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

• Alcohol
• Deficiency of insulin or inadequate treatment
• Dehydration
• Drug intoxication
• Failure of pump therapy
• Medications (corticosteroid, pentamidine, clozapine)
• MI
• Pneumonia
• Pregnancy
• Surgery
• UTI

Management

Diabetic ketoacidosis

H/O suggestive of DKA: Abdominal pain, altered mentation, drowsiness, fever, Kussmaul breathing, malaise, vomiting Precipitating factors: Infections, insulin deficiency, MI, new onset DM type 1, pregnancy, stress

Check labs ABG, CBC, Chem 7, CXR, EKG, serum glucose, serum & urinary ketones, urine routine

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

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/L K+

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

Continuous infusion (0.1 U/kg/hr)

SC insulin 0.2 U/kg every 2 hrs

Recheck

High Na+ levels

Normal Na+ levels

Low Na+ levels

Double insulin infusion if blood sugar doesn't 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 IV insulin to 0.02-0.05 U/kg/hr or SC insulin (0.1 U/kg) every 2 hrs Target blood sugar to 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 Transition to SC insulin (0.8 U/kg/day) when pt tolerates oral feeding Stop IV insulin gradually. Monitor for complications: Hypogylcemia, hypokalemia, cerebral edema, respiratory distress, sepsis, acute gastric dilation

Adapted from the recommendations given by American Diabetes Association (ASA) and other sources.

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.
• Assess the hydration status and treat it aggressively as needed.
• Switch to dextrose with normal saline once the blood sugar falls to 200 mg/dL.
• Monitor for complications of DKA itself or of the therapy.

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

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