[The Management of Blood Glucose Should be Emphasized in the Treatment of COVID-19].

Based on the higher mortality and the higher proportion of critically ill adults in coronavirus disease 2019 (COVID-19) patients with diabetes, good inpatient glycemic control is particularly important in the comprehensive treatment of COVID-19. Individualized blood glucose target goals and treatment strategies should be made according to specific circumstances of COVID-19 inpatients with diabetes. For mild patients, a strict glycemic control target (fasting plasma glucose (FPG) 4.4-6.1 mmol/L, 2-hour postprandial plasma glucose (2 h PG) 6.1-7.8 mmol/L) are recommended; a target for the glycemic control of common type patients (FPG 6.1-7.8 mmol/L, 2 h PG 7.8-10.0 mmol/L) and subcutaneous insulin deliver therapy are recommended; a target nonfasting blood glucose range of 10.0 mmol or less per liter for severe-type COVID-19 patients, a relatively Less stringent blood glucose control target (FPG 7.8-10.0 mmol/L, 2 h PG 7.8-13.9 mmol/L) for critically ill patients and intravenous insulin infusion therapy are recommended. Due to the rapid changes in the condition of some patients, the risk of diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar status (HHS) maybe occur during the treatment. Blood glucose monitoring, dynamic evaluation and timely adjustment of strategies should be strengthened to ensure patient safety and promote early recovery of patients.

Prevention and management of hyperglycaemic crisis.

Hyperglycaemia is a defining feature of diabetes mellitus. It involves an elevated level of glucose in the blood, which develops as a result of the body's inability to produce insulin or process insulin effectively. If left unchecked and untreated, patients with diabetes are at risk of short-term, potentially life-threatening hyperglycaemic crises such as diabetic ketoacidosis or hyperosmolar hyperglycaemic state. Nurses frequently care for patients diagnosed with diabetes in various clinical settings; therefore, it is essential that they have an awareness of the prevention and management of hyperglycaemia and hyperglycaemic crises. This article explains the causes and clinical manifestations of hyperglycaemic crises, and details the management of patients with these conditions, in accordance with national guidelines.

[Sick day management in elderly patients with diabetes mellitus].

A bad cold, the flu or a serious illness can make blood glucose too high in elderly person with diabetes. Gastrointestinal illnesses may cause hypoglycemia for individuals treated with insulin, sulfonylureas or glitinides. When the persons with diabetes discontinue insulin or diabetes medications because of appetite loss and reduced food intake, they may fall into diabetic crises, such as ketoacidosis, or hyperosmolar hyperglycemic syndrome. The elderly patients need to take extra precautions on sick days to avoid diabetic crises or hypoglycemia. Key principles of sick day management are (1) maintaining hydration and carbohydrate intake, (2) monitoring blood glucose and ketone levels, (3) adjusting diabetes medications according to carbohydrate intake, blood glucose and ketone levels. In Japan, the numbers of frail elderly diabetic patients is markedly increased, effective and efficient sick day management for frail elderly diabetic patients is requested.

Hyperglycemic crises and their complications in children.

The object of this review is to provide the definitions and criteria for diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS), and convey current knowledge of the causes of permanent disability or mortality from complications of these conditions, of the risk factors for DKA and HHS, and of early indicators and contemporary treatment of suspected cerebral edema. The frequency of DKA at onset of type 1 diabetes mellitus (DM1) varies from 10-70%, depending on availability of health care and frequency of diabetes. At the onset of type 2 diabetes (DM2), DKA occurs in 5-52%. One study reported HHS in approximately 4% of new patients with DM2. Recurrent DKA rates are equally dependent on variability in medical services and socio-economic circumstances, and are estimated to be eight episodes per 100 patient years, with 20% of patients accounting for 80% of the episodes. Mortality for each episode of DKA internationally varies from 0.15-0.31%, with idiopathic cerebral edema accounting for two-thirds or more of this mortality. Other causes of death or disability include untreated DKA or HHS, hypokalemia, hypophosphatemia, hypoglycemia, other intracerebral complications, peripheral venous thrombosis, mucormycosis, rhabdomyolysis, acute pancreatitis, acute renal failure, sepsis, aspiration pneumonia, and other pulmonary complications. Population-based studies from the UK, Australia, the USA, and Canada report cerebral edema incidence in DKA of 0.5-2.0%. Published information does not support the notion that treatment factors are causal in cerebral edema. Younger age, greater severity of acidosis, degree of hypocapnia, and severity of dehydration have been suggested as risk factors in several studies. Bimodal distribution of the time of onset of cerebral edema and wide variation in brain imaging findings suggest the variability and likely multiple causation of the clinical picture. Functional brain scanning has indicated that DKA is accompanied by increased cerebral blood flow suggesting that the predominant mechanism of edema formation is a vasogenic process. A method of monitoring for diagnostic and major and minor signs of cerebral edema has been proposed and tested which indicates that intervention will be required in five individuals to provide early intervention for a single case of cerebral edema. The preferred intervention of mannitol infusion has typically been accompanied by intubation and hyperventilation, but recent evidence indicates outcome is adversely affected by aggressive hyperventilation. The prevention of DKA and HHS at the onset of diabetes mellitus requires a high degree of awareness and suspicion by primary care providers; prevention of recurrent DKA necessitates a diligent team effort.

Hyperglycemic crises in diabetes mellitus: diabetic ketoacidosis and hyperglycemic hyperosmolar state.

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) potentially are fatal but largely preventable acute metabolic conditions of uncontrolled diabetes, the incidence of which continues to increase. Mortality from DKA has declined remarkably over the years because of better understanding of its pathophysiology and treatment. The mortality rate of HHS remains alarmingly high, however, owing to older age and mode of presentation of patients and associated comorbid conditions. DKA and HHS also are economically burdensome; therefore, any resources invested in their prevention would be rewarding.

Therapeutic management of hyperglycaemic hyperosmolar syndrome.

Hyperglycaemic hyperosmolar syndrome is a major acute complication of decompensated diabetes mellitus. It represents the second most common aetiology of diabetic coma and is associated with excess mortality. It is characterised by severe hyperglycaemia, hyperosmolality and dehydration in the absence of significant ketosis, afflicting principally middle-aged-to-elderly patients. Early clinical diagnosis and prompt treatment, consisting of fluid replacement, insulin therapy, restoration of electrolyte disturbances and management of concurrent illnesses may improve the outcome. This review provides an outline of the diagnostic approach of patients with manifestations of hyperglycaemic hyperosmolar syndrome and discusses the contemporary therapeutic recommendations.

Overview of diabetes.

The number of people with diabetes is growing to epidemic proportions in the United States. There is a great deal of research on the evolving understanding of the pathogenesis of diabetes as compared to normoglycemia. The diagnostic criteria for diabetes have become streamlined to more appropriately and accurately diagnose the disease. There are millions of people who have diabetes, but do not know it. It is essential that appropriate screening be performed to make a diagnosis in order to delay or prevent the complications from occurring. The complications of diabetes have implications for the increasing number of people with the diagnosis who are hospitalized and how they are treated. There are specific methods for recognition and treatment of both acute and chronic complications in the hospitalized patent with diabetes. Managing blood glucose control is essential for favorable outcomes.

Inpatient management of diabetes: survey in a tertiary care centre.

AIMS: Good glycaemic control in hospitalised patients with diabetes mellitus improves wellbeing and aids recovery. This survey aimed to: (1) assess glycaemic control in patients with diabetes admitted to hospital for reasons other than diabetes, (2) compare the glycaemic control in patients treated in medical and surgical units, and (3) see the impact of specialists' input on glycaemic control. METHODS: The first 150 patients admitted to hospital were identified; those with acute metabolic complications of diabetes mellitus, acute myocardial infarction, pregestational or gestational diabetes, and patients in different intensive care units were excluded. Case notes were reviewed with particular attention to glycaemic control, frequency of blood monitoring, complications, and the actions taken to improve glycaemic control. RESULTS: Four of the 150 patients died in hospital. When subcutaneous insulin was used glycaemic control was good in 48%, suboptimal in 15%, and poor in 37% of patients. The results were not significantly different with subcutaneous or intravenous insulin. There was also no difference in glycaemic control among medical and surgical patients. Patients managed by designated specialists had better control than those managed by physicians (p<0.001). Hypoglycaemia was documented in 20% and two patients developed non-ketotic hyperosmolar coma while in hospital. In a few cases treatment at discharge was not changed despite poor control while in hospital. CONCLUSION: More attention should be given to improving glycaemic control in patients hospitalised for reasons other than diabetes. Particular care should be taken to modify the dose of insulin needed to get good glycaemic control; control was better with specialists' input. A follow up survey will be conducted.

[The role of serum osmolality monitoring in patients with severe intracranial lesion].

We dynamically determined serum osmolality in 1379 patients with severe intracranial lesion for 2843 times between January 1992 and July 1995. Using auto-control and after abandoned osmolality related interference factors we obtained the following results. Quantitative correlation analysis on the level of serum osmolality, intracranial pressure and the dose of mannitol showed that there was a negative correlation between the level of serum osmolality and intracranial pressure, while a positive correlation existed between the intracranial pressure and the dose of mannitol. The reasonable dose of mannitol was that which elevated the level of serum osmolality some 15-20 mOsm/kgH2O than its normal upper limit. The level of serum osmolality increesed to raised up 20-30 mOsm/kgH2O after administration of a single dose of mannitol. Complication increased with the increased level of osmolality of 300 mOsm/kgH2O, a warning level. An elevation of osmolality over 320 mOsm/kgH2O was considered the critical level for developing acute renal failure. The level of over 330 mOsm/kg H2O was another warning level for inducing nonketotic hyperosmotic diabetic coma. The efficious duration of mannitol, two different ways of diminishing or withdrawing the dose of mannitol, and the more safer velocity for correcting the state of hyperosmolality were also discussed. We conclude that to monitor the dynamic change of serum osmolality from time to time is of great help in lowering the incidence and mortality of hyperosmotic complications. Serum osmolality monitoring plays an important role in making fluid balance and compromizing the contradiction between dehydration and infusion as well as prevention and therapy of hyperosmotic complications, and outcome estimation as well.

Coma hiperglicémico, hiperosmolar, no cetósico: realidad del servicio de medicina adultos del hospital Gustavo Fricke de Viña de Mar 1984-1993 / Hyperglycemic, hyperosmolar, nonketotic coma: reality of the adult medicine service at Gustavo Fricke Hospital in Viña del Mar

Se revisaron retrospectivamente las fichas clínicas de 16 pacientes egresados del Hospital "Gustavo Fricke", entre 1984 y 1993, con el diagnóstico de coma hiperglicémico hiperosmolar no cetósico; a fin de explotar y describir la experiencia del centro asistencial en dicha patología. Se observó una mayor prevalencia en pacientes del sexo femenino y añosos. El antecedente diabético estuvo presente en aproximadamente dos tercios de la muestra. Dentro de los factores precipitantes destacan los cuadros infecciosos (81,2 por ciento). Resalta una hiperglicemia promedio de 723 mgr por ciento y una osmolaridad plasmática promedio de 369,4 mOsm/lt. En el período estudiado de nueve años, sólo logró detectarse 16 casos de esta complicación diabética; sobresaliendo su mortalidad (50 por ciento), mayor que lo expuesto en la literatura

Hyperglycemic emergencies.

Hyperglycemic emergencies are the most common endocrinopathies that require intensive care. It is estimated that between 10% and 15% of patients admitted to intensive care units experience complications of acute hyperglycemia. The common denominator of hyperglycemic emergencies is diabetes mellitus, a group of diseases in which, either because of beta-cell destruction of the pancreas or insulin receptor-site defects, there is a relative or absolute deficiency of insulin that results in hyperglycemia. In response to various precipitating factors, staggering hyperglycemia may develop in the form of diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNK). The existence of DKA has been known since ancient times, and critical care nurses are familiar with the diagnosis. The more lethal disorder of HHNK was "rediscovered" in the 1950s and is occurring with greater frequency as clinical awareness of the condition grows and the elderly (who are at greatest risk for the disorder) populate critical care units in increasing numbers. Prevention is instrumental in abating deadly hyperglycemic emergencies. A positive outcome can be realized but only with timely diagnosis and prompt hormonal and fluid replacement.

The diabetic hyperosmolar state.

The diabetic hypersomolar state is defined by a serum glucose greater than 600 mg/dl and a serum osmolarity greater than 320 m Osm/L. Ketoacidosis or lactic acidosis may co-exist with DHS in the same patient. The incidence of this acute complication of diabetes is high enough (17.5 cases per 100,000 person-years) for primary care physicians to encounter a case every year or two. Predisposing factors include older age, female sex, nursing home residence, and infection. A substantial proportion of cases occur in patients with no prior history of diabetes. Common presenting signs include fatigue or weakness, polydipsia, polyuria, nausea, and alteration of consciousness. The mainstay of therapy is intravenous fluid replacement with close monitoring of glucose and electrolytes in a hospital setting. Current mortality figures are high, at 10% to 20%, and the chance of survival is adversely affected by older age, higher osmolarity, and the presence of an associated severe illness. Prevention includes screening for diabetes, educating diabetic patients and their care givers about the symptoms of hyperglycemia, prompt treatment of any infection in a diabetic person, avoidance of drugs that increase carbohydrate intolerance in diabetic people, and encouraging compliance with treatment of diabetes.

[Hyperosmolar diabetic coma. Case reports and review of the literature]. / Coma diabetico iperosmolare. Contributo casistico e revisione della letteratura.

The physiopathology and clinical picture of hyperosmolar diabetic coma are described, and four personal cases are presented. This form of coma is a rare, but particularly serious complication of diabetes mellitus. Since its prognosis is poor, even when suitable treatment is provided, the greatest possible care should be devoted to preventing its main cause, namely dehydration.

Hyperosmolar nonketotic coma: prevention, diagnosis, and treatment.

With the multi-faceted approach to head and neck cancer today, maintaining caloric intake by long-term enteral hyperalimentation is commonplace. Along with the tremendous advantages of this form of nutrition, the disadvantage of hyperosmolar nonketotic diabetic acidotic coma is present. Mortality rates are quoted from 40% to 70% according to the literature reviewed. Therefore, prevention is the best form of treatment. The cause, diagnosis, and treatment will be discussed.

Avoidance of surgical hyperglycemia in diabetic patients.

Strict intraoperative glucose level control was accomplished with constant low-dose glucose infusion of 100 mg/kg/hr and variable infusion rates of insulin to control serum glucose levels as follows: 20 units/hr for serum glucose levels greater than 200 mg/dL, 1 unit/hr for levels between 80 and 200 mg/dL, and no insulin for levels less than 80 mg/dL. Using this technique, eight diabetic patients with serum glucose levels greater than 250 mg/dL before surgery had their serum glocose levels brought rapidly under control (ie, glucose level less than 200 mg/dL), which continued postoperatively.

A review of hypersomolar hyperglycemic nonketotic dehydration (HHND): etiology, pathophysiology and prevention during intravenous hyperalimentation.

The records of 200 patients, nutritionally supported by synthetic means, were reviewed for evidence of clinical hyperosmolar hyperglycemic nonketotic dehydration (HHND). There was a 3% incidence of morbidity, with a single mortality. Laboratory values demonstrated a positive correlation between persistent glucosuria and HHND. The pathophysiology of HHND demonstrated a relative insulin lack with sufficient insulin to prevent lipolysis, but insufficient to prevent hyperglycemia, glucosuria and osmotic diuresis. The mechanism and management of the pseudodiabetes of stress is reviewed. It is concluded that HHND is an avoidable iatrogenic morbidity. Prevention of osmotic diuresis secondary to glucosuria and, therefore, prevention of HHND is achieved by providing exogenous insulin sufficient to prevent glucosuria.