HYPERGLYCEMIC EMERGENCIES IN ADULTS
Rohit Gandhi
PGY-2 Family Medicine
September 2015
HYPERGLYCEMIC EMERGENCIES

DKA = Diabetic Ketoacidosis


Type 1 DM
HHS = Hyperosmolar Hyperglycemic State

Type 2 DM

Relative Insulin Deficiency
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DKA AND HSS

Pathophysiology / Common Features:
Insulin deficiency  hyperglycemia  urinary loss of water and
electrolytes
 Volume depletion + electrolyte deficiency +
hyperosmolarity
 Insulin deficiency (absolute)  breakdown of FFA
 Ketoacidosis (in DKA)


Common Symptoms:
 Abdominal Pain (unusual HSS), N/V
 Polyurea, Polydipsia, Polyphagia
 Signs of dehydration
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DKA AND HSS: CAUSES
o
Medication (insulin) Non-Compliance
o
Infection (pneumonia and UTI)
o
New diagnosis of DM I
o
Drugs
o
Thyrotoxicosis
o
Stroke
o
MI
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DKA VS HHS
DKA
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HHS
Ketoacidosis
ECFV contraction
Milder hyperosmolarity
Normal to high glucose
May have LOC

Beware hypokalemia
Must use insulin
Absolute insulin deficiency +
glucagon
Rapid Evolution

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Minimal acid-base problem
ECFV contraction
Hyperosmolarity (more severe
hyperglycemia)
Marked hyperglycemia
Marked LOC
Beware hypokalemia
May need insulin
Relative insulin deficiency
Insidious onset
SUSPECT DKA IF:

pH ≤7.3

Bicarbonate ≤15 mmol/L

Anion gap >12 mmol/L
= (Na + K) – (Cl + HCO3)

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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INITIAL EVALUATION
Airway, breathing, and circulation (ABC) status
 Mental status
 Precipitating events (eg, source of infection,
myocardial infarction)
 Volume status

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WHAT TO ORDER
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Serum glucose
Serum electrolytes (with calculation of the anion gap),
blood urea nitrogen (BUN), and plasma creatinine
Complete blood count (CBC) with differential
Urinalysis and urine ketones by dipstick
Plasma osmolality
Serum ketones (if urine ketones are present)
Arterial blood gas if the serum bicarbonate is
substantially reduced or hypoxia is suspected
Electrocardiogram
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HYPONATREMIA AND HYPERKALEMIA


Hyponatremia

Due to osmotic diuresis induced by glycosuria

Corrected plasma [Na+] = Measured [Na+] + [3/10 ×
([Glucose (mmol/L)] − 5)]
Hyperkalemia

K+ / H+ exchanger

Total body K+ can be low (but not very commonly)
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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
Always get and ECG/CK/TNI to rule out MI
ECG changes may reflect hyperkalemia
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Acidosis
REPLACE FLUIDS WITH IV 0.9% NACL UNTIL
EUVOLEMIC
Start with
1-2 L bolus,
avg deficit
7-8L
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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
Correct K+ before
Insulin
Insulin should be
maintained until the
anion gap normalizes
Insulin used to treat the
acidosis, not the
glucose!
0.1U/Kg bolus to start
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INSULIN INFUSION PARAMETERS

Glucoscans q1h

<5.1: never hold Insulin, give D5W
5.1 – 10.0 and AG > 12: give D5W and consider small decrease in
IV insulin dose
10.1 – 15.0 and AG > 12: give D5W with IV insulin
15.1-20: increase insulin 1U/h
20.1 – 25.0: increase insulin 2U/h

GOAL: 10-14 in DKA

Switch to SC insulin when AG and pH are normal and
patient wants to eat / can tolerate PO

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Transition with Lantus, give SC 2h before DC IV
pH can still be elevated from fluids (hypercloeremic acidosis), but will have
a Normal Anion Gap
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DKA IN PEDIATRICS

#1: Fluids
Never bolus, risk of cerebral edema
 Give 1.5 maintenance


#2: K+


Similar guidelines as adults
#3: Insulin
Started by end of initial fluid resuscitation
 Bolus not indicated in Pediatrics, 0.1U/kg/h until acidosis corrected



No Bicarb – never indicated in kids
HyperNa+ – indicates significant fluid loss, correct for Glucose
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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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2013
RECOMMENDATION 3
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 shortacting 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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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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