Sara Watson, MD, MS
Associate Professor, Pediatric Endocrinology
University of Louisville, United States
Disclosure information not submitted.
Suzanne Kingery, MD
Associate Professor, Pediatric Endocrinology
University of Louisville, United States
Disclosure information not submitted.
Eleanor Peterson, MD, FAAP
Associate Professor, Pediatric Critical Care Medicine
University of Louisville, United States
Disclosure information not submitted.
Title: A Case Series: Mixed Presentations of Hyperglycemic Hyperosmolar Syndrome and Diabetic Ketoacidosis
Introduction: Hyperglycemic hyperosmolar syndrome (HHS) in children presents a unique set of clinical challenges for which there is currently a paucity of data on management and complications. In addition to the rare occurrence of HHS in children (0.8%) often leading to delay in recognition, a mixed diabetic ketoacidosis (DKA)-HHS presentation is noted in up to 13.8% of hyperglycemic emergencies. The aim of this study was to describe the clinical characteristics of children presenting with a mixed DKA/HHS picture and to describe the association between presentation, initial management, and incidence of complications.
Methods: A retrospective chart review was conducted for patients admitted to our institution’s pediatric intensive care unit with an ICD 10 code diagnosis of DKA and/or HHS with osmolality greater than 320 and glucose greater than 600 mg/dl for the time period January 2012 to December 2020. Data collected included initial lab values, fluid and insulin management, and incidence of complications. A univariate analysis was conducted to determine the association of clinical and demographic characteristics with development of complications.
Results: Of 500 patients with an ICD 10 diagnosis of DKA and/or HHS, 32 patients met the inclusion criteria. The cohort was mostly Caucasian with a median age of 12.5 years and an equal number of males and females. Most patients had type 1 diabetes mellitus (n=28) with a median osmolarity of 376 and median glucose of 1066 at presentation. All patients had ketonuria and only one patient had a pH >7.25. 14 patients experienced one of six complications described in literature, the most common of which was acute kidney injury. Cerebral edema was uncommon and noted in only 2 of 32 patients. There was a correlation between the degree of initial osmolarity and vasopressor requirement, but no other associated complications. Initial insulin and fluid management did not correlate with the development of complications.
Conclusions: Consistent with current literature, all patients presented with a mixed DKA/HHS picture. Further studies are needed to gain a better understanding of mixed DKA/HHS presentations and the role of initial management in preventing complications. This may guide improvement efforts in the care of these patients.