Hyperglycemic crises resident survival guide

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. DKA is characterized by hyperglycemia, acidosis and ketosis; whereas HHS is characterized by hyperglycemia, hyperosmolarity, and dehydration without ketosis.

Causes

Life Threatening Causes

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

Common Causes

Low insulin

• Failure of pump therapy
• Inadequate treatment of DM
• Insulin deficiency

Iatrogenic

• Medications (corticosteroid, pentamidine, thiazide diuretics, clozapine)

Ischemia

• MI
• Cerbrovascular accident
• Ischemic bowel disease

Inflammation

• Pancreatitis
• Cholecystitis

Infection

• Pneumonia
• UTI

Intoxication

• Alcohol
• Drug intoxication

Miscellaneous

• Pregnancy
• Surgery
• Dehydration

Management

The diagnostic approach and management management of DKA and HHS are based on the 2009 Diabetic Care recommendations.

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)
Diagnostic criteria Mild DKA Moderate DKA Severe DKA HHS Plasma glucose >250 mg/dL >250 mg/dL >250 mg/dL >600 mg/dL Arterial pH 7.25-7.30 7.00 to <7.24 <7.00 >7.30 Serum bicarbonate (mEq/l) 15-18 10 to <15 <10 >18 Urine ketone Positive Positive Positive Small Serum ketone Positive Positive Positive Small Effective serum osmolality Variable Variable Variable >320 mOsm/kg Anion gap >10 >12 >12 Variable Mental status Alert Alert/drowsy Stupor/coma Stupor/coma
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 DKA: ❑ 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

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 200 mg/dL in DKA (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+>3.3 mEq/L ❑ 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 200 mg/dL for DKA (300 mg/dL for 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 and 200 mg/dL until resolution of DKA (200-300 mg/dL for HHS)

❑ Check glucose every 3-4 hours until stable

❑ Confirm resolution of DKA 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 DKA

Management: Bicarbonate

❑ Assess pH

pH≥6.9

pH<6.9

❑ No HCO3-

❑ 100 mmol HCO3- in 400 mL H20 and 20 mEq KCl infusion for 2 hours

❑ Repeat every 2 hours until pH≥7 ❑ Monitor serum K+ every 2 hours

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.
• 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

• Do not stop IV insulin until DKA has resolved.
• Do not stop IV insulin, even if SC insulin is administered because it needs time to kick in.
• Do not give insulin if K+ levels are below 3.3 mEq/l because it may further exacerbate the hypokalemia.
• Do not use 0.9% NaCl if corrected Na+ levels > 145 mEq/l, use 0.45% instead.
• Do not supplement phosphate excessively, clinical trials have not shown any benefits. Supplement phosphate only if there is an actual deficit.

References

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