volume-repletion of osmotic losses in addition to insulin therapy, plus treatment of the underlying cause.
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Affiliation(s)
- Spencer S Lovegrove
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor Suite 200, Baltimore, MD 21201, USA
| | - Sarah B Dubbs
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor Suite 200, Baltimore, MD 21201, USA.
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Everett EM, Copeland T, Wisk LE, Chao LC. Risk Factors for Hyperosmolar Hyperglycemic State in Pediatric Type 2 Diabetes. Pediatr Diabetes 2023; 2023:1318136. [PMID: 37614411 PMCID: PMC10445777 DOI: 10.1155/2023/1318136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
Background There is a paucity of data on the risk factors for the hyperosmolar hyperglycemic state (HHS) compared with diabetic ketoacidosis (DKA) in pediatric type 2 diabetes (T2D). Methods We used the national Kids' Inpatient Database to identify pediatric admissions for DKA and HHS among those with T2D in the years 2006, 2009, 2012, and 2019. Admissions were identified using ICD codes. Those aged <9yo were excluded. We used descriptive statistics to summarize baseline characteristics and Chi-squared test and logistic regression to evaluate factors associated with admission for HHS compared with DKA in unadjusted and adjusted models. Results We found 8,961 admissions for hyperglycemic emergencies in youth with T2D, of which 6% were due to HHS and 94% were for DKA. These admissions occurred mostly in youth 17-20 years old (64%) who were non-White (Black 31%, Hispanic 20%), with public insurance (49%) and from the lowest income quartile (42%). In adjusted models, there were increased odds for HHS compared to DKA in males (OR 1.77, 95% CI 1.42-2.21) and those of Black race compared to those of White race (OR 1.81, 95% CI 1.34-2.44). Admissions for HHS had 11.3-fold higher odds for major or extreme severity of illness and 5.0-fold higher odds for mortality. Conclusion While DKA represents the most admissions for hyperglycemic emergencies among pediatric T2D, those admitted for HHS had higher severity of illness and mortality. Male gender and Black race were associated with HHS admission compared to DKA. Additional studies are needed to understand the drivers of these risk factors.
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Affiliation(s)
- Estelle M. Everett
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Timothy Copeland
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Lauren E. Wisk
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Lily C. Chao
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Injeyan M, Baron S, Lauzier B, Gaillard‐Le Roux B, Denis M. Hyperglycaemic hyperosmolar state and cerebral thrombophlebitis in paediatrics: A case report. Endocrinol Diabetes Metab 2023; 6:e389. [PMID: 36722309 PMCID: PMC10000624 DOI: 10.1002/edm2.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/12/2022] [Accepted: 10/16/2022] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Hyperglycaemic hyperosmolar state (HHS) is a known complication of type 2 diabetes mellitus; however, carbonated carbohydrate fluid intake may precipitate a more severe presentation of type 1 diabetes mellitus with hyperosmolar state. The management of these patients is not easy and can lead to severe complications such as cerebral venous thrombosis. METHODS We present the case of a 21-month-old boy admitted for consciousness disorders revealing a hyperglycaemic hyperosmolar state on a new-onset type 1 diabetes and who developed cerebral venous thrombosis. RESULTS AND CONCLUSION Emergency physicians should be aware of HHS in order to start the appropriate treatment as early as possible and to monitor the potential associated acute complications. This case highlights the importance of decreasing very gradually the osmolarity in order to avoid cerebral complications. Cerebral venous thrombosis in HHS paediatric patients is rarely described, and it is important to recognize that not all episodes of acute neurological deterioration in HHS or diabetic ketoacidosis are caused by cerebral oedema.
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Affiliation(s)
- Maud Injeyan
- Department of PediatricsCHU de NantesNantesFrance
| | - Sabine Baron
- Department of PediatricsCHU de NantesNantesFrance
- Department of Pediatric EndocrinologyCHU de NantesNantesFrance
| | - Benjamin Lauzier
- Pediatric Intensive Care UnitCHU de NantesNantesFrance
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thoraxNantesFrance
| | | | - Manon Denis
- Pediatric Intensive Care UnitCHU de NantesNantesFrance
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thoraxNantesFrance
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5
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Hamud AA, Mudawi K, Shamekh A, Kadri A, Powell C, Abdelgadir I. Diabetic ketoacidosis fluid management in children: systematic review and meta-analyses. Arch Dis Child 2022; 107:1023-1028. [PMID: 35738870 DOI: 10.1136/archdischild-2022-324042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/13/2022] [Indexed: 11/04/2022]
Abstract
IMPORTANCE Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, which may lead to significant morbidity and mortality. OBJECTIVES To compare the safety and efficacy of liberalised versus conservative intravenous fluid regimens in the management of DKA in children. DATA SOURCE AND STUDY SELECTION Databases from inception to January 2022: MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials were included. Only randomised controlled trials (RCTs) that included children aged under 18 years were assessed. Two reviewers performed data assessment and extraction. DATA EXTRACTION AND SYNTHESIS Three studies out of 1536 citations were included. MAIN OUTCOMES The time to the recovery from the DKA; the frequency of paeditric intensive care unit (PICU) admissions; development of brain oedema; reduction in Glasgow Coma Scale (GCS); development of acute kidney injury and all-cause mortality. RESULTS We included three RCTs (n=1457). No evidence of difference was noted in the GCS reduction (risk ratio (RR)=0.77, 95% CI 0.44 to 1.36) or development of brain oedema (RR=0.50, 95% CI 0.15 to 1.68). The time to recovery from DKA was longer in the conservative group (mean difference=1.42, 95% CI 0.28 to 2.56). Time to hospital discharge, adverse or serious adverse events were comparable in the two studied groups. CONCLUSION There is no evidence from this meta-analysis that rate of fluid administration has any effect on adverse neurological and other outcomes or length of hospital stay.
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Affiliation(s)
| | - Khalid Mudawi
- Paediatric Emergency Department, Sidra Medicine, Doha, Qatar
| | - Ahmed Shamekh
- Paediatric Emergency Department, Sidra Medicine, Doha, Qatar
| | - Ayodeji Kadri
- Paediatric Emergency Department, Sidra Medicine, Doha, Qatar
| | - Colin Powell
- Paediatric Emergency Department, Sidra Medicine, Doha, Qatar
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Glaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, Wolfsdorf JI, Codner E. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022; 23:835-856. [PMID: 36250645 DOI: 10.1111/pedi.13406] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/01/2023] Open
Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Austria Medical University of Graz, Graz, Austria
| | - Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Valentino Cherubini
- Department of Women's and Children's Health, G. Salesi Hospital, Ancona, Italy
| | - Sylvia Estrada
- Department of Pediatrics, Division of Endocrinology and Metabolism, University of the Philippines, College of Medicine, Manila, Philippines
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Brar PC, Tell S, Mehta S, Franklin B. Hyperosmolar diabetic ketoacidosis-- review of literature and the shifting paradigm in evaluation and management. Diabetes Metab Syndr 2021; 15:102313. [PMID: 34731818 DOI: 10.1016/j.dsx.2021.102313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 09/22/2021] [Accepted: 10/10/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hyperosmolar diabetic ketoacidosis (H-DKA), a distinct clinical entity, is the overlap of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). AIM We describe the clinical presentation, metabolic aberrations, and associated morbidity/mortality of these cases with H-DKA. We highlight the problem areas of medical care which require particular attention when caring for pediatric diabetes patients presenting with H-DKA. METHODS In our study we reviewed the literature back to 1963 and retrieved twenty-four cases meeting the criteria of H-DKA: glucose >600 mg/dL, pH < 7.3, bicarbonate <15 mEq/L, and serum osmolality >320 mOsm/kg, while adding three cases from our institution. RESULTS Average age of presentation of H-DKA was 10.2 years ± 4.5 years in females and 13.3 years ± 4 years in males, HbA1c was 13%. Biochemical parameters were consistent with severe dehydration: serum osmolality = 394.8±55 mOsm/kg, BUN = 48±22 mg/dL, creatinine = 2.81±1.03 mg/dL. Acute kidney injury, present in 12 cases, was the most frequent end-organ complication. CONCLUSION Multi-organ involvement with AKI, rhabdomyolysis, pancreatitis, neurological and cardiac issues such as arrhythmias, are common in H-DKA. Aggressive fluid management, insulin therapy and supportive care can prevent acute and long term adverse outcomes in children and adolescents.
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Affiliation(s)
- Preneet Cheema Brar
- Division of Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, New York, USA.
| | - Shoshana Tell
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado Anschutz Medical Campus & Children's Hospital Colorado, Aurora, CO, USA
| | - Shilpa Mehta
- Division of Pediatric Endocrinology and Diabetes, New York Medical College, Hawthorne, NY, USA
| | - Bonita Franklin
- Division of Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, New York, USA
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Gohil A, Malin S, Abulebda K, Hannon TS. A Complicated Case of COVID-19 and Hyperglycemic Hyperosmolar Syndrome in an Adolescent Male. Horm Res Paediatr 2021; 94:71-75. [PMID: 33789280 PMCID: PMC8089435 DOI: 10.1159/000514281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/07/2021] [Indexed: 11/29/2022] Open
Abstract
Emerging data demonstrate that comorbid conditions and older age are contributing factors to COVID-19 severity in children. Studies involving youth with COVID-19 and diabetes are lacking. We report the case of a critically ill adolescent male with obesity, type 2 diabetes, and COVID-19 who presented with hyperglycemic hyperosmolar syndrome (HHS). This case highlights a challenge for clinicians in distinguishing severe complications of COVID-19 from those seen in HHS. Youth with obesity and type 2 diabetes may represent a high-risk group for severe COVID-19 disease, an entity that to date has been well-recognized in adults but remains rare in children and adolescents.
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Affiliation(s)
- Anisha Gohil
- Division of Endocrinology & Diabetes, Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana, USA,* Anisha Gohil, Division of Endocrinology & Diabetes, Department of Pediatrics, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 5960, Indianapolis, IN 46202 (USA),
| | - Stefan Malin
- Division of Pediatric Critical Care, Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kamal Abulebda
- Division of Pediatric Critical Care, Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tamara S. Hannon
- Division of Endocrinology & Diabetes, Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Maduemem KE, Adesanya O, Anuruegbe OO, Rafiq A. Hyperglycaemic hyperosmolar state: first presentation of type 1 diabetes mellitus in an adolescent with complex medical needs. BMJ Case Rep 2021; 14:14/2/e237793. [PMID: 33542015 PMCID: PMC7868183 DOI: 10.1136/bcr-2020-237793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This is a case of hyperglycaemic hyperosmolar state (HHS) as first presentation of type 1 diabetes mellitus in a 14-year-old girl with background complex medical needs. She presented with marked hyperglycaemia (56 mmol/L) without significant ketonaemia (2.6 mmol/L) and serum hyperosmolality (426 mOsm/kg). Managing her profound hypernatraemic (>180 mmol/L) dehydration was challenging but resulted in good outcome. Paediatric patients with HHS will likely be treated with the diabetes ketoacidosis (DKA) protocol because of perceived rarity of HHS leading to inadequate rehydration and risk of vascular collapse. Hence, emphasis on the differences in the management protocols of DKA and HHS is paramount. Prompt recognition and adequate management are crucial to avert complications. The undesirable rate of decline of hypernatraemia due to the use of hypotonic fluid was captured in this case. We describe the pivotal role of liberal fluid therapy with non-hypotonic fluids.
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Affiliation(s)
- Kene Ebuka Maduemem
- College of Medicine and Veterinary Medicine, University of Edinburgh Division of Medical and Radiological Sciences, Edinburgh, Edinburgh, UK,Paediatrics, Northampton General Hospital NHS Trust, Northampton, Northamptonshire, UK
| | - Omotayo Adesanya
- Paediatrics, Northampton General Hospital NHS Trust, Northampton, Northamptonshire, UK
| | - Obinna O Anuruegbe
- Paediatrics, Northampton General Hospital NHS Trust, Northampton, Northamptonshire, UK
| | - Anjum Rafiq
- Paediatrics, Northampton General Hospital NHS Trust, Northampton, Northamptonshire, UK
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Ing TS, Ganta K, Bhave G, Lew SQ, Agaba EI, Argyropoulos C, Tzamaloukas AH. The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications. Front Med (Lausanne) 2020; 7:477. [PMID: 32984372 PMCID: PMC7479837 DOI: 10.3389/fmed.2020.00477] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/15/2020] [Indexed: 12/15/2022] Open
Abstract
In hyperglycemia, hypertonicity results from solute (glucose) gain and loss of water in excess of sodium plus potassium through osmotic diuresis. Patients with stage 5 chronic kidney disease (CKD) and hyperglycemia have minimal or no osmotic diuresis; patients with preserved renal function and diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) have often large osmotic diuresis. Hypertonicity from glucose gain is reversed with normalization of serum glucose ([Glu]); hypertonicity due to osmotic diuresis requires infusion of hypotonic solutions. Prediction of the serum sodium after [Glu] normalization (the corrected [Na]) estimates the part of hypertonicity caused by osmotic diuresis. Theoretical methods calculating the corrected [Na] and clinical reports allowing its calculation were reviewed. Corrected [Na] was computed separately in reports of DKA, HHS and hyperglycemia in CKD stage 5. The theoretical prediction of [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu] in most clinical settings, except in extreme hyperglycemia or profound hypervolemia, was supported by studies of hyperglycemia in CKD stage 5 treated only with insulin. Mean corrected [Na] was 139.0 mmol/L in 772 hyperglycemic episodes in CKD stage 5 patients. In patients with preserved renal function, mean corrected [Na] was within the eunatremic range (141.1 mmol/L) in 7,812 DKA cases, and in the range of severe hypernatremia (160.8 mmol/L) in 755 cases of HHS. However, in DKA corrected [Na] was in the hypernatremic range in several reports and rose during treatment with adverse neurological consequences in other reports. The corrected [Na], computed as [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu], provides a reasonable estimate of the degree of hypertonicity due to losses of hypotonic fluids through osmotic diuresis at presentation of DKH or HHS and should guide the tonicity of replacement solutions. However, the corrected [Na] may change during treatment because of ongoing fluid losses and should be monitored during treatment.
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Affiliation(s)
- Todd S Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, United States
| | - Kavitha Ganta
- Medicine Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Gautam Bhave
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Susie Q Lew
- Department of Medicine, George Washington University School of Medicine, Washington, DC, United States
| | | | - Christos Argyropoulos
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Antonios H Tzamaloukas
- Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM, United States
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Schmitt J, Rahman AKMF, Ashraf A. Concurrent diabetic ketoacidosis with hyperosmolality and/or severe hyperglycemia in youth with type 2 diabetes. Endocrinol Diabetes Metab 2020; 3:e00160. [PMID: 32704574 PMCID: PMC7375104 DOI: 10.1002/edm2.160] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Prevalence of diabetic ketoacidosis (DKA) complicated by severe hyperglycaemia and hyperosmolality and its outcomes in youth with type 2 diabetes (T2DM) are not well-described. Our aim is to determine the frequency and clinical outcomes of isolated DKA, DKA with severe hyperglycaemia (DKA + SHG) and DKA with hyperglycaemia and hyperosmolality (DKA + HH) in youth with T2DM admitted for acute hyperglycaemic crisis. METHODS Through retrospective medical record review, patients with T2DM were identified and categorized into isolated DKA, DKA + SHG (DKA + glucose ≥33.3 mmol/L) and DKA + HH (DKA + glucose ≥33.3 mmol/L + osmolality ≥320 mmol/kg). RESULTS Forty-eight admissions in 43 patients ages 9-18 were included: 28 (58%) had isolated DKA, six (13%) had DKA + SHG and 14 (29%) had DKA + HH. Subgroups' demographics and medical history were similar. Seventeen patients (35%) had acute kidney injury (AKI). Odds of AKI were higher in DKA + SHG and DKA + HH relative to isolated DKA (P = .015 and .002 respectively). Frequency of altered mental status (AMS) was similar among groups. Three patients (6%) had concurrent soft-tissue infections at presentation with no differences among subgroup. Three patients (6%) had other medical complications. These occurred only in patients with AKI and DKA + SHG or AKI and DKA + HH. CONCLUSIONS In youth with T2DM, severe hyperglycaemia ± hyperosmolality frequently complicates DKA. Youth with DKA and features of hyperglycaemic hyperosmolar syndrome, including isolated severe hyperglycaemia, have increased odds of AKI.
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Affiliation(s)
- Jessica Schmitt
- Department of PediatricsUniversity of Alabama at BirminghamBirminghamALUSA
| | - AKM. Fazlur Rahman
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamALUSA
| | - Ambika Ashraf
- Department of PediatricsUniversity of Alabama at BirminghamBirminghamALUSA
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12
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Unresponsive: A Case of Hyperglycemia and Altered Mental Status. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2019. [DOI: 10.1016/j.cpem.2019.100726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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13
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Reddy A, Finley L, Horrall S. Hyperosmolar hyperglycemic syndrome in a young boy. Proc (Bayl Univ Med Cent) 2019; 32:627-628. [PMID: 31656445 DOI: 10.1080/08998280.2019.1646598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 07/10/2019] [Accepted: 07/18/2019] [Indexed: 01/11/2023] Open
Abstract
We describe a 6-year-old boy who presented to the emergency department with the complaint of nausea and vomiting with diarrhea. Workup revealed a glucose level of 1904 mg/dL, and hyperglycemic hyperosmolar syndrome was diagnosed. Hyperglycemic hyperosmolar syndrome is very rare in the pediatric population, but recent published reports suggest that the incidence of this disorder may be increasing.
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Affiliation(s)
- Archana Reddy
- College of Medicine, Texas A&M Health Science CenterTempleTexas
| | - Leland Finley
- Department of Emergency Medicine, Baylor Scott & White Medical Center-TempleTempleTexas
| | - Shawn Horrall
- Department of Emergency Medicine, Baylor Scott & White Medical Center-TempleTempleTexas
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 364] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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15
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Tufan-Pekkucuksen N, Gazzaneo MC, Afonso NS, Swartz SJ, Angelo JR, Srivaths P. Thrombocytopenia-associated multi-organ failure secondary to hyperglycemic, hyperosmolar non-ketotic syndrome: A case report. Pediatr Diabetes 2018; 19:574-577. [PMID: 29165898 DOI: 10.1111/pedi.12608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/28/2017] [Accepted: 10/17/2017] [Indexed: 11/30/2022] Open
Abstract
Thrombocytopenia associated multi-organ failure (TAMOF) is a clinical syndrome with features of new onset thrombocytopenia, increased lactate dehydrogenase, and multi-organ failure in critically ill patients. TAMOF can be the initial presentation of an underlying disease process or can develop during the course of illness either during the hospital stay. TAMOF has a high mortality rate if not treated; therefore, early detection is critical. TAMOF has been rarely reported in diabetic ketoacidosis. We are describing the first case of a patient diagnosed with hyperglycemic, hyperosmolar non-ketotic syndrome who developed TAMOF on the third day of his hospital course. In addition to supportive care in the intensive care unit the patient received serial therapeutic plasma exchanges and improved quickly after treatment. Early diagnosis and treatment of TAMOF decreases morbidity and mortality.
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Affiliation(s)
| | | | | | - Sarah J Swartz
- Pediatric Nephrology, Baylor College of Medicine, Houston, Texas
| | - Joseph R Angelo
- Pediatric Nephrology, Baylor College of Medicine, Houston, Texas
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16
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Nambam B, Menefee E, Gungor N, Mcvie R. Severe complications after initial management of hyperglycemic hyperosmolar syndrome and diabetic ketoacidosis with a standard diabetic ketoacidosis protocol. J Pediatr Endocrinol Metab 2017; 30:1141-1145. [PMID: 28988226 DOI: 10.1515/jpem-2017-0183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/31/2017] [Indexed: 11/15/2022]
Abstract
Hyperglycemic hyperosmolar syndrome (HHS) is a clinical entity not identical to diabetic ketoacidosis (DKA), and with a markedly higher mortality. Children with HHS can also present with concomitant DKA. Patients with HHS (with or without DKA) are profoundly dehydrated but often receive inadequate fluid resuscitation as well as intravenous insulin therapy based on traditional DKA protocols, and this can lead to devastating consequences. In this article, we briefly review HHS along with a report of an adolescent who presented with HHS and DKA and was initially managed as DKA. She went into hypotensive shock and developed severe, multiorgan failure. A thorough understanding of the pathophysiology of HHS and its differences from DKA in terms of initial management is crucial to guide management and improve outcomes. Additionally, fluid therapy in amounts concordant with the degree of dehydration remains the mainstay therapy.
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18
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Abstract
Type 2 diabetes mellitus in children and adolescents is becoming an increasingly important public health concern throughout the world. This epidemic is closely associated with the increased prevalence of obesity among youth of all ethnic backgrounds, as increased visceral adipose tissue produces adipokines that increase insulin resistance. Type 2 diabetes represents one arm of the metabolic syndrome, which includes abdominal obesity, disturbed glucose regulation and insulin resistance, dyslipidemia, and hypertension. The treatment of type 2 diabetes and the metabolic syndrome poses a challenge for pediatric endocrinologists. This review provides information regarding diagnosis of type 2 diabetes in children, as well as prevention strategies, such as lifestyle modification and pharmacologic options for weight loss, including metformin, orlistat, and sibutramine. Pharmacologic treatment options, their modes of action, and clinical indications for use are also reviewed. Treatment regimens for youth-onset type 2 diabetes that are discussed include metformin, sulfonylureas, glucosidase inhibitors, thiazolidinediones, glucagon-like peptide-1, and insulin.
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Affiliation(s)
- Jennifer L Miller
- Division of Pediatric Endocrinology, University of Florida, Gainesville, Florida, USA
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19
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Price A, Losek J, Jackson B. Hyperglycaemic hyperosmolar syndrome in children: Patient characteristics, diagnostic delays and associated complications. J Paediatr Child Health 2016; 52:80-4. [PMID: 26228354 DOI: 10.1111/jpc.12980] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2015] [Indexed: 11/28/2022]
Abstract
AIMS The aim of this study was to describe the demographical and clinical characteristics, diagnostic difficulties, and morbidity and mortality in children with hyperglycaemic hyperosmolar syndrome (HHS). METHODS Retrospective cross-section descriptive study of children (<18 years of age) at an urban, tertiary, academic Children's Hospital diagnosed with HHS from January 2002 to December 2011. RESULTS Six patients met inclusion criteria for the diagnosis of HHS. Age ranged from 6 to 16 years with 4 (67%) patients younger than 13 years. Four (67%) patients were women and 5 (83%) were African-American. Body mass index (BMI)-for-age percentile was >97% in four (67%) patients. Three (60%) of five patients seen as outpatients were misdiagnosed, two cases were seen twice before an accurate diagnosis of HHS was made. There was one (17%) death. Complications included three patients with acute renal failure, one patient with seizures, and one patient with rhabdomyolysis and compartment syndrome leading to below the knee amputation. Malignant hyperthermia and ventricular arrhythmias occurred in the patient who expired. Three of the five patients who had autoantibody tests had positive results and were diagnosed with type 1 diabetes mellitus. CONCLUSIONS Characteristics of children with HSS are variable for age, gender and BMI-for-age percentile and not predominately limited to obese male adolescent African-American. Delay in diagnosis is common and morbidity and mortality in paediatric HHS are significant. The subsequent diagnosis of patients presenting with HHS includes type 1 and 2 diabetes mellitus.
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Affiliation(s)
- Amanda Price
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Joseph Losek
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Benjamin Jackson
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, United States
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20
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Affiliation(s)
- Stuart J Brink
- New England Diabetes and Endocrinology Center (NEDEC), Waltham, MA, USA, and Associate Clinical Professor of Pediatrics; Tufts University School of Medicine; Boston MA USA
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21
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Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WWR, Mungai LNW, Rosenbloom AL, Sperling MA, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014; 15 Suppl 20:154-79. [PMID: 25041509 DOI: 10.1111/pedi.12165] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 12/16/2022] Open
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22
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Regulation of carbohydrate metabolism by indole-3-carbinol and its metabolite 3,3′-diindolylmethane in high-fat diet-induced C57BL/6J mice. Mol Cell Biochem 2013; 385:7-15. [DOI: 10.1007/s11010-013-1808-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 08/30/2013] [Indexed: 10/26/2022]
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23
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Arora R, Chiwane S, Hartwig E, Kannikeswaran N. A child with altered sensorium, hyperglycemia, and elevated troponins. J Emerg Med 2013; 46:184-90. [PMID: 23880446 DOI: 10.1016/j.jemermed.2013.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Revised: 01/23/2013] [Accepted: 05/01/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are potentially life-threatening complications of diabetes mellitus. Although DKA and HHS share similar features, they are distinct clinical entities requiring different treatment measures. OBJECTIVE This case illustrates that the clinical distinction between these two entities can be difficult at times, especially in children who can present with an overlapping picture. CASE REPORT We report an interesting case of a 12-year-old whose initial presentation of diabetes was a mixed picture of hyperosmolar DKA and HHS coma complicated by myocardial strain and acute renal insufficiency. The myocardial strain resolved completely with resolution of the metabolic abnormalities. CONCLUSIONS Emergency physicians should be cognizant of varied presentations of hyperglycemic emergencies in children to initiate appropriate management for better outcomes.
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Affiliation(s)
- Rajan Arora
- Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Saurabh Chiwane
- Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Earl Hartwig
- Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Nirupama Kannikeswaran
- Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
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Barrio R, Ros P. Diabetes tipo 2 en población pediátrica española: cifras, pronóstico y posibilidades terapéuticas. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.avdiab.2013.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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25
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Type 2 diabetes mellitus in children and youth. Indian J Pediatr 2013; 80 Suppl 1:S87-94. [PMID: 23430571 DOI: 10.1007/s12098-013-0962-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 01/08/2013] [Indexed: 01/18/2023]
Abstract
Type 2 diabetes mellitus (T2DM) which used to be a disease of adults is now seen commonly at an early age in children and adolescents. T2DM is now an important diagnostic consideration in children who present with signs and symptoms of diabetes. The emerging epidemic of obesity in children throughout the world and the resultant insulin resistance contributes to the increasing prevalence of T2DM in this population. The recommended treatment options include metformin and insulin. Optimal glycemic control is essential considering the lifelong nature of the disease and therefore, the increased risk of long term complications - both microvascular and macrovascular. This review article summarizes the classification, diagnosis, pathogenesis, management, complications and screening of T2DM in children, incorporating and contextualizing guidelines from various professional associations.
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26
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Bagdure D, Rewers A, Campagna E, Sills MR. Epidemiology of hyperglycemic hyperosmolar syndrome in children hospitalized in USA. Pediatr Diabetes 2013; 14:18-24. [PMID: 22925225 DOI: 10.1111/j.1399-5448.2012.00897.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 05/17/2012] [Accepted: 06/01/2012] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Previous studies of hyperglycemic hyperosmolar syndrome (HHS) in children are limited to case series or single-institution reviews, which describe HHS primarily in children with type 2 diabetes mellitus. OBJECTIVE To estimate the incidence and describe the epidemiologic characteristics of HHS among children in USA. SUBJECTS All discharges in the Kids' Inpatient Database - a triennial, nationwide, stratified probability sample of hospital discharges for years 1997-2009 - with age 0-18 yr and a diagnosis of HHS. METHODS Using sample weights, we calculated the incidence and population rate of hospitalization with a diagnosis of HHS. RESULTS Our sample included 1074 HHS hospitalizations; of these, 42.9% were 16-18 yr, 70.6% had type 1 diabetes (T1D), and 53.0% had major or extreme severity of illness. The median length of stay was 2.6 d, 2.7% of hospitalizations ended in death, and median hospital charge was $10 882. When comparing HHS hospitalizations by diabetes type, the proportion with T1D fell steadily with age, from 89.1% among children 0-9 yr, to 65.1% in 16-18 yr olds. Patients with T1D had a shorter length of stay by 0.9 d, and had a lower median charge by $5311. There was no difference in mortality by diabetes type. Population rates for HHS hospitalization rose 52.4% from 2.1 to 3.2 per 1 000 000 children from 1997 to 2009. CONCLUSION Hospitalizations for a diagnosis of HHS have high morbidity and are increasing in incidence since 1997. In contrast to prior reports, we found a substantial percentage of HHS hospitalizations occurred among children with T1D.
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Affiliation(s)
- Dayanand Bagdure
- Department of Pediatrics, University of Maryland School of Medicine, Division of Pediatric Critical Care Medicine, Baltimore, MD 21201, USA.
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27
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Abstract
Kinnier Wilson coined the term metabolic encephalopathy to describe a clinical state of global cerebral dysfunction induced by systemic stress that can vary in clinical presentation from mild executive dysfunction to deep coma with decerebrate posturing; the causes are numerous. Some mechanisms by which cerebral dysfunction occurs in metabolic encephalopathies include focal or global cerebral edema, alterations in transmitter function, the accumulation of uncleared toxic metabolites, postcapillary venule vasogenic edema, and energy failure. This article focuses on common causes of metabolic encephalopathy, and reviews common causes, clinical presentations and, where relevant, management.
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Affiliation(s)
- Michael J Angel
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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28
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Tsai SL, Hadjiyannakis S, Nakhla M. Hyperglycemic hyperosmolar syndrome at the onset of type 2 diabetes mellitus in an adolescent male. Paediatr Child Health 2012; 17:24-6. [DOI: 10.1093/pch/17.1.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2011] [Indexed: 11/13/2022] Open
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29
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Dean H, Sellers E, Kesselman M. Acute hyperglycemic emergencies in children with type 2 diabetes. Paediatr Child Health 2011; 12:43-4. [PMID: 19030340 DOI: 10.1093/pch/12.1.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2006] [Indexed: 11/13/2022] Open
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30
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Abstract
The object of this review is to provide the definitions, frequency, risk factors, pathophysiology, diagnostic considerations, and management recommendations for diabetic ketoacidosis (DKA) in children and adolescents, and to convey current knowledge of the causes of permanent disability or mortality from complications of DKA or its management, particularly the most common complication, cerebral edema (CE). DKA frequency at the time of diagnosis of pediatric diabetes is 10%-70%, varying with the availability of healthcare and the incidence of type 1 diabetes (T1D) in the community. Recurrent DKA rates are also dependent on medical services and socioeconomic circumstances. Management should be in centers with experience and where vital signs, neurologic status, and biochemistry can be monitored with sufficient frequency to prevent complications or, in the case of CE, to intervene rapidly with mannitol or hypertonic saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours; an initial bolus of 10-20 mL/kg 0.9% saline is followed by 0.45% saline calculated to supply maintenance and replace 5%-10% dehydration. Potassium (K) must be replaced early and sufficiently. Bicarbonate administration is contraindicated. The prevention of DKA at onset of diabetes requires an informed community and high index of suspicion; prevention of recurrent DKA, which is almost always due to insulin omission, necessitates a committed team effort.
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31
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Hyperglycemic hyperosmolar syndrome in children: pathophysiological considerations and suggested guidelines for treatment. J Pediatr 2011; 158:9-14, 14.e1-2. [PMID: 21035820 DOI: 10.1016/j.jpeds.2010.09.048] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 07/23/2010] [Accepted: 09/20/2010] [Indexed: 12/31/2022]
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32
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Angel MJ, Chen R, Bryan Young G. Metabolic encephalopathies. HANDBOOK OF CLINICAL NEUROLOGY 2010; 90:115-66. [PMID: 18631820 DOI: 10.1016/s0072-9752(07)01707-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Michael J Angel
- University of Toronto, Division of Neurology, Toronto Western Hospital, Toronto, Ontario, Canada.
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33
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Abstract
The object of this review is to provide the definitions, frequency, risk factors, pathophysiology, diagnostic considerations, and management recommendations for diabetic ketoacidosis (DKA) in children and adolescents, and to convey current knowledge of the causes of permanent disability or mortality from complications of DKA or its management, particularly the most common complication, cerebral edema (CE). DKA frequency at the time of diagnosis of pediatric diabetes is 10%-70%, varying with the availability of healthcare and the incidence of type 1 diabetes (T1D) in the community. Recurrent DKA rates are also dependent on medical services and socioeconomic circumstances. Management should be in centers with experience and where vital signs, neurologic status, and biochemistry can be monitored with sufficient frequency to prevent complications or, in the case of CE, to intervene rapidly with mannitol or hypertonic saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours; an initial bolus of 10-20 mL/kg 0.9% saline is followed by 0.45% saline calculated to supply maintenance and replace 5%-10% dehydration. Potassium (K) must be replaced early and sufficiently. Bicarbonate administration is contraindicated. The prevention of DKA at onset of diabetes requires an informed community and high index of suspicion; prevention of recurrent DKA, which is almost always due to insulin omission, necessitates a committed team effort.
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Affiliation(s)
- Arlan L Rosenbloom
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA,
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34
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Rosenbloom AL. Hyperglycemic hyperosmolar state: an emerging pediatric problem. J Pediatr 2010; 156:180-4. [PMID: 20105637 DOI: 10.1016/j.jpeds.2009.11.057] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Revised: 10/12/2009] [Accepted: 11/19/2009] [Indexed: 01/14/2023]
Affiliation(s)
- Arlan L Rosenbloom
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, USA.
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35
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Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee W, Rosenbloom A, Sperling M, Hanas R. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes 2009; 10 Suppl 12:118-33. [PMID: 19754623 DOI: 10.1111/j.1399-5448.2009.00569.x] [Citation(s) in RCA: 172] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Joseph Wolfsdorf
- Division of Endocrinology, Children's Hospital Boston, MA 02115, USA.
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36
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Rosenbloom AL, Silverstein JH, Amemiya S, Zeitler P, Klingensmith GJ. Type 2 diabetes in children and adolescents. Pediatr Diabetes 2009; 10 Suppl 12:17-32. [PMID: 19754615 DOI: 10.1111/j.1399-5448.2009.00584.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Arlen L Rosenbloom
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL 32608, USA.
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37
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Rosenbloom AL, Silverstein JH, Amemiya S, Zeitler P, Klingensmith GJ. ISPAD Clinical Practice Consensus Guidelines 2006-2007. Type 2 diabetes mellitus in the child and adolescent. Pediatr Diabetes 2008; 9:512-26. [PMID: 18694453 DOI: 10.1111/j.1399-5448.2008.00429.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Arlan L Rosenbloom
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL 32608, USA.
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38
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Mahmud FH, Ramsay DA, Levin SD, Singh RN, Kotylak T, Fraser DD. Coma with diffuse white matter hemorrhages in juvenile diabetic ketoacidosis. Pediatrics 2007; 120:e1540-6. [PMID: 18039811 DOI: 10.1542/peds.2007-0366] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Cerebral edema is the most common neurologic complication of diabetic ketoacidosis in children. A minority of young patients with intracerebral crises in diabetic ketoacidosis present with cerebrovascular accidents. We report 2 adolescent patients with diabetic ketoacidosis who presented with coma and diffuse white matter hemorrhages in the absence of either cerebral edema or cerebrovascular accidents. These 2 cases illustrate a novel clinical and neuropathologic description of diffuse white matter hemorrhages, possibly related to a cytotoxic process as the underlying mechanism. These case descriptions emphasize that pediatric patients with diabetic ketoacidosis and coma can present with pathology not related to either cerebral edema or cerebrovascular accidents.
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Affiliation(s)
- Farid H Mahmud
- Division of Pediatric Endocrinology, Children's Hospital of Western Ontario, 800 Commissioners Rd E, London, Ontario, Canada N6C 2V5.
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39
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Abstract
Type 2 diabetes mellitus (T2DM) has dramatically increased throughout the world in many ethnic groups and among people with diverse social and economic backgrounds. This increase has also affected the young such that over the past decade, the increase in the number of children and youth with T2DM has been labeled an 'epidemic'. Before the 1990s, it was rare for most pediatric centers to have significant numbers of patients with T2DM. However, by 1994, T2DM patients represented up to 16% of new cases of diabetes in children in urban areas and by 1999, depending on geographic location, the range of percentage of new cases because of T2DM was 8-45% and disproportionately represented among minority populations. Although the diagnosis was initially regarded with skepticism, T2DM is now a serious diagnostic consideration in all young people who present with signs and symptoms of diabetes in the USA.
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Affiliation(s)
- Orit Pinhas-Hamiel
- Pediatric Endocrinology and Diabetes Unit, Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
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40
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Canarie MF, Bogue CW, Banasiak KJ, Weinzimer SA, Tamborlane WV. Decompensated hyperglycemic hyperosmolarity without significant ketoacidosis in the adolescent and young adult population. J Pediatr Endocrinol Metab 2007; 20:1115-24. [PMID: 18051930 DOI: 10.1515/jpem.2007.20.10.1115] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM To identify patients aged 10-30 years with probable hyperglycemic hyperosmolar syndrome (HHS), to describe demographic and clinical profiles, and to attempt to assess risk factors for poor outcomes. STUDY DESIGN Retrospective cohort study (medical records review). SETTING A 944-bed tertiary care teaching and research hospital and a 425-bed affiliated facility. PATIENTS 10-30 year-old patients with a primary or secondary discharge diagnosis of HHS or diabetic ketoacidosis (DKA). Patients with a serum glucose >600 mg/dl in the absence of significant ketoacidosis (possible HHS) were profiled. Further stratification based on measured or calculated serum osmolarity >320 mOsm/kg (probable HHS) was undertaken. INTERVENTIONS Patients received treatment for hyperglycemic crises, consisting primarily of fluids, electrolyte replacement and insulin. MEASUREMENTS AND MAIN RESULTS Of the 629 admissions, 10 with a diagnosis of HHS and 33 with a diagnosis of DKA met the initial study criteria for HHS. 60% were African Americans and 89% were new-onset diabetics. From this group, 20 admissions had serum osmolarity > or =320 mOsm/kg. Fisher's exact test and Pearson coefficients were used to examine associations between risk factor and poor outcomes and correlations between admission data and length of hospital stay, respectively. Serious complications occurred in four patients (including two deaths, 10% mortality) and were limited to those with unreversed shock over the first 24 hours of admission and who received <40 ml/kg of intravenous fluids over the first 6 hours of treatment. CONCLUSIONS HHS was underdiagnosed in this population and occurred disproportionately in African Americans. Serious complications occurred exclusively in those with unreversed shock and inadequate fluid resuscitation.
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Affiliation(s)
- Michael F Canarie
- Section of Critical Care Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA.
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41
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Abstract
With the increase in prevalence of type 2 diabetes mellitus in adolescents, a rise in incidence of secondary comorbidities--including hypertension, hyperlipidaemia, nephropathy, and retinopathy--is anticipated. Furthermore, findings of studies in young adults have suggested that the development and progression of clinical complications might be especially rapid when the onset of type 2 diabetes is early, raising the possibility of a serious public-health challenge in the next few decades. To date, reports of the epidemiology and natural history of secondary complications specifically in adolescents with type 2 diabetes have been scarce. Yet, we must begin to understand the extent of the coming challenge. To this end, we have reviewed reports on acute and long-term comorbidities associated with type 2 diabetes in young people and have looked at mounting evidence that this group could be at increased risk for development of early complications.
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Affiliation(s)
- Orit Pinhas-Hamiel
- Pediatric Endocrinology and Diabetes, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel.
| | - Philip Zeitler
- Division of Endocrinology, Department of Pediatrics, University of Colorado, Denver, CO, USA
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42
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Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee WRW, Rosenbloom A, Sperling MA, Hanas R. Diabetic ketoacidosis. Pediatr Diabetes 2007; 8:28-43. [PMID: 17341289 DOI: 10.1111/j.1399-5448.2007.00224.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Joseph Wolfsdorf
- Division of Endocrinology, Children's Hospital Boston, Boston, MA, USA
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Rapid onset of coma and death in the initial presentation of type 2 diabetes in an 11-year-old child. Paediatr Child Health 2007. [DOI: 10.1093/pch/12.1.41] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Rhabdomyolysis is a clinical picture which is rarely seen in children. In this case report here it is presented a patient who has biochemical and clinical signs of rhabdomyolysis and admitted to our clinic with hypernatremia. The authors think that it is necessary to be alert for rhabdomyolysis in severe hypernatremia cases.
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Affiliation(s)
- Faruk Incecik
- Cukurova University Medical Faculty, Department of Pediatric Neurology, Adana, Turkey.
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Libman IM, Arslanian SA. Prevention and treatment of type 2 diabetes in youth. HORMONE RESEARCH 2006; 67:22-34. [PMID: 17008794 DOI: 10.1159/000095981] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Parallel to the increase in obesity worldwide, there has been a rise in the prevalence of type 2 diabetes mellitus (T2DM) in children and adolescents. The etiology of T2DM in youth, similar to adults, is multifactorial including genetic and environmental factors, among them obesity, sedentary lifestyle, family history of the disease, high-risk ethnicity and insulin resistance phenotype playing major roles. Treatment of T2DM should not have a glucocentric approach; it should rather target improving glycemia, dyslipidemia, hypertension, weight management and the prevention of short- and long-term complications. Prevention strategies, especially in high-risk groups, should focus on environmental change involving participation of families, schools, the food and entertainment industries and governmental agencies. Presently, limited pharmacotherapeutic options need to be expanded both for childhood T2DM and obesity. The coming decades will prove very challenging for healthcare providers battling socioeconomic waves conducive to obesity and T2DM. Evidence-based research and clinical experience in pediatrics, possibly modeled after adult trials, need to be developed if this public health threat is to be contained.
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Affiliation(s)
- Ingrid M Libman
- Division of Weight Management & Wellness, Children's Hospital of Pittsburgh, Pittsburgh, PA 15213, USA
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Abstract
The incidence of type 1 and type 2 diabetes mellitus in the pediatric population has increased over the past decade. The practitioner is often faced with the challenge of differentiating between type 1 and type 2 diabetes at the time of initial diagnosis because of the overlap of clinical and laboratory characteristics between these two entities. Adipokines are proteins secreted by the adipose tissue. Leptin and adiponectin are two adipokines that have been extensively studied in vitro, in animal studies, and in human subjects with type 1 and type 2 diabetes. Leptin and adiponectin play a significant role in the regulation of lipid and carbohydrate metabolism. Adiponectin increases insulin sensitivity in both the liver and skeletal muscle. Leptin decreases appetite, increases energy expenditure, suppresses insulin synthesis and secretion and increases insulin sensitivity. Changes in the secretion or sensitivity to leptin and adiponectin may contribute to the development of type 1 and type 2 diabetes. Adiponectin is higher in adult and pediatric patients with type 1 diabetes compared to those with type 2 diabetes. Data regarding leptin levels are contradictory. Most studies report decreased serum leptin at the time of diagnosis in type 1 diabetes compared to type 2 diabetes subjects and non-diabetic controls. This paper will review basic research and clinical evidence supporting the role of adiponectin and leptin in the development of type 1 and type 2 diabetes and discuss their potential use as tools in the differential diagnosis of pediatric diabetes.
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Rosenbloom AL. Hyperglycemic crises at the onset of type 2 diabetes in obese children. Endocr Pract 2006; 12:107. [PMID: 16524869 DOI: 10.4158/ep.12.1.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Cochran JB, Walters S, Losek JD. Pediatric hyperglycemic hyperosmolar syndrome: diagnostic difficulties and high mortality rate. Am J Emerg Med 2006; 24:297-301. [PMID: 16635701 DOI: 10.1016/j.ajem.2005.10.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2005] [Revised: 09/09/2005] [Accepted: 10/07/2005] [Indexed: 11/18/2022] Open
Abstract
Childhood obesity has become a pandemic health care problem. A complication of childhood obesity is type 2 diabetes mellitus which has increased 10-fold in the past 20 years. A serious complication of type 2 diabetes mellitus is hyperglycemic hyperosmolar syndrome (HHS). The following case is an obese adolescent boy with a newly diagnosed HHS. The demographic and clinical characteristics of our case and those of 17 other cases from recently published small case series are presented. Of the 18 cases, there were 13 deaths (72%). The purpose of this report and literature review is to emphasize the importance of early diagnoses and treatment of pediatric HHS.
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Affiliation(s)
- Joel B Cochran
- Pediatric Department, Medical University of South Carolina, Charleston, SC 29425, USA
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Kilbane BJ, Mehta S, Backeljauw PF, Shanley TP, Crimmins NA. Approach to management of malignant hyperthermia-like syndrome in pediatric diabetes mellitus. Pediatr Crit Care Med 2006; 7:169-73. [PMID: 16531950 DOI: 10.1097/01.pcc.0000192340.09136.82] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is usually associated with type 2 diabetes mellitus and is rare in children. However, a fatal malignant hyperthermia-like syndrome (MHLS) with rhabdomyolysis associated with new-onset diabetes mellitus and HHNS in adolescents has been described. DESIGN/METHODS Case series. RESULTS A 16-yr-old obese male (case A) and a 10-yr-old mid-pubertal nonobese female (case B) presented within a 6-month period with emesis, altered mental status, blood glucose >1600 mg/dL, and laboratory evidence of rhabdomyolysis. Case A developed fever after initiation of insulin therapy, along with refractory hypotension and multiorgan failure. He died 14 hrs after admission. Case B developed fever before insulin therapy, was treated with dantrolene, and made a full recovery. Metabolic workup showed evidence of short-chain acyl-CoA dehydrogenase (SCAD) deficiency. CONCLUSIONS We report two cases of malignant hyperthermia-like syndrome associated with HHNS in adolescents. Their respective fluid management and clinical courses are described. Dantrolene therapy should be initiated immediately after this syndrome is recognized. We believe it is unlikely insulin is the sole trigger for MHLS. Case B is unique in that there was evidence of SCAD deficiency, a metabolic defect that we propose could lead to MHLS. We recommend that all patients with HHNS and MHLS be evaluated for an underlying metabolic disorder.
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Affiliation(s)
- Brendan J Kilbane
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH, USA
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Abstract
Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) was infrequently diagnosed till recently. Now it is being diagnosed with increasing frequency in obese children with type 2 diabetes mellitus (T2 DM) and its incidence is likely to go up, given global increase in incidence of childhood obesity, increased insulin resistance, and T2 DM. The syndrome is characterized by severe hyperglycemia, a marked increase in serum osmolality and dehydration without accumulation of beta -hydroxybutyric or acetoacetic ketoacids. Significant ketogenesis is restrained by the ability of the pancreas to secrete small amount of insulin. Prolonged phase of osmotic diuresis leads to severe depletion of body water, which excees that of sodium, resulting in hypertonic dehydration. These children, usually obese adolescents with T2 DM, present with signs of severe dehydration and depressed mental status but continue to have increased rather than decreased urine output and are at increased risk of developing rhabdomyolysis and malignant hyperthermia. Emergency treatment is directed at restoration of the intravascular volume, followed by correction of deficits of fluid and electrolyte (Na+, K+, Ca++, Mg++, PO4++), hyperglycemia and serum hyperosmolarity, and a thorough search for conditions that may lead to this metabolic decompensation and their treatment. Use of iso-osomolar isotonic fluid (0.9% saline) until hemodynamic stabilization initially, followed by 0.45% saline with insulin infusion at the rate of 0.1 units/kg/hour, addition of 5% dextrose in fluids and reduction of insulin infusion once the blood glucose is 250 to 300 mg/dl is generally recommended. However, evidence-based guidelines about composition and tonicity of fluids and electrolyte solutions for early resuscitation and rehydration, the rate of infusion-rapid vs slow, and insulin dose-low vs normal, in treatment of HHNS in children are awaited. Careful monitoring of glucose levels and ensuring adequate hydration in patients 'at risk' of HHNS, including those receiving medications that interfere with the secretion or effectiveness of insulin should decrease the risk of HHNS.
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Affiliation(s)
- R Venkatraman
- Department of Pediatrics, Advanced Pediatrics Center, Post Graduate Institute of Medical Education and Research Center, Chandigarh, India
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