Hyperglycemic crises resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: ; Vidit Bhargava, M.B.B.S [2]

Definition

Diabetic ketoacidosis is a life threatening complication of untreated or inadequately treated diabetes mellitus. Due to lack of insulin, body burns fats as fuel and leads to metabolic abnormalities.

Causes

Life Threatening Causes

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

Most Common Causes

  • Deficiency of Insulin or inadequate treatment
  • MI
  • Intercurrent illnesses - infections (UTI, Pneumonia) etc [1]
  • Stress ( surgery, infections etc.)[3]
  • Dehydration

Management

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diabetic ketoacidosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
H/o - vomiting, abdominal pain, drowsiness, altered mentation, fever, & malaise Precipitating factors - Insulin deficiency, Intercurrent illness, stress, MI, Pregnancy, new onset DM type 1
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check labs - CBC, Chem 7, ABG, EKG, CXR, urine dipstick & routine
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic criteria
Blood glucose > 250 mg/dL pH < 7.3 Serum bicarbonate < 18 mEq/L
Serum ketones (+)
Anion gap > 10
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IV fluid therapy
 
 
 
 
 
 
 
Insulin
 
 
 
 
 
 
 
Need for K+ replacement?
 
 
 
 
 
 
 
Need for bicarbonate replacement?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check hydration status
 
 
 
 
 
IV
 
SC for uncomplicated DKA
 
<3.3 mEq/dL
 
3.3-5.3 mEq/dL
 
>5.3 mEq/dL
 
pH < 6.9
 
pH > 7.0
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild dehydration
 
Severe dehydration
 
Cardiogenic shock
 
Regular insulin (0.1 U/kg) bolus
 
Rapid action insulin 0.3 U/kg then 0.2 U/kg after 1 hr
 
Hold insulin, supplement K+ (20-30 mEq/hr) till K+ > 3.3 mEq/L
 
Administer 20-30 mEq K+ per L of fluid
 
Don't supplement, check 2 hourly
 
Dilute NaHCo3 (100 mmol) in 400 ml H2O with 20 mEq KCl infused over 2 hrs
 
No bicarbonate needed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate for corrected Na+ levels
 
Start 0.9% NaCl (1L/hr) initially.
 
Pressors/ Monitor hemodynamics
 
Continous infusion (0.1 U/kg/hr)
 
s.c. insulin 0.2 U/kg every 2 hrs
 
 
 
 
 
 
 
 
 
 
 
 
 
Recheck
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High Na+ levels
 
Normal Na+ levels
 
Low Na+ levels
 
 
 
 
 
 
 
Double insulin infusion if blood sugar doesnt fall by 50-70 mg/dL in first hr
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Switch to 0.45% NaCl (250-500mL/hr)
 
 
 
Continue to 0.9% NaCl (250-500mL/hr)
 
 
 
 
 
 
 
At serum glucose = 200 mg/dL reduce i.v. insulin to 0.02-0.05 U/kg/hr or s.c. insulin (0.1 U/kg) every 2 hrs. Target blood sugar - 150-200 mg/dL till DKA resolves
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check blood glucose levels
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
At serum glucose levels ~ 200 mg/dL switch to 5% dextrose with 0.45% NaCl (150-250 ml/hr)
 
 
 
 
 
 
 
 
 
 
Check labs every 2-4 hrs, once pt. tolerates oral feeds transition to s.c. insulin (0.8 U/kg/day). Stop i.v. insulin gradually.
Look out for complications - Hypogylcemia, Hypokalemia, Cerebral edema, Respiratory distress, Sepsis, Acute gastric dilation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

The managment protocol is based on the recommendations given by American Diabetes Association (ASA) and other sources.[8]

Do's

  • Check labs initially and every 2-4 hours
  • Check urine for ketones immediately with dipstick and send urine to lab for analysis
  • Initiate i.v. insulin as soon as the patient arrives and satisfies criteria for DKA
  • Assess to understand what precipitated DKA and treat the cause
  • Admit the patient. If pH < 7.0, pt unconscious admit to ICU else may be shifted directly to floor
  • Assess hydration status of the patient, treat aggressively
  • switch to Dextrose with normal saline once blood sugar falls to 200 mg/dL
  • Check for complications from the condition itself as well as those developing due to therapy

Don'ts

  • DO not stop i.v. insulin until DKA has resolved
  • Do not stop i.v. insulin, as soon as s.c. insulin is administered, as it needs time to kick in
  • DO not give insulin if K+ levels are below 3.5 mEq/l, may further cause hypokalemia
  • Do not use 0.9% NaCl if corrected Na+ levels > 145 mEq/l, use 0.45% instead
  • Do not supplement phosphate overzealously, clinical trials have not shown any benefits. Give only if there is am actual deficiency

References

  1. Umpierrez, GE.; Kitabchi, AE. (2003). "Diabetic ketoacidosis: risk factors and management strategies". Treat Endocrinol. 2 (2): 95–108. PMID 15871546.
  2. Parker, JA.; Conway, DL. (2007). "Diabetic ketoacidosis in pregnancy". Obstet Gynecol Clin North Am. 34 (3): 533–43, xii. doi:10.1016/j.ogc.2007.08.001. PMID 17921013. Unknown parameter |month= ignored (help)
  3. MacGillivray, MH.; Bruck, E.; Voorhess, ML. (1981). "Acute diabetic ketoacidosis in children: role of the stress hormones". Pediatr Res. 15 (2): 99–106. doi:10.1203/00006450-198102000-00002. PMID 6789292. Unknown parameter |month= ignored (help)
  4. 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. PMID 3150636. Unknown parameter |month= ignored (help)
  5. Ai, D.; Roper, TA.; Riley, JA. (1998). "Diabetic ketoacidosis and clozapine". Postgrad Med J. 74 (874): 493–4. PMID 9926128. Unknown parameter |month= ignored (help)
  6. Rosenbloom, AL. (2010). "The management of diabetic ketoacidosis in children". Diabetes Ther. 1 (2): 103–20. doi:10.1007/s13300-010-0008-2. PMID 22127748. Unknown parameter |month= ignored (help)
  7. Baird, JS. (2009). "Relapse of diabetic ketoacidosis secondary to insulin pump malfunction diagnosed by capillary blood 3-hydroxybutyrate: a case report". Cases J. 2: 8012. doi:10.4076/1757-1626-2-8012. PMID 19918445.
  8. Nyenwe, EA.; Kitabchi, AE. (2011). "Evidence-based management of hyperglycemic emergencies in diabetes mellitus". Diabetes Res Clin Pract. 94 (3): 340–51. doi:10.1016/j.diabres.2011.09.012. PMID 21978840. Unknown parameter |month= ignored (help)


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