Diabetologische Notfälle: Ketoazidose und hyperglykämes Koma

Abstract

Background Diabetic ketoacidosis and the hyperosmolar hyperglycemic state are the most serious diabetic emergencies. Before the discovery of insulin in 1921 by Banting and Best the diagnosis of type 1 diabetes was fatal ending in diabetic ketoacidosis equivalent to a torturous death. Today, mortality from diabetic ketoacidosis is low at approximately 2 %. But each death from these two acute metabolic complications of diabetes is potentially avoidable by improved patient and healthcare professional education. Therefore, there is a need to raise awareness of hyperglycemic crisis and its management amongst physicians.

Pathogenesis Insulin deficiency or resistence and increased concentrations of counterreulatory hormones (glucagon, catecholamines, cortisol and growth hormone) are responsible for the development of diabetic ketoacidosis and the hyperosmolar hyperglycemic state. Hyperglycemia develops as a result of increased gluconeogenesis and accelerated glyconeogenesis. In DKA, the absolute insulin deficiency additionally leads to increased lipolysis and production of ketone bodies and resulting metabolic acidosis.

Diagnosis Both DKA and HHS require prompt recognition and management. The diagnosis can be suspected by clinical features and confirmed by laboratory findings.

Treatment The treatment of DKA and HHS is similar, including correction of fluid and electrolyte abnormalities and the administration of insulin.

Die Diabetische Ketoazidose (DKA) und das hyperglykämische Koma sind akut lebensbedrohliche Komplikationen des Diabetes mellitus. Vor der Entdeckung des Insulins 1922 war die Diagnose eines Typ-1-Diabetes gleichbedeutend mit einem qualvollen Tod in der DKA. Heute liegt die Letalität der DKA mit 2 % vergleichbar niedrig. Dennoch bleibt jeder dieser Todesfälle vermeidbar, nicht zuletzt durch die geeignete Schulung von Patienten und Ärzten.

Schlüsselwörter

Diabetes mellitus - hyperglykäme Krise - hyperglykäme Notfälle - Coma diabeticum

Key words

diabetes - hyperglycemic crisishyperglycemic emergencies - diabetic coma

• Literatur

• 1 Johnson DD, Palumba PJ, Chu CP. Diabetic ketoacidosis in a community-based population. Mayo Clin Proc 1980; 555: 83-88
• 2 National Diabetes Audit – 2008-09: Executive Summary. Figure 10. Im Internet: https://digital.nhs.uk/catalogue/PUB02577
• 3 Kearney T, Dang C. Diabetic and endocrine emergencies. Postgrad Med J 2007; 83: 79-86
• 4 Centers for Disease Control and Prevention, Diabetes Public Health Resource. Im Internet: www.cdc.gov/diabetes/statistics/hospitalization_national.htm
• 5 Kitabchi AE, Umpierrez GE, Murphy MB. et al. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care Dec 2006; 29: 2739-2748
• 6 Kitabachi AE, Umpierrez GE, Miles JM. et al. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care 2009; 32: 1335-1343
• 7 Savage MW, Dhatariya KK, Kilvert A. et al. for the Joint British Diabetes Societies. Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabetic Medicine 2011; 28: 508-515
• 8 Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2007; 3: CD000567
• 9 Umpierrez GE, Latif K, Stoever J. et al. Efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for the treatment of patients with diabetic ketoacidosis. Am J Med 2004; 117: 291
• 10 Umpierrez GE, Cuervo R, Karabell A. et al. Treatment of diabetic ketoacidosis with subcutaneous insulin aspart. Diabetes Care 2004; 27: 1873
• 11 Umpierrez GE, Kelly JP, Navarrete JE. et al. Hyperglycemic crisis in urban blacks. Arch Intern Med 1997; 157: 669-675
• 12 Umpierrez GE, Jones S, Smiley D. et al. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care 2009; 32: 1164-1169