Hyperglycemic Crises in Adult Patients With Diabetes

Abbas E. Kitabchi, PHD, MD; Guillermo E. Umpierrez, MD; John M. Miles, MD; Joseph N. Fisher, MD


Diabetes Care. 2009;32(7):1335-1343. 

In This Article


Many cases of DKA and HHS can be prevented by better access to medical care, proper patient education, and effective communication with a health care provider during an intercurrent illness. Paramount in this effort is improved education regarding sick day management, which includes the following:

  1. Early contact with the health care provider.

  2. Emphasizing the importance of insulin during an illness and the reasons never to discontinue without contacting the health care team.

  3. Review of blood glucose goals and the use of supplemental short- or rapid-acting insulin.

  4. Having medications available to suppress a fever and treat an infection.

  5. Initiation of an easily digestible liquid diet containing carbohydrates and salt when nauseated.

  6. Education of family members on sick day management and record keeping including assessing and documenting temperature, blood glucose, and urine/blood ketone testing; insulin administration; oral intake; and weight. Similarly, adequate supervision and staff education in long-term facilities may prevent many of the admissions for HHS due to dehydration among elderly individuals who are unable to recognize or treat this evolving condition.

The use of home glucose-ketone meters may allow early recognition of impending ketoacidosis, which may help to guide insulin therapy at home and, possibly, may prevent hospitalization for DKA. In addition, home blood ketone monitoring, which measures ß-hydroxybutyrate levels on a fingerstick blood specimen, is now commercially available[37].

The observation that stopping insulin for economic reasons is a common precipitant of DKA[74,75] underscores the need for our health care delivery systems to address this problem, which is costly and clinically serious. The rate of insulin discontinuation and a history of poor compliance accounts for more than half of DKA admissions in inner-city and minority populations[9,74,75]. Several cultural and socioeconomic barriers, such as low literacy rate, limited financial resources, and limited access to health care, in medically indigent patients may explain the lack of compliance and why DKA continues to occur in such high rates in inner-city patients. These findings suggest that the current mode of providing patient education and health care has significant limitations. Addressing health problems in the African American and other minority communities requires explicit recognition of the fact that these populations are probably quite diverse in their behavioral responses to diabetes[76].

Significant resources are spent on the cost of hospitalization. DKA episodes represent >1 of every 4 USD spent on direct medical care for adult patients with type 1 diabetes and 1 of every 2 USD in patients experiencing multiple episodes[77]. Based on an annual average of 135,000 hospitalizations for DKA in the U.S., with an average cost of 17,500 USD per patient, the annual hospital cost for patients with DKA may exceed 2.4 billion USD per year[3]. A recent study[2] reported that the cost burden resulting from avoidable hospitalizations due to short-term uncontrolled diabetes including DKA is substantial (2.8 billion USD). However, the long-term impact of uncontrolled diabetes and its economic burden could be more significant because it can contribute to various complications. Because most cases occur in patients with known diabetes and with previous DKA, resources need to be redirected toward prevention by funding better access to care and educational programs tailored to individual needs, including ethnic and personal health care beliefs. In addition, resources should be directed toward the education of primary care providers and school personnel so that they can identify signs and symptoms of uncontrolled diabetes and so that new-onset diabetes can be diagnosed at an earlier time. Recent studies suggest that any type of education for nutrition has resulted in reduced hospitalization[78]. In fact, the guidelines for diabetes self-management education were developed by a recent task force to identify ten detailed standards for diabetes self-management education[79].


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