Endocrinology and metabolism clinics of North America
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Endocrinol. Metab. Clin. North Am. · Dec 2006
ReviewHyperglycemic crises in diabetes mellitus: diabetic ketoacidosis and hyperglycemic hyperosmolar state.
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) potentially are fatal but largely preventable acute metabolic conditions of uncontrolled diabetes, the incidence of which continues to increase. Mortality from DKA has declined remarkably over the years because of better understanding of its pathophysiology and treatment. The mortality rate of HHS remains alarmingly high, however, owing to older age and mode of presentation of patients and associated comorbid conditions. DKA and HHS also are economically burdensome; therefore, any resources invested in their prevention would be rewarding.
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Critically ill patients usually develop hyperglycemia, a condition referred to as "diabetes of injury." More and more evidence argues against the concept that this is an adaptive beneficial response. Indeed, the development of hyperglycemia seems to be detrimental for the outcome of critically ill patients, because maintenance of normoglycemia with intensive insulin therapy prevents morbidity and reduces mortality of critically ill patients to a large extent. The mechanisms underlying these clinical benefits are being studied further.
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Endocrinol. Metab. Clin. North Am. · Dec 2006
ReviewCatecholamines and vasopressin during critical illness.
This article summarizes the effects of catecholamines and vasopressin on the cardiovascular system, focusing on their metabolic and immunologic properties. Particular attention is dedicated to the septic shock condition.
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Adrenal insufficiency is a rare disorder, usually with gradually evolving clinical symptoms and signs. Occasionally, an acute adrenal insufficiency crisis can become a life-threatening condition because of acute interruption of a normal or hyperfunctioning adrenal or pituitary gland or sudden interruption of a adrenal replacement therapy. ⋯ A simple strategy or diagnostic screening and early intervention with sodium chloride-containing fluids and hydrocortisone should be widely implemented for cases with suspicion of an acute Addison disease crisis. In contrast, the chronic replacement dosage for patients with adrenal insufficiency should be as low as possible with clear instructions for dosage adjustments in case of stress or acute emergencies.
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Myxedema coma is the term given to the most severe presentation of profound hypothyroidism and is often fatal in spite of therapy. Decompensation of the hypothyroid patient into a coma may be precipitated by a number of drugs, systemic illnesses (eg, pneumonia), and other causes. ⋯ Although thyroid hormone therapy is critical to survival, it remains uncertain whether it should be administered as thyroxine, triiodothyronine, or both. Adjunctive measures, such as ventilation, warming, fluids, antibiotics, pressors, and corticosteroids, may be essential for survival.