Identifying interhospital variation in hyperosmolar hyperglycemic syndrome (HHS) care: development and outcomes of the DEKODE HHS model

Hyperglycemic Hyperosmolar Syndrome (HHS) is a critical complication of diabetes mellitus that requires immediate diagnosis and treatment. Patients with this syndrome present with hyperglycemia, hyperosmolality and significant dehydration that are often accompanied by acute neurological deficits. In this chapter, we will review the diagnostic characteristics and common triggers of HHS within the framework of a case presentation. Approaches to therapeutic interventions such as intravenous fluid therapy, intravenous insulin, and electrolyte repletion are reviewed. Finally, some direction is given to controversial issue regarding the type of intravenous fluid used and the role of anticoagulation in HSS. Management of patients with HHS begins with aggressive intravenous isotonic saline. Potential triggers, such as infection, diet or medication changes and ischemic events are evaluated and appropriately treated. Intravenous insulin is necessary to reduce both hyperglycemia and counter-regulatory hormones that have been activated by HHS. Dextrose infusions are used in conjunction with insulin drip to avoid acute drops in serum osmolality, or to allow for continued insulin infusion when lipolysis and ketogenesis complicate HHS. Severe dehydration is evident by elevated serum sodium, and total body water deficit may be calculated to guide fluid repletion. Other electrolytes, such as potassium, magnesium and phosphate, require attentive monitoring and repletion. Hyperglycemic emergency states are well recognized as hypercoaguable, with increased risk for thrombotic events. For this reason, DVT prophylaxis with subcutaneous heparin is generally recommended.

Diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar syndrome (HHS) and severe hypoglycemia are considered as the life-threatening diabetic emergencies of diabetic patients worldwide. As the prevalence of diabetes grows in developing countries, so too does the impact of these costly human and economic complications. Noticeable scarcity of data concerning the magnitude, the cost expenditures as well as well unidentified predictors of these complications made the management more difficult in the resource limited health care settings. Thus, this systematic review aimed to assess the magnitude, risk factors and economic impacts of diabetes emergencies among diabetic patients in the developing countries. Following PRISMA (2020) guidelines, databases of PubMed, EMBASE, Cochrane and Scopus were searched for studies reporting on prevalence, risk factors, and direct costs of diabetes emergencies published in English from 2000 to 2023. Forty eligible studies were extracted and retrieved using manual data extraction form and automation tools. Studies were analyzed and combined in a narrative synthesis. The estimations of direct cost expenditure were standardized to 2023 USD. A comprehensive examination was conducted on the 40 eligible studies, with the majority originating from African sources. The review shows the prevalence of diabetic emergencies; DKA episodes in the range of (3.8%-73.4%), HHS (0.9%-58%) and Severe hypoglycemia (3.3%-64.7%) per year in the developing countries. Infection, new onset of the diabetes, and non-compliance to medications and diets were reported as the most common risk factors of theses diabetic emergencies. Besides, the costs of hospitalization taken from the patients' perspective, that were associated per one diabetic emergency event per patient was reported in the range of 105-230 USD in the developing countries. The rising prevalence of diabetic emergencies in poor nations, where infections, non-compliance, and new onset of diabetes are major causes, highlighted the urgent need for preventative interventions. Identifying high-risk individuals is crucial for implementing tailored strategies to reduce emergency visits and hospital admissions. The significant economic burden of these emergencies exacerbates the strain on already limited healthcare resources. In order to enhance health outcomes and lessen the financial strain on healthcare systems in these areas, preventive strategies must be incorporated into diabetes management programs.

In this session, we describe the acute phase in patients with metabolic syndrome from two sides; acute disease that occurs higher in patients with metabolic syndrome such as colonary heart disease and stroke, and acute aggravation of diabetes such as diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome. The electrolyte imbalance is frequently detected in critical ill patients. It is reported that the extreme abnormalities of ionized calcium concentrations are independent predictors of mortality. In addition, from clinical database MIMIC-Ⅱ,calcium supplementation improves clinical outcome in intensive care unit patients. Although metabolic syndrome; lifestyle-related disease, is a chronic disease, the possibility of falling into acute disease by having it becomes very high and improvement of electrolyte imbalance, especially hypocalcaemia is expected to effective on clinical outcome.

An inter-humanitarian agency study of diabetes care and surveillance in humanitarian settings

To address racial and ethnic disparities, physical therapy organizations, educational institutions, and clinical practices seek to advance diversity, equity, inclusion (DEI), and social justice in health care. Although our professional organizations have crafted proclamations, resource lists, developed new accreditation standards, and strategic plans, we lack a unifying framework and action tools for substantial and sustained progress. In addition, the DEI acronym is missing the essential element of belonging (B), that is, sharing a sense of purpose and feeling safe to contribute opinions as a valued member of an organization. Therefore, the purpose of this position paper is to propose the utilization of a continuous quality-improvement (CQI) framework using Plan-Do-Study-Act (PDSA) cycles to advance DEI-B in physical therapy education and practice. The CQI framework and PDSA cycles are data-driven, iterative approaches for identifying areas for improvement, implementing interventions, collecting data, analyzing outcomes, and taking evidence-based next action steps. Application of this framework can enhance sustainability of DEI-B goals and foster progress toward the proposed accreditation criteria of the Commission on Accreditation in Physical Therapy Education in this critical area. Tenants for PDSA team success are presented, and PDSA cycles are described. Addressing racism and advancing DEI-B efforts in the physical therapy profession requires bold, sustained, and intentional action that incorporates standards, strategies, and methods for measuring change. Examples of PDSA DEI-B initiatives, interventions, and outcomes are provided to illustrate how this approach can be implemented within a physical therapy education program. Using this CQI framework provides our profession with a DEI-B roadmap for advancing incremental and sustained progress.

Hyperglycemic Hyperosmolar State: An Emerging Pediatric Problem

Posterior reversible encephalopathy syndrome complicating hyperosmolar hyperglycemic syndrome.

Hyperosmolar hyperglycemic syndrome (HHS) is a common complication of diabetes mellitus. The episodes of HHS have been reported in patients with no prior history of diabetes. However, these incidents have rarely been reported in the literature. The present study reports the case of hyperosmolar hyperglycemic syndrome in a patient without diabetes history after being prescribed high-dose steroid therapy. This case highlights the importance of regularly monitoring blood glucose levels in patients prescribed supraphysiological doses of steroids. The present study presents a 29-year-old male patient with no previous history of diabetes who presented with HHS, manifested by a decreased level of consciousness, lethargy, and history of polyuria. Laboratory work revealed significantly high serum glucose and high serum osmolality, with no ketones. Two weeks prior to the presentation, the patient was started on 1 mg/kg of oral prednisolone for his new diagnosis of minimal change disease with a nephrotic syndrome picture. The management of HHS included aggressive fluid intake and insulin therapy, and the steroid was tapered quickly. Hyperglycemia resolved completely with normalization of his HbA1c after the complete stoppage of steroids and he did not require to continue lifelong insulin. The present study highlights the importance of assessing the risk of hyperglycemia, screening, and regular glucose monitoring in patients prescribed supraphysiological doses of steroids, even if no prior history of diabetes has been recorded..

The objective of this study is to assess the safety and effectiveness of an electronic glucose monitoring system (eGMS) versus paper-based protocols (PBPs) to manage diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) within the VA setting. This study is a retrospective chart review of patients on an insulin drip, treated in the emergency department (ED) or intensive care unit (ICU) at Veteran Health Indiana for DKA or HHS. The primary outcome was evaluating the percentage of patients with hypoglycemia (blood glucose [BG] level <70 mg/dL) in patients admitted with DKA and HHS comparing an eGMS versus a PBP. A total of 168 patients were included in the analysis, with 84 patients in each group. The primary outcome comparing rates of hypoglycemia in the eGMS group versus the PBP group showed a lower rate of hypoglycemia in the eGMS group (0.024%) compared with the PBP group (0.060%); however, this difference was not found to be statistically significant (P = .90). Statistically significant secondary outcomes include the percentage of glucose checks drawn within the protocol recommendation (80.7% vs 52.6%, P = .02). While the primary endpoint of decreased hypoglycemia was not found to be statistically significant, it did reduce the overall number of hypoglycemia events in the eGMS group compared with the PBP group which may be clinically significant. This demonstrates that eGMS use has the potential to minimize hypoglycemia and glycemic variability in a critically-ill Veteran population by individualizing insulin drip titration based on a variety of patient-specific factors and providing reminders for staff to obtain BG checks in a timely manner.

Diabetic Emergencies in Small Animals

Emergency presentations in people with diabetes are relatively common. These include the traditional diabetic emergencies such as diabetic ketoacidosis, hyperglycaemic hyperosmolar syndrome and hypoglycaemia, as well as people with diabetes presenting with other medical emergencies such as a cerebrovascular accident (CVA) or an acute coronary syndrome (ACS). The evidence behind the clinical management of these emergencies is often inconclusive and there is considerable variation in clinical practice. This chapter aims to systematically review the published evidence behind the clinical management for the traditional diabetic emergencies and the common medical emergencies, as well as to critique existing guidelines.

Point-of-care (POC) blood glucose (BG) measurement is currently not recommended in the treatment of patients presenting with diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar syndrome (HHS). We prospectively evaluated and compared capillary and venous POC BG values with laboratory venous glucose in patients with DKA or HHS admitted to one critical care unit over 8 months. Venous laboratory glucose was strongly correlated with venous (r = 0.98) and capillary (r = 0.96) POC glucose values, though POC glucose values were higher than venous laboratory values (venous POC 21 ± 3 mg/dl, capillary POC 30 ± 4 mg/dl; both p < .001). Increased plasma osmolality had no effect on glucose meter error, while acidemia (pH < 7.3) was associated with greater glucose meter error (p = .04) independent of glucose levels. Comparing hypothetical insulin infusion rates based on laboratory venous glucose to actual infusion rates based on POC glucose values showed that 33/61 insulin infusion rates would have been unchanged, while 28 out of 61 rates were on average 7% ± 2% higher. There were no instances of hypoglycemia in any of the patients. Overall, both venous and capillary POC BG values were safe for the purpose of titrating insulin infusions in patients with severe hyperglycemia. Acidemia, but not hyperosmolality, increased POC BG value errors.

Management of acute hyperglycemic emergencies: focus on diabetic ketoacidosis.

Objective: To study the epidemiological, clinical and therapeutic profile of diabetic metabolic emergencies. Patients and methods: This was a prospective study in descriptive and analytical referred conducted over a period of 6 months in the National Teaching Hosptial HKM of Cotonou December 1, 2011 to May 31, 2012. The patients included in the case of our study were those who, conscious or comatose, had submitted a diabetic hypoglycemia or abnormal blood sugar (2.5 g/l), with a positive glycosuria and ketonuria positive or not. All patients gave their consent for this study. Results: 2786 patients were admitted to the emergency room, 57 (2%) of acute metabolic decompensation of diabetes. DKA accounted for 1.1%, hyperosmolar hyperglycemic syndrome 0.5% and 0.4% hypoglycemia. For hyperglycemic decompensation, sex ratio was 0.8 for females with a mean age of 50.7 ± 16.9 (16-84). For hypoglycemia, male gender was predominant. As decompensation factors for hyperglycemia, infection was found in 54% (n = 30) of cases and stroke by 29% hypertension (n = 15). As for hypoglycemia triggers were dominated by dietary error (50%) and therapeutic errors (25%). 63% (n = 36) of patients underwent resuscitation. More than 3 out of 4 patients were resuscitated to insulin. 98% of patients were rehydrated. The outcome was favorable in 56% of cases. The death rate was 25 % (n = 14). Conclusion: Diabetes mellitus is a serious condition and its severity is mainly due to complications which can be acute or chronic.

Diabetic ketoacidosis (DKA) is an endocrine emergency that can occur in people with diabetes. Its incidence is estimated to be 220,340 hospital admissions each year. Treatment algorithms include fluid resuscitation, intravenous (IV) insulin infusion, and scheduled electrolyte and glucose monitoring. The misdiagnosis of DKA in the setting of hyperglycemic emergencies results in overtreatment and unnecessary increases in healthcare utilization and costs. The aims of this study were to determine how often DKA is overdiagnosed in the context of other acute hyperglycemic emergencies, to describe the baseline characteristics of patients, to determine the hospital treatments for DKA, and to identify the frequency of endocrinology or diabetology consultation in the hospital setting. A retrospective chart review was conducted utilizing charts from three different hospitals within a hospital system. Charts were identified utilizing ICD-10 codes for admissions to the hospital for DKA. If the patient was over 18 and had one of the diagnostic codes of interest, the chart was reviewed for further details regarding the criteria for DKA diagnosis as well as admission and treatment details. A total of 520 hospital admissions were included for review. DKA was incorrectly diagnosed in 28.4 % of the hospital admissions reviewed, based on a review of the labs and DKA diagnostic criteria. Most patients were admitted to the intensive care unit (ICU) and treated with IV insulin infusion (n=288). Consultation of endocrinology or diabetology occurred in 40.2 % (n=209) of all hospital admissions, and 128 of those consults occurred in ICU admissions. The diagnosis of DKA was incorrect in 92 of the patients admitted to the medical surgical unit (MSU) and in 49 of patients admitted to the ICU. Almost one third of hospital admissions forhyperglycemic emergencies were misdiagnosed and managed as DKA. DKA diagnostic criteria are specific; however, other diagnoses like hyperosmolar hyperglycemic syndrome (HHS), hyperglycemia, and euglycemic DKAcan make an accurate diagnosis more complicated. Education directed at improving the diagnostic accuracy of DKA among healthcare providers is needed to improve diagnostic accuracy, ensure the appropriate use of hospital resources, and potentially reduce costs to the healthcare system.