Canadian Diabetes Association
Clinical Practice Guidelines
Hyperglycemic Emergencies in
Adults
Chapter 15
Jeannette Goguen, Jeremy Gilbert
Key Points
2013
1. Suspect DKA or HHS in an ill patient with
hyperglycemia (usually) – medical emergency
2. DKA = ketoacidosis is prominent
3. HHS = ECFV contraction + hyperosmolarity
4. Rx = FLUIDS, POTASSIUM, INSULIN (DKA)
5. Treat precipitating cause
6. Prevention is critical
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Hyperglycemic Emergencies
•
DKA = Diabetic Ketoacidosis
•
HHS = Hyperosmolar Hyperglycemic State
•
Common features:
–
Insulin deficiency  hyperglycemia  urinary loss of water
and electrolytes
 Volume depletion + electrolyte deficiency +
hyperosmolarity
–
Insulin deficiency (absolute) + glucagon
 Ketoacidosis (in DKA)
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Suspect DKA or HHS in an ILL Patient with
Hyperglycemia (usually)
DKA
HHS
•
Ketoacidosis
•
Minimal acid-base problem
•
ECFV contraction
•
ECFV contraction
•
Milder hyperosmolarity
•
Hyperosmolarity
•
Normal to high glucose
•
Marked hyperglycemia
•
May haveLOC
•
Marked LOC
•
Beware hypokalemia
•
Beware hypokalemia
•
Must use insulin
•
May need insulin
•
Absolute insulin deficiency +
glucagon
•
Relative insulin deficiency
ECFV = extracellular fluid volume; LOC = level of consciousness
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Suspect DKA if……
•
pH ≤7.3
•
Bicarbonate ≤15 mmol/L
•
Anion gap >12 mmol/L
= (sodium + potassium) – (chloride + bicarbonate)
•
Positive serum or urine ketones
•
Plasma glucose ≥14 mmol/L (but may be lower)
•
Precipitating factor
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Be Aware of Conditions that may make DKA
Diagnosis Difficult
•
Mixed acid base disorder (eg. vomiting may raise the
bicarbonate)
•
Pregnancy  normal to minimally elevated glucose
levels
•
Normal AG due to loss of ketones from osmotic
diuresis
•
Negative serum ketones due to β-hydroxybutarate
  AG + negative serum ketones = order serum
β-hydroxybutarate
 Always order both urine and serum ketones
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Management of DKA in Adults
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Fluids, Potassium, Acidosis are the Pillars of
Treatment
IV fluids
Serum
Potassium
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Acidosis
Replace Fluids with IV 0.9% NaCl until
Euvolemic
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Once euvolemic, consider plasma Na+ and
glucose to determine IV fluid type
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Replace Potassium: Hypokalemia is an
avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
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Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis, not
the glucose!
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Identify and Treat the Precipitating Factor
•
Insulin omission – MOST COMMON CAUSE of DKA
•
New diagnosis of diabetes
•
Infection / Sepsis
•
Myocardial infarction
–
Small rise in troponin may occur without overt ischemia
–
ECG changes may reflect hyperkalemia
•
Thyrotoxicosis
•
Drugs
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PREVENTION of DKA / HHS
•
•
Type 1 diabetes
–
Education around sick day management
–
Continuation of insulin even when not eating
–
Frequent monitoring when ill
Type 2 diabetes
–
Education around sick day management
–
Frequent monitoring when ill
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Recommendation 1
1. In adult patients with DKA, a protocol should be
followed that incorporates the following principles of
treatment [Grade D, Consensus]
a)
Fluid resuscitation
b)
Avoidance of hypokalemia
c)
Insulin administration
d)
Avoidance of rapidly falling serum osmolality
e)
Search for precipitating cause
(See figure 1)
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Recommendation 2
2. In adult patients with HHS, a protocol should be
followed that incorporates the following principles of
treatment [Grade D, Consensus]:
a)
Fluid resuscitation
b)
Avoidance of hypokalemia
c)
Avoidance of rapidly falling serum osmolality
d)
Search for precipitating cause
e)
Possibly insulin to further reduce hyperglycemia
(See figure 1)
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Recommendation 3
2013
3. Point-of-care capillary beta-hydroxybutyrate, if
available, may be measured in the hospital in
patients with T1DM with capillary glucose >14
mmol/L to screen for DKA and a betahydroybutyrate >1.5 mmol/L warrants further
testing for DKA [Grade C, level 2]
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Recommendation 4
4. In individuals with DKA, IV 0.9% sodium chloride
should be administered initially at 500 mL/hour for 4
hours, then 250 mL/hour for 4 hours [Grade B, Level 2]
with consideration of a higher initial rate (1–2 L/hour)
in the presence of shock [Grade D, Consensus]
For persons with HHS, IV fluid administration
should be individualized based on the patient’s
needs [Grade D, Consensus]
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Recommendation 5
5. In individuals with DKA, an infusion of short-acting
IV insulin of 0.10 U/kg/hour should be used [Grade B,
Level 2]
The insulin infusion rate should be maintained until
the resolution of ketosis [Grade B, Level 2] as measured
by the normalization of the plasma anion gap [Grade D,
Consensus]
Once the plasma glucose concentration reaches
14.0 mmol/L, IV dextrose should be started to avoid
hypoglycemia [Grade D, Consensus]
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CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
http://diabetes.ca – for patients
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