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Zarse E, Knoll MM, Halpin K, Thompson M, Williams DD, Tallon EM, Kallanagowdar G, Tsai S. Recognizing Complications in Youth With Diabetes Admitted With Diabetic Ketoacidosis Versus Hyperglycemic Hyperosmolar State. J Pediatr Health Care 2024:S0891-5245(23)00374-7. [PMID: 38888521 DOI: 10.1016/j.pedhc.2023.12.012] [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: 09/11/2023] [Revised: 11/16/2023] [Accepted: 12/15/2023] [Indexed: 06/20/2024]
Abstract
INTRODUCTION We compare in-hospital complications in youth with isolated diabetic ketoacidosis (DKA) to youth with hyperosmolarity. METHOD We reviewed medical records of youth (1-20 years) admitted over two years with DKA, hyperglycemic hyperosmolar state (HHS), and hyperosmolar DKA. We evaluated outcomes, including hospital length of stay, altered mental status (AMS), and acute kidney injury (AKI). RESULTS Of 369 admissions, 334 had isolated DKA, 32 had hyperosmolar DKA, and three had isolated HHS. Hyperosmolar youth had longer length of stay, larger initial fluid boluses, more frequent pediatric intensive care unit admissions, and increased risk of AKI and AMS. The odds of AKI were positively associated with serum osmolality and negatively associated with new-onset diabetes mellitus (DM) compared with established DM. CONCLUSIONS In youth with DM, hyperosmolarity increases acute complications compared with isolated DKA. Larger-scale studies are needed to identify ways to prevent acute complications in youth experiencing hyperglycemic emergencies.
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Accamma K, Shamarao S, Ram A, Devananda NS, Krishna M, Bandagi LS, Bhattacharya AD, Kinimi I. Severe Diabetic Ketoacidosis with Malignant Hyperthermia Like Syndrome and Rhabdomyolysis Treated with ECMO: Unusual Severity and a Rare Occurrence. Indian J Crit Care Med 2023; 27:859-860. [PMID: 37936798 PMCID: PMC10626238 DOI: 10.5005/jp-journals-10071-24569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
How to cite this article: Accamma K, Shamarao S, Ram A, Devananda NS, Krishna M, Bandagi LS, et al. Severe Diabetic Ketoacidosis with Malignant Hyperthermia Like Syndrome and Rhabdomyolysis Treated with ECMO: Unusual Severity and a Rare Occurrence. Indian J Crit Care Med 2023;27(11):859-860.
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Affiliation(s)
- Krithi Accamma
- Department of Pediatric Intensive Care Unit (PICU), Manipal Hospital, Bengaluru, Karnataka, India
| | - Shivakumar Shamarao
- Department of Pediatric Intensive Care Unit (PICU), Manipal Hospital, Bengaluru, Karnataka, India
| | - Ashwath Ram
- Department of Pediatric Intensive Care Unit (PICU), Manipal Hospital, Bengaluru, Karnataka, India
| | - NS Devananda
- Department of Cardiothoracic Vascular Surgery, Manipal Hospital, Bengaluru, Karnataka, India
| | - Murali Krishna
- Department of Cardiothoracic Vascular Surgery, Manipal Hospital, Bengaluru, Karnataka, India
| | - Lalchand S Bandagi
- Department of Cardiothoracic Vascular Surgery, Manipal Hospital, Bengaluru, Karnataka, India
| | | | - Ilin Kinimi
- Department of Pediatric Pulmonology and Sleep Medicine, Manipal Hospital, Bengaluru, Karnataka, India
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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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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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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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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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Koh KH, Park MK, Choi SU, Huh H, Yoon SZ, Lim CH. Dantrolene treatment in a patient with uncontrolled hyperthemia after general anesthesia: a case report of suspected malignant hyperthermia - A case report -. Anesth Pain Med (Seoul) 2018. [DOI: 10.17085/apm.2018.13.2.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Kyung Hee Koh
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Min Kyung Park
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sung Uk Choi
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hyub Huh
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Seung Zhoo Yoon
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Choon Hak Lim
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Korea
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Abstract
We present the case of a 16-year-old boy who presented with fatigue, polyuria, and polydipsia while on chemotherapy for his relapsed acute lymphoblastic leukemia (ALL). Blood gas examination confirmed the diagnosis of hyperosmolar hyperglycemic state. The etiology for his hyperglycemia was most likely a result of oral glucocorticoid therapy combined with asparaginase therapy-both are a cornerstone of induction chemotherapy for ALL. The patient was aggressively rehydrated with saline, and medications were administered to correct his hyperkalemia. He was then slowly brought to euglycemia with a continuous infusion of insulin. Although hyperosmolar hyperglycemic state is rare during the treatment of ALL, frontline providers should be aware of this diagnosis because of the significant risk of hypovolemic shock and death if correction of hyperglycemia occurs prior to complete fluid resuscitation.
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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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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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Rosenberg H, Pollock N, Schiemann A, Bulger T, Stowell K. Malignant hyperthermia: a review. Orphanet J Rare Dis 2015; 10:93. [PMID: 26238698 PMCID: PMC4524368 DOI: 10.1186/s13023-015-0310-1] [Citation(s) in RCA: 296] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 07/22/2015] [Indexed: 02/06/2023] Open
Abstract
Malignant hyperthermia (MH) is a pharmacogenetic disorder of skeletal muscle that presents as a hypermetabolic response to potent volatile anesthetic gases such as halothane, sevoflurane, desflurane, isoflurane and the depolarizing muscle relaxant succinylcholine, and rarely, in humans, to stressors such as vigorous exercise and heat. The incidence of MH reactions ranges from 1:10,000 to 1: 250,000 anesthetics. However, the prevalence of the genetic abnormalities may be as great as one in 400 individuals. MH affects humans, certain pig breeds, dogs and horses. The classic signs of MH include hyperthermia, tachycardia, tachypnea, increased carbon dioxide production, increased oxygen consumption, acidosis, hyperkalaemia, muscle rigidity, and rhabdomyolysis, all related to a hypermetabolic response. The syndrome is likely to be fatal if untreated. An increase in end-tidal carbon dioxide despite increased minute ventilation provides an early diagnostic clue. In humans the syndrome is inherited in an autosomal dominant pattern, while in pigs it is autosomal recessive. Uncontrolled rise of myoplasmic calcium, which activates biochemical processes related to muscle activation leads to the pathophysiologic changes. In most cases, the syndrome is caused by a defect in the ryanodine receptor. Over 400 variants have been identified in the RYR1 gene located on chromosome 19q13.1, and at least 34 are causal for MH. Less than 1 % of variants have been found in CACNA1S but not all of these are causal. Diagnostic testing involves the in vitro contracture response of biopsied muscle to halothane, caffeine, and in some centres ryanodine and 4-chloro-m-cresol. Elucidation of the genetic changes has led to the introduction of DNA testing for susceptibility to MH. Dantrolene sodium is a specific antagonist and should be available wherever general anesthesia is administered. Increased understanding of the clinical manifestation and pathophysiology of the syndrome, has lead to the mortality decreasing from 80 % thirty years ago to <5 % in 2006.
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Affiliation(s)
- Henry Rosenberg
- Department of Medical Education and Clinical Research, Saint Barnabas Medical Center, Livingston, NJ, 07039, USA.
| | - Neil Pollock
- Department of Anesthesia and Intensive Care, Palmerston North Hospital, Palmerston North, New Zealand.
| | - Anja Schiemann
- Institute of Fundamental Sciences, Massey University, Palmerston North, New Zealand.
| | - Terasa Bulger
- Department of Anesthesia and Intensive Care, Palmerston North Hospital, Palmerston North, New Zealand.
| | - Kathryn Stowell
- Institute of Fundamental Sciences, Massey University, Palmerston North, New Zealand.
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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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16
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Herlich A. Perioperative temperature elevation: not all hyperthermia is malignant hyperthermia. Paediatr Anaesth 2013; 23:842-50. [PMID: 23890328 DOI: 10.1111/pan.12244] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The objective of this review is to assist the readers, anesthesiologists, intensivists, and emergency physicians in making a more accurate diagnosis of perioperative fever or hyperthermia and subsequently choose the proper course of treatment. AIM To identify the many sources of perioperative fever and after a more accurate differential diagnosis, select appropriate treatment options. Most anesthesiologists, intensivists, and emergency physicians are not familiar with an expansive differential of perioperative fever. This article attempts to expose these physicians to that differential diagnosis. BACKGROUND Much of the medical literature has anecdotal reports, small case series, or limited reviews of the possible sources of hyperthermia or fever. This is especially true of the anesthesia literature. RESULTS A literature search was performed which identified many possible common and uncommon sources of fever. Some of these sources are quite relevant to the anesthesiologist. Other sources had potential relevance in obscure cases.
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Affiliation(s)
- Andrew Herlich
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA.
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17
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Hyperglycemic hyperosmolar syndrome in the pediatric patient: a case report and review of the literature. Pediatr Emerg Care 2012; 28:699-702. [PMID: 22766588 DOI: 10.1097/pec.0b013e31825d23c9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hyperglycemic hyperosmolar syndrome (HHS) is a potentially deadly complication of diabetes mellitus that can often be the presenting symptom of the condition in the pediatric population. There is a danger that HHS may not be included in the differential of critical patients because it is still a somewhat rare entity in the pediatric population. However, recent data regarding population trends indicate that HHS will continue to appear more and more commonly in the pediatric population with diabetes. The following case describes an adolescent with many of the typical features of the pediatric patient with HHS as the presenting symptom of diabetes mellitus. The literature regarding HHS in children is still sparse, and much must be extrapolated from adult studies given its relatively recent increased incidence. Included is a brief review of the most recent data regarding epidemiology, treatment, and complications that would be pertinent to the pediatric emergency physician.
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Hirshey Dirksen SJ, Larach MG, Rosenberg H, Brandom BW, Parness J, Lang RS, Gangadharan M, Pezalski T. Special article: Future directions in malignant hyperthermia research and patient care. Anesth Analg 2011; 113:1108-19. [PMID: 21709147 DOI: 10.1213/ane.0b013e318222af2e] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Malignant hyperthermia (MH) is a complex pharmacogenetic disorder of muscle metabolism. To more closely examine the complexities of MH and other related muscle disorders, the Malignant Hyperthermia Association of the United States (MHAUS) recently sponsored a scientific conference at which an interdisciplinary group of experts gathered to share new information and ideas. In this Special Article, we highlight key concepts and theories presented at the conference along with exciting new trends and challenges in MH research and patient care.
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19
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Non-traumatic rhabdomyolysis and diabetes. DIABETES & METABOLISM 2011; 37:262-4. [PMID: 21550832 DOI: 10.1016/j.diabet.2011.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 03/09/2011] [Accepted: 03/11/2011] [Indexed: 01/22/2023]
Abstract
The present clinical report describes the case of a spontaneously resolving rhabdomyolysis episode in a type 1 diabetic patient, who presented with multiple risk factors of this muscle complication, including uncontrolled brittle diabetes with sequences of hyper- and hypoglycaemic episodes in the same day, caloric restriction and intensive exercise. It should be borne in mind that rhabdomyolysis is not particularly rare in diabetes and can be severe. To raise clinicians' awareness of a possible rhabdomyolysis diagnosis, the various clinical conditions that are likely to lead to this complication in diabetic patients are also reviewed here.
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20
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Giulivi C, Ross-Inta C, Omanska-Klusek A, Napoli E, Sakaguchi D, Barrientos G, Allen PD, Pessah IN. Basal bioenergetic abnormalities in skeletal muscle from ryanodine receptor malignant hyperthermia-susceptible R163C knock-in mice. J Biol Chem 2011; 286:99-113. [PMID: 20978128 PMCID: PMC3013050 DOI: 10.1074/jbc.m110.153247] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 10/13/2010] [Indexed: 12/25/2022] Open
Abstract
Malignant hyperthermia (MH) and central core disease in humans have been associated with mutations in the skeletal ryanodine receptor (RyR1). Heterozygous mice expressing the human MH/central core disease RyR1 R163C mutation exhibit MH when exposed to halothane or heat stress. Considering that many MH symptoms resemble those that could ensue from a mitochondrial dysfunction (e.g. metabolic acidosis and hyperthermia) and that MH-susceptible mice or humans have a higher than normal cytoplasmic Ca(2+) concentration at rest, we evaluated the role of mitochondria in skeletal muscle from R163C compared with wild type mice under basal (untriggered) conditions. R163C skeletal muscle exhibited a significant increase in matrix Ca(2+), increased reactive oxygen species production, lower expression of mitochondrial proteins, and higher mtDNA copy number. These changes, in conjunction with lower myoglobin and glycogen contents, Myh4 and GAPDH transcript levels, GAPDH activity, and lower glucose utilization suggested a switch to a compromised bioenergetic state characterized by both low oxidative phosphorylation and glycolysis. The shift in bioenergetic state was accompanied by a dysregulation of Ca(2+)-responsive signaling pathways regulated by calcineurin and ERK1/2. Chronically elevated resting Ca(2+) in R163C skeletal muscle elicited the maintenance of a fast-twitch fiber program and the development of insulin resistance-like phenotype as part of a metabolic adaptation to the R163C RyR1 mutation.
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Affiliation(s)
- Cecilia Giulivi
- Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, California 95616, USA.
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21
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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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22
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Aggressive fluid resuscitation in severe pediatric hyperglycemic hyperosmolar syndrome: a case report. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:379063. [PMID: 20339503 PMCID: PMC2842888 DOI: 10.1155/2010/379063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 01/26/2010] [Indexed: 02/02/2023]
Abstract
Objective. This report describes a severe case of hyperglycemic hyperosmolar syndrome
complicated by rhabdomyolysis, acute kidney injury, hyperthermia, and hypovolemic
shock, with management centred upon fluid administration.
Design. Case report.
Setting. Pediatric intensive care unit in university teaching hospital.
Patients. 12 years old adolescent female presenting with hyperglycemic hyperosmolar
syndrome with a new diagnosis of type 2 diabetes mellitus.
Intervention. Aggressive fluid resuscitation and insulin.
Main results. The patient had a good outcome, discharged home on hospital day 6.
Conclusions. Hyperglycemic hyperosmolar syndrome is associated with a number of
complications. Management strategies are undefined, given the rarity of its presentation,
and further studies are warranted.
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23
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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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24
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Murthy S, Sharara-Chami R. Aggressive Fluid Resuscitation in Severe Pediatric Hyperglycemic Hyperosmolar Syndrome: A Case Report. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-379063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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25
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Elsayed EF, Reilly RF. Rhabdomyolysis: a review, with emphasis on the pediatric population. Pediatr Nephrol 2010; 25:7-18. [PMID: 19529963 DOI: 10.1007/s00467-009-1223-9] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 04/30/2009] [Accepted: 05/05/2009] [Indexed: 12/12/2022]
Abstract
Rhabdomyolysis is a common clinical syndrome and accounts for 7% of all cases of acute kidney injury (AKI) in the USA. It can result from a wide variety of disorders, such as trauma, exercise, medications and infection, but in the pediatric population, infection and inherited disorders are the most common causes of rhabdomyolysis. Approximately half of patients with rhabdomyolysis present with the triad of myalgias, weakness and dark urine. The clinical suspicion, especially in the setting of trauma or drugs, is supported by elevated creatinine kinase levels and confirmed by the measurement of myoglobin levels in serum or urine. Muscle biopsy and genetic testing should be performed if rhabdomyolysis is recurrent or metabolic myopathy is suspected. Early recognition is important to prevent AKI through the use of aggressive hydration. Prevention is important in patients with inherited forms, but novel therapies may be developed with the better understanding of the pathophysiology and genetics of rhabdomyolysis.
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Affiliation(s)
- Essam F Elsayed
- Department of Internal Medicine, Section of Nephrology, VA North Texas Health Care System, The University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.
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26
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Ahuja N, Palanichamy N, Mackin P, Lloyd A. Olanzapine-induced hyperglycaemic coma and neuroleptic malignant syndrome: case report and review of literature. J Psychopharmacol 2010; 24:125-30. [PMID: 18801826 DOI: 10.1177/0269881108096901] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although the relationship between antipsychotic medication, particularly second-generation antipsychotics (SGAs), and metabolic disturbance is increasingly accepted, there is an important, but little recognised, potential interaction between this and the other important serious adverse effect of neuroleptic malignant syndrome (NMS). We report a case of a 35-year old female who developed new onset type II diabetes mellitus with hyperosmolar hyperglycaemic coma and acute renal failure following treatment with a SGA for a first manic episode. The history is strongly suggestive of concurrent NMS. This case raises important questions about non-ketotic, hyperosmolar diabetic coma with antipsychotics, the possible association between hyperglycaemia and hyperthermia, and the direction of causality in this, the recognition of either syndrome when they co-exist and management issues in such patients. These questions are considered in the context of currently available literature.
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Affiliation(s)
- N Ahuja
- Wallsend Community Mental Health Team, Sir GB Hunter Hospital, Wallsend, Tyne and Wear, UK.
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27
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Hernandez JF, Secrest JA, Hill L, McClarty SJ. Scientific advances in the genetic understanding and diagnosis of malignant hyperthermia. J Perianesth Nurs 2009; 24:19-31; quiz 32-4. [PMID: 19185818 DOI: 10.1016/j.jopan.2008.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 11/15/2008] [Accepted: 12/03/2008] [Indexed: 02/06/2023]
Abstract
Malignant hyperthermia (MH), a potentially fatal disorder triggered by certain types of general anesthesia, has received much attention in the scientific literature. From the first case report in 1960 until the present, hundreds of studies have been conducted. The diagnosis of MH has evolved from subjective assumptions by family history and clinical diagnosis to more sophisticated laboratory testing. A genetic basis for MH was recognized in the early 1990s and, since then, complex genetic pathways have been demonstrated. The purpose of this paper is to summarize the research literature on what is known scientifically about the diagnosis and genetic basis of MH.
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28
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Osuka A, Matsuoka T, Idoguchi K. Is this the worst outcome of metabolic syndrome? Hypophosphatemia and resulting cardiac arrest during the treatment of diabetic ketoacidosis with hypertriglyceridemia. Intern Med 2009; 48:1391-5. [PMID: 19687585 DOI: 10.2169/internalmedicine.48.2236] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
We report a case of diabetic ketoacidosis (DKA) and severe hypertriglyceridemia who developed cardiac arrest due to hypophosphatemia. He was diagnosed with diabetes and hyperlipidemia, indicating metabolic syndrome. Hypophosphatemia was caused by large insulin doses received while treating DKA, which were required because of insulin resistance owing to hypertriglyceridemia. Metabolic syndrome may have accelerated serum phosphate depletion. We suggest frequent monitoring of serum phosphate and phosphate replacement for patients with DKA and severe hypertriglyceridemia. Although such a critical condition has not been reported, it may occur during treatment of patients with poorly controlled type 2 diabetes with DKA.
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Affiliation(s)
- Akinori Osuka
- Critical Care, Osaka Prefectural Senshu Critical Care Medical Center, Izumisano.
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29
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Zeitler P, Pinhas-Hamiel O. Prevention and screening for type 2 diabetes in youth. Endocr Res 2008; 33:73-91. [PMID: 19156575 DOI: 10.1080/07435800802080369] [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: 02/08/2023]
Affiliation(s)
- Phil Zeitler
- Department of Pediatrics, University of Colorado at Denver and Health Sciences Center, Denver, Colorado 80218, USA.
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30
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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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31
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Malignant hyperthermia associated with diabetic hyperosmolar hyperglycemic nonketotic state in a young man. J Clin Anesth 2007; 19:470-2. [DOI: 10.1016/j.jclinane.2006.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2005] [Revised: 12/10/2006] [Accepted: 12/18/2006] [Indexed: 11/22/2022]
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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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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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34
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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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35
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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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36
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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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37
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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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38
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Rosenbloom AL. Hyperglycemic comas in children: new insights into pathophysiology and management. Rev Endocr Metab Disord 2005; 6:297-306. [PMID: 16311948 DOI: 10.1007/s11154-005-6188-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Arlan L Rosenbloom
- Division of Endocrinology, Department of Pediatrics, College of Medicine, Children's Medical Services Center, University of Florida, 1701 SW 16th Avenue, Gainesville, 32608, USA.
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Abstract
Diabetic ketoacidosis is an important complication of diabetes in children and is the most frequent diabetes-related cause of death in childhood. The pathophysiology of this condition can be viewed as an exaggeration of the normal physiologic mechanisms responsible for maintaining an adequate fuel supply to the brain and other tissues during periods of fasting and physiologic stress. The optimal therapy has been a subject of controversy, particularly because the most frequent serious complication of diabetic ketoacidosis-cerebral edema-and the relationship of this complication to treatment are incompletely understood. In this article, the author reviews the pathophysiology of diabetic ketoacidosis and its complications and presents an evidence-based approach to the management of this condition.
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Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, School of Medicine, University of California-Davis, 2516 Stockton Boulevard, Sacramento, CA 95817, USA.
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40
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Fourtner SH, Weinzimer SA, Levitt Katz LE. Hyperglycemic hyperosmolar non-ketotic syndrome in children with type 2 diabetes*. Pediatr Diabetes 2005; 6:129-35. [PMID: 16109068 DOI: 10.1111/j.1399-543x.2005.00113.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Hyperglycemic hyperosmolar non-ketotic (HHNK) syndrome is thought to be a rare entity in the pediatric population, associated with significant mortality based on case reports in the literature. As obesity and type 2 diabetes in childhood grow in prevalence, such related complications may also increase. This study will serve to provide updated information regarding typical clinical course and sequelae of HHNK syndrome in childhood. METHODS Patients diagnosed with type 2 diabetes at Children's Hospital of Philadelphia (CHOP) over a period of 5 yr were screened retrospectively for any laboratory evidence of previous episodes of HHNK syndrome. The standard diagnostic criteria of blood glucose >600 mg/dL and serum osmolality >330 mOsm/L with only mild acidosis (serum bicarbonate >15 mmol/L and small ketonuria 15 mg/dL or less) were utilized. RESULTS The records of all patients with type 2 diabetes mellitus (DM) diagnosed over a 5-yr period were reviewed (n=190). Seven patients were found to have one episode of HHNK syndrome by diagnostic criteria (five males, mean age at presentation 13.3 yr, age range 10.1--16.9 yr), yielding a frequency of 3.7%. All were African-American. HHNK syndrome was the clinical presentation at diagnosis of new onset diabetes for all seven children. Three of seven children had a previously diagnosed developmental delay. The average Glasgow Coma Scale (GCS) score at presentation was 13 (range 9--15). Mean body mass index (BMI) at presentation was 32.7 kg/m(2) (n=6). Mean serum osmolality was 393 mOsm/L (n=7), and mean blood glucose was 1604 mg/dL (n = 7). The average time until mental status returned to baseline among survivors was 3 d (range 1--7 d). The average number of hospital days for survivors was 10 (range 5--24 d). Four of seven patients had an uncomplicated course. One patient developed multisystem organ failure and died on hospital day 4. The case fatality rate was 14.3% (one of seven). Survivors had no appreciable neurodevelopmental sequelae. CONCLUSIONS This retrospective chart review provides updated information regarding the entity of HHNK syndrome in children. This study supports the need for increased awareness of type 2 diabetes in children so that morbidity and mortality related to HHNK syndrome can be prevented.
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Affiliation(s)
- Shannon H Fourtner
- Department of Pediatrics, Division of Endocrinology/Diabetes, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Abstract
Hyperosmolar hyperglycemic state (HHS) is the most serious acute complication of type 2 diabetes mellitus. Emergency department management focuses on prompt diagnosis and restoration of hemodynamic stability with appropriate fluid therapy while maintaining electrolyte homeostasis. Identification of any precipitating illness is essential. The emergence of HHS as a critical presentation of type 2 diabetes mellitus in adolescents is highlighted.
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Affiliation(s)
- Bruce W Nugent
- Division of Emergency Medicine, Spectrum Health-Butterworth, 100 Monroe NW, MC-49, Grand Rapids, MI 49503, USA.
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42
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Carchman RM, Dechert-Zeger M, Calikoglu AS, Harris BD. A new challenge in pediatric obesity: pediatric hyperglycemic hyperosmolar syndrome. Pediatr Crit Care Med 2005; 6:20-4. [PMID: 15636654 DOI: 10.1097/01.pcc.0000149134.61673.77] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe four adolescents with hyperglycemic hyperosmolar syndrome, an uncommon presentation of type 2 diabetes in pediatric patients. DESIGN Case report. SETTING Two tertiary pediatric intensive care units in university teaching hospitals. PATIENTS Four obese adolescents with hyperglycemic hyperosmolar syndrome associated with type 2 diabetes mellitus. INTERVENTIONS Isotonic fluid resuscitation and insulin. MEASUREMENTS AND MAIN RESULTS Two of the four patients died. The first patient died within the first 24 hrs of hyperglycemic hyperosmolar syndrome presumably due to hypovolemic shock. The second patient, who died, developed rhabdomyolysis and multiple-system organ failure after a prolonged intensive care unit stay. The third and fourth patients were discharged from the hospital in good health. None of the patients had cerebral edema on head computed tomography, despite differences in fluid and insulin management. CONCLUSIONS Pediatric patients with hyperglycemic hyperosmolar syndrome have a high mortality rate and may experience multiple complications such as rhabdomyolysis and hypovolemic shock. Treatment strategies to reduce mortality are unclear and warrant further investigation.
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Affiliation(s)
- Rebecca M Carchman
- Pediatric Critical Care Fellow, University of North Carolina Hospital, Chapel Hill, NC, USA
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Singhi SC. Hyperglycemic hyperosmolar state and type 2 diabetes mellitus: yet another danger of childhood obesity. Pediatr Crit Care Med 2005; 6:86-7. [PMID: 15643304 DOI: 10.1097/01.pcc.0000149309.45929.c5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Seven obese African American youth were considered to have died from diabetic ketoacidosis (DKA) due to type 1 diabetes, despite meeting the criteria for hyperglycemic hyperosmolar state and not for DKA. All had previously unrecognized type 2 diabetes, and death may have been prevented with earlier diagnosis or treatment.
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Affiliation(s)
- Alba E Morales
- Division of Pediatric Endocrinology, University of Florida College of Medicine, Gainesville, Florida 32608-1153, USA
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45
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Affiliation(s)
- Neil H White
- Division of Endocrinology and Metabolism, Department of Pediatrics, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, Campus Box 8208, St. Louis, Missouri 63110, USA.
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