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HYPERGLYCEMIA, a serum glucose value greater than 110 mg/dL. Hyperglycemia is most commonly associated with diabetes mellitus; however, hyperglycemia is sometimes secondary to an underlying disease (hemochromatosis, pancreatitis, Cushings syndrome, pheochromocytoma, acromegaly), stress induced, or iatrogenic (excessive intravenous glucose administration or steroid therapy). Symptoms of hyperglycemia include polyuria, nocturia, polydipsia, polyphagia, cephalgia, and visual changes. Patients with hyperglycemia may also present with diabetic ketoacidosis (DKA) in which case symptoms are more severe and includes those mentioned above plus air hunger, epigastric pain, a characteristic fruity odor of the breath, coma, and if not corrected, death. The presence of DKA should prompt a search for an initiating cause such as infection, myocardial infarction, pancreatitis, or new onset type I diabetes. Characteristic lab abnormalities include hyponatremia, which may be corrected for in the presence of hyperglycemia via the following equation:

Patients in DKA may present with associated lab abnormalities to include acidosis, hypokalemia, hypophosphatemia, and acute renal failure secondary to dehydration. When hypokalemia is present, it is much worse than the measured serum potassium value indicates. An efflux of potassium from out of the cells occurs in acidotic states; therefore, in patients with severe acidosis, the measured serum potassium value is falsely elevated and does not accurately reflect the depleted total body stores. Therapy for DKA is with intravenous fluids, intravenous insulin (0.1U/kg and titrated to normalize the bicarb and anion gap), and electrolyte management. Intravenous glucose should be given if the glucose levels drops below 200 mg/dL so that intravenous insulin administration may proceed uninterrupted. It is important to remember acutely that therapy is not normalization of the glucose value, but rather correction of the acidosis (low serum bicarb) and the anion gap.

In caring for patients with diabetes mellitus, assessment of long-term glycemic control is imperative. Normalization of serum glucose values decreases the incidence of some of the microvascular disease complications. Long-term assessment of serum glucose may be accomplished with measurement of the glycated hemoglobin (hemoglobin that has reacted with sugars). This value represents a history of glycemic control for the past 120 days. Hemoglobin A1C (HbA1c) is the most commonly measured glycated hemoglobin, and the level has been shown to correlate to the average blood glucose. The goal of therapy is to lower the HbA1c to between 6.5 and 7 mg/dL.

                               HbA1c(%)                                              Average Blood Glucose (mg/dL)

                                     4                                                                             60

                                     5                                                                             90

                                    6                                                                              120

                                    7                                                                              150

                                    8                                                                              180

                                    9                                                                              210

                                   10                                                                             240

                                   11                                                                             270

                                   12                                                                             300

                                   13                                                                             330