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, mainly type 1, and is characterized by decreased insulin level, hyperglycemia, acidosis and ketosis.

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

Management

General Approach

Characterize the symptoms:

Polyuria
Polydipsia
❑ Weight loss
❑ Vomiting
Dehydration
❑ Weakness
❑ Mental status change
Abdominal pain and 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 criteriaMild DKAModerate DKASevere DKAHHS
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:
❑ 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ 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-
 
❑ 400 mmol HCO3- in 100 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 3.5 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. Give only if there is an actual deficiency.

References

  1. 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)
  2. 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.
  3. 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)
  4. 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)
  5. Umpierrez, GE.; Kitabchi, AE. (2003). "Diabetic ketoacidosis: risk factors and management strategies". Treat Endocrinol. 2 (2): 95–108. PMID 15871546.
  6. 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)
  7. 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)


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