Hyperglycaemia - a Diabetes Emergency

Hyperglycaemia is the medical condition in which a patient presents with an abnormally high level of glucose circulating in their bloodstream (Better Health Channel 2014).

It is common for people not to experience the symptoms of hyperglycaemia until their blood sugar levels reach this extremely high level (Diabetes Australia).

What are the Risks?

Prompt treatment is essential – regularly having high levels of glucose can affect vital organs including kidneys, eyes and nerves (Better Health Channel 2014; Diabetes.co.uk 2019).

Hyperglycaemic emergencies require urgent assessment and management to reduce preventable morbidity. They may appear as the first case of diabetes (undiagnosed) as well as a crisis for those with known diabetes (RACGP 2019; Kitabchi et al. 2001).

Hyperglycemic emergencies continue to be prominent causes death in patients with diabetes, despite considerable advances in the understanding of their pathogenesis and agreement as to their diagnosis and treatment (Kitabchi et a.l 2001).

Hyperglycaemia Emergencies Fall into Two Distinct Categories:

Diabetic ketoacidosis and hyperosmolar hyperglycaemic state - extreme manifestations of impaired carbohydrate regulation that can occur in people with diabetes.

1. Diabetic Ketoacidosis (DKA)

Diabetic ketoacidosis (or DKA as it is known) is a life-threatening complication in patients with untreated diabetes or mismanaged diabetes.

It is prevalent in people who have type 1 diabetes, particularly among children – though it can also occur in people with type 2 diabetes.

Experiences may include an altered state of consciousness and should be monitored for rapid deterioration (RACGP 2019; Royal College of Nursing 2016).

2. Hyperosmolar Hyperglycaemic States (HHS)

Persistent hyperglycaemia is known as hyperosmolar hyperglycaemia state (HHS), in ketosis’s absence. Intense dehydration will often accompany this condition.

HHS is more closely associated with type 2 diabetes and typically affects older patients.

It is common in patients who are also going through acute sepsis, who have just had a cardiovascular event or in people with renal dysfunction. Coma may develop in some patients who have recently undergone surgery (RACGP 2019).

Both of these conditions are classified as an emergency. However, mortality is higher in HHS than in DKA - as it often relates to the precipitating condition (RACGP 2019).

Symptoms of DKA and HHS

Possible Symptoms of crisis associated with DKA

• Extreme thirst;
• Extreme fatigue;
• Nausea and or vomiting;
• Abdominal pain;
• Oral thrush or yeast infection;
• Muscle wasting;
• Constant urination;
• Weight loss; and
• Altered conscious state.

(RACGP 2019; Royal College of Nursing 2019; Better Health 2014; Health Direct 2018)

Possible Symptoms of crisis associated with HHS

• Atypical symptoms including:
  • Pain; and
  • Fever.
• Dry mouth;
• Cool extremities;
• Rapid pulse;
• Extreme hydration;
• Reduced urination; and
• An altered state of consciousness.

(RACGP 2019; American Family Physician 2017; Better Health 2014; Health Direct 2018)

Mental status can vary from full alertness to intense lethargy; though around 20% of patients with DKA or HHS are hospitalised with loss of consciousness (Kitabchi et al. 2001)

Who is at Risk of Hyperglycaemia?

People who fall into the following categories should be closely monitored:

• Pregnant women;
• Children and young people with type 1 diabetes;
• People who have unstable glycaemia control;
• People omitting diabetes-related medication: especially insulin;
• People who use an insulin pump;
• People who have had DKA in the past;
• People with pancreatitis;
• Those who have suffered:
  • Trauma;
  • Surgery;
  • Burns;
  • Acute infection; and
  • Sepsis.
• People with high-rates of alcohol or recreational drug consumption;,
• Elderly people; and
• People taking certain medications.

(RACGP 2019)

Hyperglycaemia Assessment

A clinical assessment may include the following:

• Blood glucose and ketone levels;
• Temperature checks;
• Blood pressure monitoring;
• Heart rate monitoring;
• Respiratory rate monitoring;
• Neurological assessments such as the Glasgow Coma Scale; and
• Urgent point-of-care assessment.

(RACGP 2019)

Preventative Measures

Inadequate insulin treatment (and noncompliance) and infection are the two major precipitating factors in the development of DKA (Kitabchi et al. 2001).

In many cases, these events may be prevented by:

• Better access to medical care;
• Intensive patient education; and
• Effective communication with a healthcare provider during acute illnesses.

(Kitabchi et al. 2001)

If acute illness or stress have brought on a state of hyperglycaemia, the first steps must be:

• Controlling insulin levels;
• Decreasing excess stress hormone secretion;
• Avoiding prolonged fasting state; and
• Preventing severe dehydration.

(Kitabchi et al. 2001)

An educational program should be provided to review illness management with direct information on the administration of short-acting insulin, including frequency of insulin administration, blood glucose goals during illness, methods to suppress fever and treat infection, and initiation of an easily digestible liquid diet containing carbohydrates and salt (Kitabchi et al. 2001).

It is crucial to note, the patient should never discontinue insulin and must seek professional advice early in the course of the illness (Kitabchi et al. 2001; Better Health Channel 2014). It is vital that people with diabetes have a sick day plan and checklist so as to provide information on managing their diabetes while unwell (Diabetes Australia 2016).

Additional Resources

• Diabetes Australia, Best Practice Guidelines: https://www.diabetesaustralia.com.au/best-practice-guidelines
• Diabetes Australia, Diabetes Prevention: https://www.diabetesaustralia.com.au/prevention
• Diabetes Australia, Information on Hyperglycaemia: https://www.diabetesaustralia.com.au/hyperglycaemia

References

• American Family Physician 2017, Hyperosmolar Hyperglycemic State, viewed 5 July 2019, https://www.aafp.org/afp/2017/1201/p729.html.
• Better Health Channel 2014, Hyperglycaemia, viewed 5 July 2019, https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/hyperglycaemia.
• Diabetes Australia 2015, Information on Hyperglycaemia, viewed 5 July 2019, https://www.diabetesaustralia.com.au/hyperglycaemia.
• Diabetes Australia 2016, Managing sick days for type 1 diabetes, viewed 5 July 2019, https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/89f49125-e2e9-4233-868e-c8fe46d99b4e.pdf.
• Health Direct 2018, Hyperglycaemia (high blood sugar), viewed 5 July 2019, https://www.healthdirect.gov.au/hyperglycaemia-high-blood-sugar.
• Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, Wall BM 2001, ‘Management of Hyperglycemic Crises in Patients With Diabetes’, Diabetes Care 2001 Jan, vol. 24, no. 1, pp. 131-53.
• RACGP 2019, Emergency Treatment of Hyperglycaemia, viewed 5 July 2019, https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/emergency-management-of-hyperglycaemia.
• RCNI 2016, Emergency Treatment for Diabetes, viewed 5 July 2019, https://rcni.com/hosted-content/rcn/diabetes/emergency-treatment-diabetes.

(Answers: a, b, d.)