Hyperglycemic crises resident survival guide

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For more information about DKA, click here.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2], Husnain Shaukat, M.D [3]

Hyperglycemic crises Resident Survival Guide Microchapters
Overview
Classification
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life threatening complications of untreated or inadequately treated diabetes mellitus. HHS is characterized by hyperglycemia, hyperosmolarity and dehydration; whereas DKA is characterized by hyperglycemia, acidosis, and ketosis.[1]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Hyperosmolar hyperglycemic state is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

Common causes of hyperosmolar hyperglycemic state (HHS) include:

Management

The diagnostic approach and management management of HHS and DKA are based on the ADA guidelines published in 2009.[1]

General Approach

Characterize the symptoms:

Polyuria
Polydipsia
Weight loss
Vomiting
Dehydration
❑ Weakness
❑ Mental status change
Abdominal pain
❑ Vomiting


Examine the patient:


❑ Poor skin turgor
Kussmaul breathing
Tachycardia
Hypotension
Hypothermia or hyperthermia


Identify precipitating factors:


Infections
Insulin deficiency
Myocardial infarction
❑ New onset DM type 1
❑ Pregnancy
❑ Stress
 
 
 
Order tests:

❑ Serum glucose
ABG
CBC
Electrolytes
❑ Serum & urinary ketones
Urinalysis
BUN
Creatinine
Plasma osmolality


EKG
CXR
❑ Urine, sputum, blood cultures (not routine)
Start the management of the following SIMULTANEOUSLY: (Urgent)
(Check the algorithms below for more details)

IV fluids
Insulin
Potassium
Bicarbonate

 
 
 
Check the following every two hours until the patient is stable:
❑ Glucose
Electrolytes
BUN
❑ Venous pH
Creatinine
 
 
 
Determine the resolution of HHS:

❑ Blood glucose <200 mg/dl, AND
❑ Two of the following criteria:
- Serum bicarbonate level >15 mEq/l
- Venous pH >7.3
- Calculated anion gap12 mEq/l


Determine the resolution of HHS:
❑ Normal osmolality

❑ Regain of normal mental status



VARIABLE DIABETIC KETOACIDOSIS
MILD (Plasma Glucose > 250mg/dL or 13.88 mmol/L) MODERATE (Plasma Glucose > 250mg/dL or 13.88 mmol/L) SEVERE (Plasma Glucose > 250mg/dL or 13.88 mmol/L)
Arterial pH 7.25 to 7.30 7.00 to < 7.24 < 7.00
Serum bicarbonate 15 to 18 mEq/L 10 to < 15 mEq/L < 10 mEq/L
Urine ketone (Nitroprusside reaction method) Positive Positive Positive
Serum ketone (Nitroprusside reaction method) Positive Positive Positive
Effective serum osmolality Variable Variable Variable
Anion gap > 10 mEq/L (10 mmol/L) > 12 mEq/L (12 mmol/L) > 12 mEq/L (12 mmol/L)
Mental status Alert Alert/drowsy Stupor/coma

Management: IV Fluids

 
 
 
 
 
 
Initial IV fluid
❑ 0.9% NaCl (15-20ml/kg/hour), OR
❑ 1-1.5L during the first hour
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate the hydration status
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe hypovolemia
 
 
 
Mild hypovolemia
 
Cardiogenic shock
❑ Hemodynamic monitoring/pressors
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess the corrected [Na+]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Administer 0.9% NaCl (1.0L/hour)
 
High or normal [Na+]
❑ Administer 0.45% NaCl (250-500 ml/hour)
depending on the hydration status
 
Low [Na+]
❑ Administer 0.9% NaCl (250-500 ml/hour)
depending on the hydration status
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemodynamic monitoring:
Blood pressure
❑ Laboratory results
❑ Input/output of fluids
❑ Clinical status
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
When serum glucose reaches
200mg/dL in DKA and 300mg/dl in HHS

❑ Change to 5% dextrose with 0.45% NaCl
(150-250 mL/hour)
 
 
 
 
 



Management: Insulin

 
 
Check K+ before administering insulin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
K+<3.3 mEq/L
❑ Hold insulin and give K+ 20-30 mEq/h
until K+>3.3 mEq/L
 
K+>5.5 mEq/L
❑ Do not give K
❑ Proceed with insulin
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer initial IV dose of insulin
❑ Continuous IV infusion of 0.14 U/Kg/h, OR
❑ IV bolus of 0.1 U/Kg, then continuous IV
infusion of 0.1 U/Kg/h
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check if serum glucose falls by 10% in the first hour
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Administer IV bolus of 0.14 U/Kg,
then continue previous treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
When serum glucose reaches 250mg/dl in DKA and 300mg/dl in HHS:
❑ Reduce IV regular insulin infusion to 0.02-0.05 U/kg/h, OR
❑ Administer SC rapid acting insulin at 0.1 U/kg every 2 hours
Keep serum glucose between 150-200 mg/dL until
resolution (200-300 mg/dL for HHS)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Check glucose, BUN, electrolytes, creatinine, venous pH every 3-4 hours until stable
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirm resolution and
assess ability to eat
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inability to eat
 
Able to eat
 
 
 
 
 
 
 
 
 
 
❑ Continue IV insulin infusion
and IV fluid replacement
 
Transfer from IV to SC insulin
❑ Initiate SC multidose insulin
❑ Continue IV insulin 1-2 hours after
SC insulin is initiated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient previously on insulin?
❑ Recommence the insulin home dose
 
Insulin naive patient?
❑ Start at a multidose of 0.5-0.8 U/kg/day



Management: Potassium

 
 
 
 
❑ Assess K+ level
❑ Establish adequate renal function
(urine output 50 ml/hour)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
K+<3.3 mEq/L
 
K+= 3.3-5.2 mEq/L
 
K+>5.2 mEq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Hold insulin
❑ Administer 20-30 mEq/hour
until K+>3.3 mEq/L
 
❑ Administer 20-30 mEq/hour in each
liter of IV fluid to keep serum K+
between 4 and 5 mEq/L
 
❑ Do not give K+
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Keep K+= 4-5 mEq/L
❑ Check K+ every 2 hours
until resolution of HHS
 
 
 
 
 
 
 
 
 
 
 

Do's

  • Check labs initially and every 2-4 hours.
  • Immediately check urine for ketones with dipstick and send urine to the lab for analysis.
  • Initiate IV insulin as soon as the patient arrives and satisfies the diagnostic criteria of DKA.
  • Assess the trigger that precipitated DKA and treat the cause.
  • In patients with potassium(K) < 3.3 mEq/L, fluids and potassium replacement must be done before initiating insulin therapy, to prevent further hypokalemia.
  • Admit the patient to the floor; however, if the pH < 7.0 or the patient is unconscious then admit to ICU.
  • Make sure to calculate the corrected sodium level when evaluating the sodium level. Sodium can be falsely low due to the elevated glucose level; in order to correct for this, add 1.6 mmol/L of Na+ for every 100 mg/dL of glucose > 100 mg/dL.
  • Monitor for complications of DKA itself or of the therapy.
  • In case the patient has cardiac or renal compromise, monitor serum osmolality and frequently assess the cardiac, renal and mental status.

Don'ts

References

  1. 1.0 1.1 Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN (2009). "Hyperglycemic crises in adult patients with diabetes". Diabetes Care. 32 (7): 1335–43. doi:10.2337/dc09-9032. PMC 2699725. PMID 19564476.
  2. Bouter KP, Diepersloot RJ, van Romunde LK, Uitslager R, Masurel N, Hoekstra JB, Erkelens DW (1991). "Effect of epidemic influenza on ketoacidosis, pneumonia and death in diabetes mellitus: a hospital register survey of 1976-1979 in The Netherlands". Diabetes Res. Clin. Pract. 12 (1): 61–8. PMID 1906798.
  3. Nakamura K, Inokuchi R, Doi K, Fukuda T, Tokunaga K, Nakajima S, Noiri E, Yahagi N (2014). "Septic ketoacidosis". Intern. Med. 53 (10): 1071–3. PMID 24827487.
  4. Osuchowski MF, Craciun FL, Schuller E, Sima C, Gyurko R, Remick DG (2010). "Untreated type 1 diabetes increases sepsis-induced mortality without inducing a prelethal cytokine response". Shock. 34 (4): 369–76. doi:10.1097/SHK.0b013e3181dc40a8. PMC 2941557. PMID 20610941.
  5. 5.0 5.1 Casqueiro J, Casqueiro J, Alves C (2012). "Infections in patients with diabetes mellitus: A review of pathogenesis". Indian J Endocrinol Metab. 16 Suppl 1: S27–36. doi:10.4103/2230-8210.94253. PMC 3354930. PMID 22701840.
  6. Czaja CA, Rutledge BN, Cleary PA, Chan K, Stapleton AE, Stamm WE (2009). "Urinary tract infections in women with type 1 diabetes mellitus: survey of female participants in the epidemiology of diabetes interventions and complications study cohort". J. Urol. 181 (3): 1129–34, discussion 1134–5. doi:10.1016/j.juro.2008.11.021. PMC 2699609. PMID 19152925.
  7. Ramaswamy K, Kozma CM, Nasrallah H (2007). "Risk of diabetic ketoacidosis after exposure to risperidone or olanzapine". Drug Saf. 30 (7): 589–99. PMID 17604410.
  8. Guenette MD, Hahn M, Cohn TA, Teo C, Remington GJ (2013). "Atypical antipsychotics and diabetic ketoacidosis: a review". Psychopharmacology (Berl.). 226 (1): 1–12. doi:10.1007/s00213-013-2982-3. PMID 23344556.
  9. Alavi IA, Sharma BK, Pillay VK (1971). "Steroid-induced diabetic ketoacidosis". Am. J. Med. Sci. 262 (1): 15–23. PMID 4327634.
  10. Alberti KG (1975). "Role of glucagon and other hormones in development of diabetic ketoacidosis". Lancet. 1 (7920): 1307–11. PMID 49515.
  11. Nakamura K, Kawasaki E, Imagawa A, Awata T, Ikegami H, Uchigata Y, Kobayashi T, Shimada A, Nakanishi K, Makino H, Maruyama T, Hanafusa T (2011). "Type 1 diabetes and interferon therapy: a nationwide survey in Japan". Diabetes Care. 34 (9): 2084–9. doi:10.2337/dc10-2274. PMC 3161293. PMID 21775762.
  12. Lu CP, Wu HP, Chuang LM, Lin BJ, Chuang CY, Tai TY (1995). "Pentamidine-induced hyperglycemia and ketosis in acquired immunodeficiency syndrome". Pancreas. 11 (3): 315–6. PMID 8577688.
  13. Lambertus MW, Murthy AR, Nagami P, Goetz MB (1988). "Diabetic ketoacidosis following pentamidine therapy in a patient with the acquired immunodeficiency syndrome". West. J. Med. 149 (5): 602–4. PMC 1026553. PMID 3150636.
  14. Borberg C, Gillmer MD, Beard RW, Oakley NW (1978). "Metabolic effects of beta-sympathomimetic drugs and dexamethasone in normal and diabetic pregnancy". Br J Obstet Gynaecol. 85 (3): 184–9. PMID 24459.
  15. Rodgers BD, Rodgers DE (1991). "Clinical variables associated with diabetic ketoacidosis during pregnancy". J Reprod Med. 36 (11): 797–800. PMID 1684993.
  16. Trachtenbarg DE (2005). "Diabetic ketoacidosis". Am Fam Physician. 71 (9): 1705–14. PMID 15887449.
  17. Nair S, Yadav D, Pitchumoni CS (2000). "Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA". Am. J. Gastroenterol. 95 (10): 2795–800. doi:10.1111/j.1572-0241.2000.03188.x. PMID 11051350.
  18. Umpierrez GE, Kitabchi AE (2003). "Diabetic ketoacidosis: risk factors and management strategies". Treat Endocrinol. 2 (2): 95–108. PMID 15871546.
  19. Dhatariya KK (2007). "Diabetic ketoacidosis". BMJ. 334 (7607): 1284–5. doi:10.1136/bmj.39237.661111.80. PMC 1895683. PMID 17585123.
  20. Razavi Z (2010). "Frequency of ketoacidosis in newly diagnosed type 1 diabetic children". Oman Med J. 25 (2): 114–7. doi:10.5001/omj.2010.31. PMC 3215499. PMID 22125712.
  21. Borus JS, Laffel L (2010). "Adherence challenges in the management of type 1 diabetes in adolescents: prevention and intervention". Curr. Opin. Pediatr. 22 (4): 405–11. doi:10.1097/MOP.0b013e32833a46a7. PMC 3159529. PMID 20489639.
  22. Gosmanov AR, Gosmanova EO, Dillard-Cannon E (2014). "Management of adult diabetic ketoacidosis". Diabetes Metab Syndr Obes. 7: 255–64. doi:10.2147/DMSO.S50516. PMC 4085289. PMID 25061324.
  23. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID doi.org/10.2337/dc09-9032 Check |pmid= value (help).
  24. Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI; et al. (2001). "Management of hyperglycemic crises in patients with diabetes". Diabetes Care. 24 (1): 131–53. doi:10.2337/diacare.24.1.131. PMID 11194218.
  25. Pasquel FJ, Lansang MC, Dhatariya K, Umpierrez GE (2021). "Management of diabetes and hyperglycaemia in the hospital". Lancet Diabetes Endocrinol. 9 (3): 174–188. doi:10.1016/S2213-8587(20)30381-8. PMID 33515493 Check |pmid= value (help).

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