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Three Part Question

In [an elderly patient with diabetic nonketotic hyperosmolar state presenting in emergency room] with [congestive cardiac failure] [what is the evidence based management]?

Clinical Scenario

It is not uncommon for non-insulin dependent diabetes mellitus patients having the co-morbidity of cardiovascular disease. You are working in a busy Intensive Care Unit when the nurse informs you that a congestive cardiac failure patient with Hyperosmolar non-ketotic diabetes mellitus has just arrived. You wonder the management, as treatment of one condition is contraindication for the other.
Cardiovascular disease complicating Hyperosmolar Nonketotic diabetes mellitus is not a rare phenomenon and lethal if not treated properly. Both diseases are treatable individually. Treatment of one condition being the contraindication to the other, clinical judgment on management is difficult, when one complicates the other.

Search Strategy

(Diabetic Ketoacidosis) and (Congestive Cardiac Failure) in PUBMED interface on the world wide web, was searched using the terms above. Limit was set to human species. No other limits were set. Search date - 25/11/10.
We used the following keywords in pubmed search:
Diabetic Ketoacidosis in Congestive Cardiac Failure
Diabetic Ketoacidosis complicating Congestive Cardiac Failure
Diabetic Ketoacidosis in Congestive Cardiac Failure
Management of Diabetic Ketoacidosis in Congestive Cardiac Failure
Management of Diabetic Ketoacidosis complicating Congestive Cardiac Failure

Search Outcome

A total of 48 articles were retrieved. Only one article was relevant. In addition we did the “related articles search” for that single relevant article, but found no further articles of relevance.
Each of the above keywords gave variable number of results from 7-40. Only one literature was relevant clinically in human population.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Cozzolino D 1996 Italy	132 elderly diabetics with Hyperglcemic Hyperosmolar Non-ketotic state(HHNS).	This is literature review of case series and case reports documenting management of cardiac illness complicating Hyperosmolar non-ketotic diabetes mellitus (HHNS). One of the case series provides approximate answer to our research question. In a series of 132 elderly diabetics with HHNS (Pinies et al., 1994), ten (8%) of them precipitated by cardiovascular events: its overall mortality was calculated to be 16.9%; in other series this rate was widely different with reports ranging from 12 to 70%, but it remains high anyway. One of the cases- the patient has acute congestive heart failure associated or not with a large size myocardial infarction.	Aggressive intravenous fluid therapy is required as a necessary tool in acute severe decompensation of diabetes, but caution should be exercised in geriatric patients because: (i) The hemodynamic state of these patients may be somewhat critical to rapid infusion regimen of fluids. (ii) Cardiovascular events, such as acute heart failure, stroke, and myocardial infarction are described as precipitating factors, and they account for almost 10 % among these, according to some workers (Hockaday and Alberti, 1972; Wachtel et al., 1987). The conclusions of this case series were: (i) The mortality was higher (50%) in patients with cardiovascular precipitating events; [ii) cardiovascular accidents were frequent (23%) cause of death. The Logical treatment guidance was: In more moderate cases, the dangers inherent to aggressive intravenous fluid therapy of the geriatric patient with Hyperglcemic Hyperosmolar Non-ketotic state (HHNS) can be reduced by monitoring the central venous pressure (CVP): the first 2-3 liters of half-normal solutions should be given rapidly without exceeding 5 liters for fear that pulmonary edema may occur (Unger and Foster, 1985). The necessarily rapid rate of administration of intravenous infusions can be quickly reduced if the CVP begins to rise excessively avoiding the complications of congestive heart failure. The rapid liquid replacement should be avoided if the CVP is higher than 8-10 cmH20.	Cardiovascular disease complicating Hyperosmolar Nonketotic diabetes mellitus is not a rare phenomenon and lethal if not treated properly. Aggressive intravenous fluid therapy is required as a necessary tool in acute severe decompensation of diabetes, caution should be exercised in geriatric patients. In more moderate cases, the dangers inherent to aggressive intravenous fluid therapy of the geriatric patient with HHNS can be reduced by monitoring the central venous pressure (CVP) for fear that pulmonary edema may occur.	This is a literature review. The conclusion of treatment strategy is the logical derivation of one or more case series report. The evidence does not meet Level 1 standards and cannot be treated as evidence based guideline for treatment. This logical treatment strategy is only for more moderate cases. Also, there is no guideline to determine mild, moderate, more moderate or severe case. There is no way to ascertain if the reported experiences were unbiased. There is no literature through controlled/uncontrolled clinical trials.

Comment(s)

The treatment strategy has been outlined based on logical conclusion from experiences documented in case series. There is lack of evidence for the management of cardiovascular disease complicating hyperosmolar nonketotic diabetic coma. There exists a need for documentation of case reports, case series and more clinical data for construction of evidence towards the management of decompensated diabetic disease in cardiac disease.

Clinical Bottom Line

Cardiovascular disease complicating Hyperosmolar Nonketotic diabetes mellitus is not a rare phenomenon and lethal if not treated properly. Aggressive intravenous fluid therapy is required as a necessary tool in acute severe decompensation of diabetes, especially in geriatric patients. It can be undertaken with monitoring the central venous pressure. Insufficient evidence is available on management of cardiac illness complicating hyperosmolar non-ketotic diabetes mellitus. Well designed studies are needed from various institutions to ascertain the management of cardiac illness complicating Hyperosmolar non-ketotic diabetes mellitus.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Cozzolino D Diabetic non ketotic hyperosmolar state: a special care in aged patients. Arch Gerontol Geriatr. 1996;22 Suppl 1:245-53.