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 and is characterized by hyperglycemia, acidosis and elevated ketone levels.

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.

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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