Hyperglycemic Conditions - Symptoms, Causes, Evaluation, and Management

Introduction

Diabetes is a condition that causes high levels of sugar in the blood. In diabetes, when food is taken, it is broken into sugar, and these sugars are unable to be converted into energy by the insulin, which is secreted by the pancreas. This condition occurs due to the inability of the body to secrete enough insulin or the inability to use it. Type 1 diabetes is due to the inability of the pancreas to produce insulin, and type 2 occurs when the body cannot use the insulin well. The complications of high blood sugar can lead to diabetic ketoacidosis (DKA), which is common in type 1 young patients, and Hyperglycemic hyperosmolar state (HHS), which is common in type 2 diabetes. In some patients, both complications can also be present. These compilations require emergency evaluation and management.

What Is Hyperglycemia?

Hyperglycemia is a condition of high levels of sugar in the blood, which is above 200 mg/dL (milligrams per deciliter) or 11.1 millimoles per liter (mmol/L). Hyperglycemic hyperosmolar state and diabetic ketoacidosis are emergency complications that can occur in patients with poorly controlled blood sugar levels.

What Is Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State?

Diabetic ketoacidosis occurs when the body is devoid of insulin and the sugar levels are more than 250 mg/dL. When this occurs, the body cannot utilize the sugar for energy. Instead, it breaks down the fat in the body. But, when fat is broken, a toxic product is released called ketones, which gets piled up in the blood and urine. If this condition is not treated, the person can go into a serious life-threatening condition called a diabetic coma. It consists of triads of ketonemia, hyperglycemia, and metabolic acidosis.

The hyperglycemic hyperosmolar state occurs when the insulin does not work properly and sugar levels exceed 600 mg/dL. There are increased levels of sugar in the blood but without increased levels of ketones. Therefore, the body does not use fat or glucose for energy. If not treated, the person can go into severe dehydration and coma.

What Are the Symptoms of Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State?

The symptoms of Diabetic ketoacidosis develop quickly within 24 hours which are:

• Increased frequency of urination.

• Polydipsia (extreme thirst).

• Nausea.

• Stomach pain.

• Weak and tiered.

• Fruity-scented breath.

• Being confused.

• Short of breath.

The symptoms of a hyperglycemic hyperosmolar state occur slowly (days to weeks) which are:

• State of confusion, hallucinations, and delirium.

• Loss of consciousness.

• Polydipsia.

• Loss of vision or blurred vision.

• Paralysis affects one side of the body.

• Frequent urination.

What Are the Precipitating Causes of Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State?

The precipitating causes of Diabetic ketoacidosis and hyperglycemic hyperosmolar state are:

• Urinary tract infections

• Pneumonia (lung infection).

• Poor Insulin treatment.

• Acute myocardial infarction (heart attack).

• Neurovascular accidents.

• Pancreatitis (inflammation of the pancreas).

• Alcohol use.

• Psychological disorders such as eating disorders or depression.

• Insulin pump malfunction.

• Medications such as beta-blockers, glucocorticoids, atypical antipsychotics (Olanzapine and Risperidone), certain chemotherapeutic agents, and thiazide diuretics. Other medications, such as sodium-glucose co-transporter 2 (SGLT2) inhibitors, a type of oral antidiabetic, can also cause DKA.

How Are Hyperglycemic Conditions Evaluated?

The evaluation of diabetic ketoacidosis includes:

• Patients with DKA have short-onset symptoms such as polydipsia, polyuria, loss of weight, nausea, vomiting, abdominal pain, lethargy, and about 25 percent of patients have a loss of consciousness. In the case of severe DKA, the patient undergoes a coma or stupor (near-unconsciousness).

• Physical examination includes dehydration with poor skin turgor (the skin takes a long time to return to normal position when lifted) and dry mucous membrane. Dehydration causes increased serum sodium concentration. Apart from these, the patients also present with increased heartbeat and increased blood pressure. Patients also show Kussmaul respirations (rapid, deep breathing) and fruity breath odor.

• Blood sugar levels are more than 250 mg/dl in case of severe DKA.

• Serum bicarbonate levels are less than 10 milliequivalents per liter (mEq/L) in severe DKA.

• Arterial pH (potential hydrogen, which measures acidity or alkalinity) is less than 7.

• Increased serum ketone levels. A nitroprusside test is done to estimate the acetone levels.

• Anion gap blood test (measure the acid-base balance) is more than 12 in severe DKA.

• Urine or serum β-hydroxybutyrate is more than three millimoles per liter (mmol/L).

• Leukocytosis (increased white blood cells) due to infection.

The evaluation of the hyperglycemic hyperosmolar state includes:

• Patients (older than 60) with HHS have symptoms such as weakness, extreme thirst, increased frequency of urination, and blurred vision. Apart from these, they have signs of dehydration too.

• Plasma glucose levels are more than 600 mg/dl.

• There are absent or small amounts of ketone bodies in the urine.

• Serum bicarbonate levels are less than 18 mEq/L.

• The arterial pH is more than 7.3.

• Urine or serum β-hydroxybutyrate is less than 3 mmol/L.

• Effective serum osmolality is more than 320 mOsm/kg (milliosmoles per kilogram).

How to Manage the Hyperglycemic Condition?

The management of hyperglycemic conditions should involve the correction of high blood sugar levels, hyperosmolality, dehydration, increased ketonemia, and electrolyte imbalance. Apart from these, the cause should be identified and treated. The management includes:

• Monitoring the vital signs, insulin dosage, rate of fluid administration, and urine output.

• Laboratory tests should be repeated every two hours, such as pH levels, glucose and electrolytes levels, anion gap, and bicarbonate levels.

• Intravenous (IV) fluids are given by administering 0.9 % NaCl at the rate of 500 to 1000 mL/hour (milliliter per hour) at the starting period of 2 to 4 hours. This restores renal perfusion, expands intravascular volume, and decreases insulin resistance. After the correction of intravascular volume, the saline is administered at the rate of 250 mL/hour, or the concentration of saline is changed to 0.45 %. When the blood sugar levels have reached below 200 mg/dl, 5 to 10 % of dextrose is given.

• If serum potassium levels are less than 3.3 mEq/L, then insulin should be on hold, and 20 to 30 mEq (milliequivalent) of potassium per liter of fluids should be administered. In case of chronic renal failure, low doses are recommended. If serum potassium levels are more than 5.2 mEq/L, potassium is not administered but should be monitored every two hours.

• If the pH is more than 6.9, there is no need for bicarbonate therapy. If the pH is less than 6.9 (severe acidosis), sodium bicarbonate of 50 to 100 mmol in 400 mL of water is given and is repeated every two hours until the pH becomes more than 6.9.

• Insulin should be administered because it lowers serum glucose levels and inhibits ketogenesis, lipolysis, and secretion of glucagon. Therefore, all these lead to decreasing ketoacidosis. Insulin should be given in an IV route continuously. 0.1 u/kg (unit per kilogram) body of bolus is given, followed by an infusion of insulin at the rate of 0.1 u/kg/hr (unit per kilogram per hour) till the glucose levels are reached up to 200 mg/dl. Then, the insulin is infused at the rate of 0.05 u/kg/hr along with 5 % dextrose to maintain the glucose levels between 150 to 200 mg/dl. This is continued till ketoacidosis is reduced.

• An alternative to IV infusion is the subcutaneous administration of rapid insulin every two hours. 0.2 u/kg body of subcutaneous bolus is given, followed by a subcutaneous infusion of insulin at the rate of 0.2 u/kg/hr till the glucose levels are reached 250 mg/dl. Then, the insulin is infused at the rate of 0.05 u/kg/hr to maintain the glucose levels below 200 mg/dl. This is continued till ketoacidosis is reduced.

Conclusion

The complications of hyperglycemic conditions are mainly diabetic ketoacidosis and hyperglycemic hyperosmolar state, which are serious conditions, and the patient may also go into a coma. These required immediate evaluations by signs and symptoms, along with laboratory tests. Management includes fluid therapy, bicarbonate therapy, insulin therapy, and potassium therapy.