Hyperglycemic crises resident survival guide

For more information about DKA, click here.

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. HHS is characterized by hyperglycemia, hyperosmolarity and dehydration; whereas DKA is characterized by hyperglycemia, acidosis, and ketosis.

Causes

Life Threatening Causes

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

Common Causes

Common causes of hyperosmolar hyperglycemic state (HHS) include:

• Infections:
  • Pneumonia
  • Sepsis
  • Genitourinary tract infections
• Drugs:
  • Antipsychotic agents (clozapine, olanzapine, risperidone)
  • Illicit drugs (cocaine and alcohol)
  • Corticosteroids
  • Glucagon
  • Interferon
  • Pentamidine
  • Sympathomimetic agents (albuterol, dopamine, dobutamine, terbutaline, ritodrine, thiazide diuretics)
• Myocardial infarction
• Pancreatitis
• Shock/hypovolemia
• Trauma
• Undiagnosed diabetes mellitus
• Noncompliance to insulin treatment:
  • Body image issues
  • Financial problems
  • Lack of insulin
  • Psychological factors
  • Self-neglect
  • Accidental
  • Neglect by caregivers

Management

The diagnostic approach and management management of HHS and DKA are based on the ADA guidelines published in 2009.

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)
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 HHS: ❑ 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

• The diagnosis of diabetic ketoacidosis is made in the presence of:
  • Hyperglycemia- Plasma glucose > 250 mg/dL
  • Anion gap metabolic acidosis- pH < 7.3; Serum bicarbonate < 15 mEq/L
  • Ketonemia/ Ketonuria
• Shown below is a table summarizing the diagnosis of Diabetic ketoacidosis according the the American Diabetes Association (ADA) guidelines.

VARIABLE	DIABETIC KETOACIDOSIS
	MILD (Plasma Glucose > 250mg/dL or 13.88 mmol/L)	MODERATE (Plasma Glucose > 250mg/dL or 13.88 mmol/L)	SEVERE (Plasma Glucose > 250mg/dL or 13.88 mmol/L)
Arterial pH	7.25 to 7.30	7.00 to < 7.24	< 7.00
Serum bicarbonate	15 to 18 mEq/L	10 to < 15 mEq/L	< 10 mEq/L
Urine ketone (Nitroprusside reaction method)	Positive	Positive	Positive
Serum ketone (Nitroprusside reaction method)	Positive	Positive	Positive
Effective serum osmolality	Variable	Variable	Variable
Anion gap	> 10 mEq/L (10 mmol/L)	> 12 mEq/L (12 mmol/L)	> 12 mEq/L (12 mmol/L)
Mental status	Alert	Alert/drowsy	Stupor/coma

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 200mg/dL in DKA and 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+>5.5 mEq/L ❑ Do not give K ❑ 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 250mg/dl in DKA and 300mg/dl in 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 150-200 mg/dL until resolution (200-300 mg/dL for HHS)

❑ Check glucose, BUN, electrolytes, creatinine, venous pH every 3-4 hours until stable

❑ Confirm resolution 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 HHS

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.
• In patients with potassium(K) < 3.3 mEq/L, fluids and potassium replacement must be done before initiating insulin therapy, to prevent further hypokalemia.
• 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 subcutaneous 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.
• Avoid rapid correction of plasma osmolality and serum sodium, to prevent fatal cerebral edema.
• Maximum reduction in plasma osmolality should be 3 mOsmol/kg per hour.
• Do not supplement phosphate excessively, clinical trials have not shown any benefits. Supplement phosphate only if there is an actual deficit.
• DO not use subcutaneous sliding scale insulin in management of hyperglycemia due to diabetes type 1.