Hyperglycemic crises resident survival guide

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 and is characterized by hyperglycemia, acidosis and elevated ketone levels.

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

• Deficiency of insulin or inadequate treatment
• Dehydration
• Failure of pump therapy
• Infections (UTI, pneumonia)
• Medications (corticosteroid, pentamidine, clozapine)
• MI
• Pregnancy
• Surgery

Management

Diabetic ketoacidosis

H/O suggestive of DKA: Vomiting, abdominal pain, drowsiness, altered mentation, fever, malaise Precipitating factors:Insulin deficiency, infections, stress, MI, pregnancy, new onset DM type 1

Check labs CBC, Chem 7, ABG, EKG, CXR, urine dipstick & routine

Diagnostic criteria Blood glucose > 250 mg/dL pH < 7.3 Serum bicarbonate < 18 mEq/L Serum ketones (+) Anion gap > 10

IV fluid therapy

Insulin

Need for K+ replacement?

Need for bicarbonate replacement?

Check hydration status

IV

SC for uncomplicated DKA

<3.3 mEq/dL

3.3-5.3 mEq/dL

>5.3 mEq/dL

pH < 6.9

pH > 7.0

Mild dehydration

Severe dehydration

Cardiogenic shock

Regular insulin (0.1 U/kg) bolus

Rapid action insulin 0.3 U/kg then 0.2 U/kg after 1 hr

Hold insulin, supplement K+ (20-30 mEq/hr) till K+ > 3.3 mEq/L

Administer 20-30 mEq K+ per L of fluid

Don't supplement, check 2 hourly

Dilute NaHCo3 (100 mmol) in 400 ml H2O with 20 mEq KCl infused over 2 hrs

No bicarbonate needed

Evaluate for corrected Na+ levels

Start 0.9% NaCl (1L/hr) initially.

Pressors/ Monitor hemodynamics

Continous infusion (0.1 U/kg/hr)

s.c. insulin 0.2 U/kg every 2 hrs

Recheck

High Na+ levels

Normal Na+ levels

Low Na+ levels

Double insulin infusion if blood sugar doesnt fall by 50-70 mg/dL in first hr

Switch to 0.45% NaCl (250-500mL/hr)

Continue to 0.9% NaCl (250-500mL/hr)

At serum glucose = 200 mg/dL reduce i.v. insulin to 0.02-0.05 U/kg/hr or s.c. insulin (0.1 U/kg) every 2 hrs. Target blood sugar - 150-200 mg/dL till DKA resolves

Check blood glucose levels

At serum glucose levels ~ 200 mg/dL switch to 5% dextrose with 0.45% NaCl (150-250 ml/hr)

Check labs every 2-4 hrs, once pt. tolerates oral feeds transition to s.c. insulin (0.8 U/kg/day). Stop i.v. insulin gradually. Look out for complications - Hypogylcemia, Hypokalemia, Cerebral edema, Respiratory distress, Sepsis, Acute gastric dilation

The managment protocol is based on the recommendations given by American Diabetes Association (ASA) and other sources.

Do's

• Check labs initially and every 2-4 hours
• Check urine for ketones immediately with dipstick and send urine to lab for analysis
• Initiate i.v. insulin as soon as the patient arrives and satisfies criteria for DKA
• Assess to understand what precipitated DKA and treat the cause
• Admit the patient. If pH < 7.0, pt unconscious admit to ICU else may be shifted directly to floor
• Assess hydration status of the patient, treat aggressively
• switch to Dextrose with normal saline once blood sugar falls to 200 mg/dL
• Check for complications from the condition itself as well as those developing due to therapy

Don'ts

• Do not stop i.v. insulin until DKA has resolved
• Do not stop i.v. insulin, as soon as s.c. insulin is administered, as it needs time to kick in
• Do not give insulin if K+ levels are below 3.5 mEq/l, may further cause hypokalemia
• Do not use 0.9% NaCl if corrected Na+ levels > 145 mEq/l, use 0.45% instead
• Do not supplement phosphate overzealously, clinical trials have not shown any benefits. Give only if there is am actual deficiency

References

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