Diabetic ketoacidosis and hyperosmolar coma, a new presentation in pediatrics

Abstract

Admissions for hyperglycemic crises in children and adolescents with diabetes continue to be a challenge for the health team.

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are life-threatening events. Ketoacidosis is the most common form of presentation in pediatric type 1 diabetes (30-70%). The hyperosmolar hyperglycemic state is more frequent in type 2 diabetes, adults, and occurs in only 2% of adolescents at the time of diagnosis.

However, recent case reports inform that the incidence of HHS in children may be increasing due to a higher incidence of obesity and type 2 diabetes in this group¹.

Currently we can find a mixed form of presentation, ketoacidosis complicated with severe hyperglycemia, hyperosmolar DKA, with metabolic acidosis, glycemia ≥ 600 mg/dl and osmolarity ≥ 320 mosm/kg in 14% of children and 27% of  adults. Up to 30% of ketoacidosis episodes have features combined with the hyperosmolar hyperglycemic state. Series of cases have suggested that the intake of large amounts of carbonated beverages rich in sugars, days prior to the consultation, worsen the initial symptoms, with greater risk of ketoacidosis with severe hyperglycemia. This mixed form can also occur in children with limited access to fluids, exacerbating hypertonic dehydration².

This mixed form of presentation is not frequently recognized as such, which implies a greater risk of serious complications and mortality due to inappropriate management.

In hyperosmolar DKA and HHS states, unlike the usual symptoms of DKA, signs of dehydration may be less evident, due to hypertonicity that preserves intravascular volume, and consequently, polyuria and polydipsia gradually increase, leading to a more prolonged state of dehydration, with greater loss of water and electrolytes as a result. Profound dehydration secondary to states of severe hyperglycemia leads to renal hypoperfusion, with a drop in glomerular filtration rate and decreased renal glucose clearance, exacerbating hyperglycemia and contributing to the hyperosmolarity³.

The highest rate of complications in mixed presentations and HHS are related to underlying dehydration and initial fluid deficit. Recognition of hyperosmolarity in a mixed presentation is the first step to ensure adequate treatment, more aggressive in rehydration and monitoring of possible complications in a hyperglycemic emergency⁴.