RESUMEN
OBJECTIVES: Hyperglycemic hyperosmolar state (HHS) is one of the most severe acute complications of diabetes mellitus (DM) characterized by severe hyperglycemia and hyperosmolality without significant ketosis and acidosis. What is new? Since HHS in the pediatric population is rare and potentially life-threatening, every reported case is very valuable for raising awareness among healthcare professionals. CASE PRESENTATION: A 7-year-old boy with previously diagnosed Joubert syndrome was admitted due to vomiting, polydipsia and polyuria started several days earlier. He was severely dehydrated, and the initial blood glucose level was 115 mmol/L. Based on clinical manifestations and laboratory results, he was diagnosed with T1DM and HHS. The treatment with intravenous fluid was started and insulin administration began later. He was discharged after 10 days without any complications related to HHS. CONCLUSIONS: Since HHS has a high mortality rate, early recognition, and proper management are necessary for a better outcome.
Asunto(s)
Glucemia/metabolismo , Diabetes Mellitus Tipo 1/patología , Coma Hiperglucémico Hiperosmolar no Cetósico/patología , Insulina/administración & dosificación , Niño , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 1/metabolismo , Humanos , Coma Hiperglucémico Hiperosmolar no Cetósico/complicaciones , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Coma Hiperglucémico Hiperosmolar no Cetósico/metabolismo , Hipoglucemiantes/administración & dosificación , Masculino , PronósticoRESUMEN
INTRODUCTION: Isolated Hyperosmolar Hyperglycaemic Syndrome (HHS) is a life-threatening condition characterized by elevated serum glucose concentrations and hyperosmolality without significant ketosis. It is often described in obese adults with unknown Type 2 Diabetes (T2D), rarely in youth. In childhood the most common cause of metabolic glucose related derangement is Diabetic Ketoacidosis (DKA) in Type 1 Diabetes (T1D). Interestingly, both components can be combined with each other, thus the prevalent condition needs to be recognised implying a different therapeutic approach. CASE PRESENTATION: In this case, we report a prepubertal Caucasian obese girl admitted for two episodes of combined HHS/DKA in order to elucidate her clinical course taking into account the current pediatric recommendations based on adult guidelines for HHS. CONCLUSIONS: The treatment of HHS and even more of HHS/DKA in youth is still controversial as no specific guidelines for children are available especially during the prepubertal age. The description of our case might be helpful and offer relevant points for future consensus.
Asunto(s)
Glucemia/metabolismo , Diabetes Mellitus Tipo 2/complicaciones , Coma Hiperglucémico Hiperosmolar no Cetósico/etiología , Insulina de Acción Prolongada/administración & dosificación , Metformina/administración & dosificación , Obesidad Infantil/complicaciones , Niño , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Relación Dosis-Respuesta a Droga , Quimioterapia Combinada , Femenino , Humanos , Coma Hiperglucémico Hiperosmolar no Cetósico/diagnóstico , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológicoRESUMEN
For patients presenting with suspected diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycemic state (HHS) understanding of the etiology and pathophysiology will ensure optimal emergency management. Morbidity and mortality is most often due to the underlying precipitating cause, which may include infection, infarction/ischemia, noncompliance with insulin therapy, pregnancy, and dietary indiscretion. Current guidelines are based primarily on expert opinion and consensus statements, but more recent evidence suggests that recommendations related to arterial blood gas, insulin bolus, and IV fluid replacement should be re-evaluated. This issue presents an approach to DKA and HHS management based on current evidence, with a simplified pathway for emergency department management.
Asunto(s)
Fluidoterapia/métodos , Hiperglucemia/fisiopatología , Complicaciones de la Diabetes/tratamiento farmacológico , Complicaciones de la Diabetes/fisiopatología , Diabetes Mellitus/tratamiento farmacológico , Cetoacidosis Diabética/tratamiento farmacológico , Cetoacidosis Diabética/fisiopatología , Humanos , Hiperglucemia/tratamiento farmacológico , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Coma Hiperglucémico Hiperosmolar no Cetósico/fisiopatología , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéuticoAsunto(s)
Adenocarcinoma del Pulmón/tratamiento farmacológico , Diabetes Mellitus/inducido químicamente , Cetoacidosis Diabética/inducido químicamente , Coma Hiperglucémico Hiperosmolar no Cetósico/inducido químicamente , Inhibidores de Puntos de Control Inmunológico/efectos adversos , Neoplasias Pulmonares/tratamiento farmacológico , Nivolumab/efectos adversos , Dolor Abdominal/fisiopatología , Lesión Renal Aguda/fisiopatología , Adenocarcinoma del Pulmón/secundario , Anciano , Autoanticuerpos/metabolismo , Confusión/fisiopatología , Diabetes Mellitus/tratamiento farmacológico , Diabetes Mellitus/metabolismo , Diabetes Mellitus/fisiopatología , Cetoacidosis Diabética/tratamiento farmacológico , Cetoacidosis Diabética/metabolismo , Cetoacidosis Diabética/fisiopatología , Femenino , Cadenas HLA-DRB1/genética , Humanos , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Coma Hiperglucémico Hiperosmolar no Cetósico/metabolismo , Coma Hiperglucémico Hiperosmolar no Cetósico/fisiopatología , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Neoplasias Pulmonares/patología , Masculino , Persona de Mediana Edad , Polidipsia/fisiopatología , Poliuria/fisiopatologíaRESUMEN
Hyperglycaemic hyperosmolar state (HHS) may occur in young patients with type 1 and type 2 diabetes and in infants with hyperglycaemia. Hyperglycaemic hyperosmolar state is characterised by extremely high glucose concentration, which, by increasing osmotic diuresis, intensifies dehydration. Hyperglycaemic hyperosmolar state criteria include the following: plasma glucose > 600 mg/dl, venous pH > 7.25, sodium bicarbonate > 15 mmol/l, slight ketonuria, plasma osmolality > 320 mOsm/kg, and impairment of consciousness (aggression, unconsciousness, convulsions). We describe the case of a 13-year-old patient with severe obesity (at presentation body mass > 120 kg, BMI > 40 kg/m2), who developed HHS (glycaemia 647 mg/dl, pH 7.18, pCO2 96.5 mmHg, BE - 5.0 mmol/l, HCO3 35.2 mmol/l; Na 167 mmol/l, plasma osmolarity 370 mOsm/kg) in the course of pneumonia and newly diagnosed type 2 diabetes (HbA1c 15.5%, C-peptide 2.63 ng/ml). In the follow-up, due to the hypoglycaemia, insulin was discontinued, metformin was administered at a dose of 2 g/day, with a further reduction to 500 mg/day, together with physical rehabilitation and a low-calorie diet. Weight reduction during 6 months of observation was approximately 37 kg. Due to breathing disorders occurring at night, the girl still needs breathing assistance (CPAP).
Asunto(s)
Diabetes Mellitus Tipo 2/complicaciones , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Adolescente , Glucemia , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Femenino , Humanos , Insulina/uso terapéutico , Metformina/uso terapéutico , Obesidad , PoloniaAsunto(s)
Coma Hiperglucémico Hiperosmolar no Cetósico/diagnóstico , Glucemia , Niño , Diabetes Mellitus Tipo 2/diagnóstico , Femenino , Fluidoterapia/métodos , Humanos , Coma Hiperglucémico Hiperosmolar no Cetósico/sangre , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Coma Hiperglucémico Hiperosmolar no Cetósico/terapia , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéuticoRESUMEN
OBJECTIVES: Insulin infusion therapy is commonly used in the hospital setting to manage diabetic ketoacidosis and hyperosmolar hyperglycemic state. Clinical evidence suggests both hypoglycemia and glycemic variability negatively impact patient outcomes. The hypothesis of this study was that moderate-intensity insulin therapy decreases hospital length of stay and prevalence of hypoglycemia in patients with diabetic ketoacidosis and hyperosmolar hyperglycemic state. DESIGN: Pre-post study. SETTING: Large academic medical center in the United States. PATIENTS: Two-hundred one consecutive, nonpregnant, adult patients admitted for diabetic ketoacidosis and hyperosmolar hyperglycemic state between October 2010 and December 2014. INTERVENTIONS: High-intensity insulin therapy versus moderate-intensity insulin therapy. High-intensity insulin therapy was designed to rapidly normalize blood glucose levels with bolus doses of insulin and rapid insulin titration. Moderate-intensity insulin therapy was designed to mitigate glycemic variability and hypoglycemia through avoidance of bolus dosing, a liberalized blood glucose target, and gradual insulin titration. MEASUREMENTS AND MAIN RESULTS: Hospital and ICU length of stay were reduced by 23.6% and 38%, respectively. The relative risk of remaining in the hospital at day 7 (0.51; p = 0.022) and day 14 (0.28; p = 0.044) were significantly reduced by the moderate-intensity insulin therapy strategy. The relative risk of remaining in the ICU at 48 hours was significantly lower in the moderate-intensity insulin therapy cohort (0.34; p = 0.0048). The prevalence (35% vs 1%; p = 0.0003) and relative risk (0.028; p = 0.0004) of hypoglycemia were significantly lower in the moderate-intensity insulin therapy cohort. Glycemic variability decreased by 28.6% (p < 0.0001). There was no difference in the time to anion gap closure (p = 0.123). CONCLUSIONS: Moderate-intensity insulin therapy for diabetic ketoacidosis and hyperosmolar hyperglycemic state resulted in improvements in hospital and ICU length of stay, which appeared to be associated with decreased glycemic variability.
Asunto(s)
Enfermedad Crítica/terapia , Cetoacidosis Diabética/tratamiento farmacológico , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Tiempo de Internación/estadística & datos numéricos , Adulto , Estudios de Cohortes , Femenino , Humanos , Hiperglucemia/tratamiento farmacológico , Resistencia a la Insulina , Masculino , Persona de Mediana EdadAsunto(s)
Trastornos de la Conciencia/diagnóstico , Coma Hiperglucémico Hiperosmolar no Cetósico/diagnóstico , Anciano de 80 o más Años , Trastornos de la Conciencia/complicaciones , Servicio de Urgencia en Hospital/organización & administración , Fluidoterapia/métodos , Humanos , Hiperglucemia/diagnóstico , Hiperglucemia/tratamiento farmacológico , Coma Hiperglucémico Hiperosmolar no Cetósico/sangre , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Masculino , Pruebas de Estado Mental y Demencia , Concentración OsmolarRESUMEN
We report the case of a 77-year-old woman with diabetic chorea, which presented as hemiballism of the right limbs. Initial blood examination revealed that sugar and hemoglobin A1c levels were 732â mg/dl and 12.2%, respectively. Thus, a diagnosis of hyperglycemic hyperosmolar syndrome was made at a previous hospital. Ballism of the right limbs developed after 10 days and progressively worsened. After a month, the patient was admitted to our hospital. Brain MRI (axial T1-weighted imaging) revealed a high-signal-intensity area in the left striatum. Dopamine transporter SPECT demonstrated reduced 123I-ioflupane binding in the bilateral striatum with left side predominance. Although haloperidol and risperidone were ineffective for her involuntary movement, chlorpromazine had a little effect. Levodopa and gabapentin combination treatments were effective in decreasing the symptoms. It was considered that dopamine antagonist was the medical treatment for diabetic chorea and that levodopa could worsen neurological symptoms such as chorea-ballism. However, in our case, levodopa treatment was effective.
Asunto(s)
Corea/tratamiento farmacológico , Cuerpo Estriado/diagnóstico por imagen , Complicaciones de la Diabetes/tratamiento farmacológico , Proteínas de Transporte de Dopamina a través de la Membrana Plasmática/metabolismo , Discinesias/tratamiento farmacológico , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Levodopa/administración & dosificación , Tomografía Computarizada de Emisión de Fotón Único , Anciano , Aminas/administración & dosificación , Corea/diagnóstico por imagen , Corea/etiología , Cuerpo Estriado/metabolismo , Ácidos Ciclohexanocarboxílicos/administración & dosificación , Complicaciones de la Diabetes/diagnóstico por imagen , Quimioterapia Combinada , Discinesias/diagnóstico por imagen , Discinesias/etiología , Femenino , Gabapentina , Humanos , Coma Hiperglucémico Hiperosmolar no Cetósico/diagnóstico por imagen , Resultado del Tratamiento , Ácido gamma-Aminobutírico/administración & dosificaciónAsunto(s)
Aspergilosis/microbiología , Infecciones Fúngicas del Ojo/microbiología , Coma Hiperglucémico Hiperosmolar no Cetósico/etiología , Fallo Renal Crónico/complicaciones , Enfermedades Orbitales/microbiología , Enfermedades de los Senos Paranasales/microbiología , Anciano , Antifúngicos/uso terapéutico , Aspergilosis/complicaciones , Aspergilosis/diagnóstico , Aspergilosis/terapia , Desbridamiento , Infecciones Fúngicas del Ojo/complicaciones , Infecciones Fúngicas del Ojo/diagnóstico , Infecciones Fúngicas del Ojo/terapia , Humanos , Coma Hiperglucémico Hiperosmolar no Cetósico/diagnóstico , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Hipoglucemiantes/administración & dosificación , Infusiones Intravenosas , Insulina/administración & dosificación , Fallo Renal Crónico/diagnóstico , Fallo Renal Crónico/terapia , Enfermedades Orbitales/complicaciones , Enfermedades Orbitales/diagnóstico , Enfermedades Orbitales/terapia , Enfermedades de los Senos Paranasales/complicaciones , Enfermedades de los Senos Paranasales/diagnóstico , Enfermedades de los Senos Paranasales/terapia , Diálisis Renal , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Atypical antipsychotics are very widely used for various psychiatric ailments because of their less extrapyramidal side effects. Various reports of disturbances in glucose metabolism in the form of new onset diabetes mellitus, exacerbation of preexisting diabetes mellitus, diabetic ketoacidosis, hyperosmolar nonketotic coma, acute pancreatitis, and increased adiposity have been reported. We present a case of new onset diabetic ketoacidosis in a patient without a history of glucose intolerance who was being treated with olanzapine for bipolar disorder. He presented in hyperglycemic, hyperosmolar, hyperketotic state with hyperkalemia, and peaked T waves on electrocardiogram. He was treated with vigorous intravenous hydration, insulin, and kaexylate which stabilized his metabolic profile. He was discontinued off of his olanzapine and started on resperidol for his bipolar disorder. Over the course of 6 months, the patient was discontinued off of his insulin and has been doing well on his follow-up appointments. This case highlights the necessity of close blood glucose monitoring of patient on atypical antipsychotic medications irrespective of their diabetic status.
Asunto(s)
Antipsicóticos/efectos adversos , Benzodiazepinas/efectos adversos , Trastorno Bipolar/tratamiento farmacológico , Cetoacidosis Diabética/inducido químicamente , Coma Hiperglucémico Hiperosmolar no Cetósico/inducido químicamente , Quelantes/uso terapéutico , Cetoacidosis Diabética/tratamiento farmacológico , Humanos , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Hiperpotasemia/inducido químicamente , Hiperpotasemia/tratamiento farmacológico , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Masculino , Persona de Mediana Edad , Olanzapina , Poliestirenos/uso terapéuticoRESUMEN
Decompensated hypothyroidism is a rare endocrine emergency but a differential that should be considered in patients presenting critically unwell with systemic illness. We report a case of myxoedema coma in a woman presenting with respiratory failure, hypotension, hypothermia and a reduced level of consciousness, all of which are poor prognostic features in decompensated hypothyroidism. The patient was admitted to critical care for mechanical ventilation and cardiovascular support and treated with a combination of insulin, liothyronine and levothyroxine, making a good recovery. We wanted to highlight this case of myxoedema coma occurring in the context of a hyperglycaemic hyperosmolar state (HHS), as the former condition is normally associated with hypoglycaemia, hyponatraemia and hypo-osmolality. Decompensated hypothyroidism should be considered in presentations of HHS as well as with other metabolic derangements, as delays in thyroid hormone replacement are associated with poorer outcomes. It has multisystem effects challenging its recognition and we discuss potential complications and their management.
Asunto(s)
Coma Hiperglucémico Hiperosmolar no Cetósico/diagnóstico , Mixedema/diagnóstico , Femenino , Humanos , Coma Hiperglucémico Hiperosmolar no Cetósico/complicaciones , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Hipoglucemiantes/uso terapéutico , Hipotensión/etiología , Hipotermia/etiología , Insulina/uso terapéutico , Persona de Mediana Edad , Mixedema/complicaciones , Mixedema/tratamiento farmacológico , Insuficiencia Respiratoria/etiología , Tiroxina/uso terapéutico , Resultado del Tratamiento , Triyodotironina/uso terapéuticoAsunto(s)
Histiocitosis de Células de Langerhans/complicaciones , Coma Hiperglucémico Hiperosmolar no Cetósico/etiología , Diabetes Insípida Nefrogénica/complicaciones , Diabetes Insípida Nefrogénica/tratamiento farmacológico , Diabetes Mellitus Tipo 2/complicaciones , Femenino , Fluidoterapia , Histiocitosis de Células de Langerhans/tratamiento farmacológico , Humanos , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Neoplasias Hipotalámicas/complicaciones , Neoplasias Hipotalámicas/diagnóstico por imagen , Neoplasias Hipotalámicas/tratamiento farmacológico , Imagen por Resonancia Magnética , Persona de Mediana Edad , Inducción de RemisiónRESUMEN
Diabetic ketoacidosis and hyperosmolar hyperglycaemic syndrome are important hyperglycaemic emergencies seen in patients with diabetes. Occasionally, differentiation between the two conditions can be difficult. We present the case of a patient whose hyperglycaemic emergency was managed in a way that could have adversely influenced the outcome. We also discuss important aspects of the new Joint British Diabetes Societies Guidelines on the management of hyperglycaemic emergencies.
Asunto(s)
Cetoacidosis Diabética/diagnóstico , Cetoacidosis Diabética/tratamiento farmacológico , Coma Hiperglucémico Hiperosmolar no Cetósico/diagnóstico , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , Lesión Renal Aguda/complicaciones , Adulto , Cetoacidosis Diabética/complicaciones , Diagnóstico Diferencial , Urgencias Médicas , Fluidoterapia , Humanos , Coma Hiperglucémico Hiperosmolar no Cetósico/complicaciones , Insulina/uso terapéutico , Masculino , Cloruro de Sodio/uso terapéutico , Reino UnidoRESUMEN
The hyperglycemic emergencies, diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are potentially fatal complications of uncontrolled diabetes mellitus. The incidence of DKA and the economic burden of its treatment continue to rise, but its associated mortality rate which was uniformly high has diminished remarkably over the years. This Improvement in outcome is largely due to better understanding of the pathogenesis of hyperglycemic emergencies and the application of evidence-based guidelines in the treatment of patients. In this article, we present a critical review of the evidence behind the recommendations that have resulted in the improved prognosis of patients with hyperglycemic crises. A succinct discussion of the pathophysiology and important etiological factors in DKA and HHS are provided as a prerequisite for understanding the rationale for the effective therapeutic maneuvers employed in these acute severe metabolic conditions. The evidence for the role of preventive measures in DKA and HHS is also discussed. The unanswered questions and future research needs are also highlighted.
Asunto(s)
Complicaciones de la Diabetes/tratamiento farmacológico , Diabetes Mellitus/fisiopatología , Cetoacidosis Diabética/tratamiento farmacológico , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Complicaciones de la Diabetes/etiología , Cetoacidosis Diabética/etiología , Medicina Basada en la Evidencia , Humanos , Coma Hiperglucémico Hiperosmolar no Cetósico/etiologíaRESUMEN
Diabetic ketoacidosis (DKA) is the main hyperglycemic complication in type 1 Diabetes Mellitus (DM1). The basic principles in treatment have to be followed carefully. The patient with DKA has a very deep volume depletion. To restore the circulatory capacity is the first step. From this point on, the restoration of the lost fluids is slow, around 1% per hour, aiming at the correction of the metabolic disturbance already on and avoiding great fluctuations in osmolality, which increases the risk of having complications. Attention to the development of cerebral edema, which, once suspected, deserves an urgent treatment plan, trying to avoid neurologic sequelae or even death. Subcutaneous ultra-rapid insulin has been demonstrated to be efficient and easier to use. As the perfusion gets improved and the levels of insulin increase, the lipolysis is blocked, as well as the generation of ketones and so the acidemia tends to be solved. DKA is still a high-mortality condition. And to be in a hurry frequently leads to neurologic sequelae and even to a fatal outcome.
Asunto(s)
Diabetes Mellitus Tipo 1/fisiopatología , Cetoacidosis Diabética/fisiopatología , Enfermedad Aguda , Adolescente , Edema Encefálico/etiología , Edema Encefálico/fisiopatología , Niño , Preescolar , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/fisiopatología , Cetoacidosis Diabética/complicaciones , Cetoacidosis Diabética/tratamiento farmacológico , Diagnóstico Diferencial , Femenino , Humanos , Hiperglucemia/complicaciones , Hiperglucemia/fisiopatología , Coma Hiperglucémico Hiperosmolar no Cetósico/complicaciones , Coma Hiperglucémico Hiperosmolar no Cetósico/tratamiento farmacológico , Coma Hiperglucémico Hiperosmolar no Cetósico/fisiopatología , Hipoglucemiantes/uso terapéutico , Lactante , Infusiones Intravenosas , Insulina/análogos & derivados , Insulina/uso terapéutico , MasculinoRESUMEN
A principal complicação hiperglicêmica no diabetes melito tipo 1 (DM1) é a cetoacidose diabética (CAD). Embora variações nos protocolos possam ocorrer, os princípios básicos que norteiam o tratamento devem ser os mesmos. A recuperação inicial da capacidade circulatória, com a infusão rápida de solução salina na dose de 20 mL/kg, que pode ser repetida, é o ponto de partida para o tratamento. A partir daí, a reposição de volume é relativamente lenta, e o objetivo principal é corrigir gradualmente os distúrbios metabólicos instalados, sem ocasionar variações muito intensas e muito rápidas na osmolalidade, fator de risco para complicações. Atenção ao desenvolvimento de edema cerebral que, uma vez suspeitado, deve ser imediatamente corrigido, sob pena de óbito ou seqüelas neurológicas. A administração de insulina ultra-rápida, por via subcutânea, mostra-se eficaz e simplifica o atendimento do paciente. A CAD é uma situação grave, ainda com alta mortalidade, e seu tratamento deve ser dirigido aos pontos principais que levaram ao quadro clínico, com correções graduais, sob risco de se agravar o quadro.
Diabetic ketoacidosis (DKA) is the main hyperglycemic complication in type 1 Diabetes Mellitus (DM1). The basic principles in treatment have to be followed carefully. The patient with DKA has a very deep volume depletion. To restore the circulatory capacity is the first step. From this point on, the restoration of the lost fluids is slow, around 1 percent per hour, aiming at the correction of the metabolic disturbance already on and avoiding great fluctuations in osmolality, which increases the risk of having complications. Attention to the development of cerebral edema, which, once suspected, deserves an urgent treatment plan, trying to avoid neurologic sequelae or even death. Subcutaneous ultra-rapid insulin has been demonstrated to be efficient and easier to use. As the perfusion gets improved and the levels of insulin increase, the lipolysis is blocked, as well as the generation of ketones and so the acidemia tends to be solved. DKA is still a high-mortality condition. And to be in a hurry frequently leads to neurologic sequelae and even to a fatal outcome.