Hyperglycemia

    Hyperglycemia is known as  high blood glucose (blood sugar). High blood glucose happens when the body has too little insulin or when the body can't use insulin properly.diabetic ketoacidosis(DKA) and hyperosmolar hyperglycemic nonketotic syndrome(HHNS) are acute complications of hyperglycemia crisis that may occur with diabetes.if not treated properly,it may lead to coma or death.DKA occurs often in patients with type 1 diabetes And may be first evidence of disease .hhns occurs most often in patients with type 2 diabetes ,but it also occurs in any one whose insulin tolerance is stressed  and  in patients who have undergone certain therapeutic procedure such as peritoneal dialysis,hemolysis

,tube feeding ,or total parental nutrition.

     Acute insulin deficiency absolute in DKA ,relative in HHNS precipitated both conditions causes include illness,stress,infection and in patient with DKA failure to take insulin.

Inadequate insulin hinders glucose uptake by fat and muscle cells because the cells can't take in glucose to convert to energy ,glucose accumulates in theblood.at the same time ,the liver responds to demands of the energy starved cells by converting glycogen to glucose and releasing glucose into the blood,further increasing the  blood glucose levels.when this level increased the renal threshold ,excess glucose is ex created in the urine.

Still the insulin deprived cells can't utilize glucose .their response is rapid metabolism of protein ,which results in loss of intracellular potassium and phosphorous and excessive liberation of amino acids .the liver converts these amino acids into urea and glucose .as a result of these process ,blood glucose levels are grossly elevated.the Aftermath is increased serum osmolality and glycosuria leading to osmotic dieresis.glycosuria is higher in HHNS than in DKA because blood glucose levels are higher in HHNS.

Clinical Features

Investigations

Management

1. Fluid replacement
• The fluids will be replaced initially orally and if the patient is un cooperative intravenously too replace the fluid lost by severe dehydration in both DKA and HHS.
2. Electrolyte replacement
• The absence of insulin will lower the levels of certain electrolytes. Electrolytes are minerals in the blood that is need for the tissues to function properly. The client should be given an IV infusion of electrolytes to maintain the functions of the heart, muscles and the nerve cells normal.
3. Insulin therapy
• Insulin will reverse the processes that build up ketones in the blood.  This is normally given intravenously.

If the severe hyperglycemia has caused the client to a coma, the patient should be intubated and kept on the ventilator. And monitor the patient while continuing the treatments.

Once the blood glucose level drops to normal the causes for the acute hyperglycemic episode should be found by further investigations. Then the treatments should be done for the causes triggered for the acute hyperglycemic episode.  

References

1. Bartoli E, Sainaghi PP, Bergamasco L, Castello L. Hyperosmolar coma due to exclusive glucose accumulation: recognition and computations. Nephrology (Carlton). Apr 2009;14(3):338-44. .
2. Bartoli E, Bergamasco L, Castello L, Sainaghi PP. Methods for the quantitative assessment of electrolyte disturbances in hyperglycaemia. Nutr Metab Cardiovasc Dis. Jan 2009;19(1):67-74. 
3. Emedicine.medscape.com, (2015). Hyperosmolar Hyperglycemic State. [online] Available at: http://emedicine.medscape.com/article/1914705-overview [Accessed 29 Apr. 2015].
4.         Mayo, 2015. Hyperglycemia in diabetes. [Online] Available at:http://www.mayoclinic.org/diseases-conditions/hyperglycemia/basics/complications/con-20034795 [Accessed 25 April 2015].
   5.      Tidy, C., 2011. Diabetic ketoacidosis. [Online] Available at:http://www.patient.co.uk/doctor/diabetic-ketoacidosis [Accessed 25 April 2015].
   6.      Tidy, C., 2011. Hyperosmolar hyperglycemic state. [Online] Available at:http://www.patient.co.uk/doctor/hyperosmolar-hyperglycaemic-state [Accessed 25 April 2015].