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, mainly type 1, and is characterized by decreased insulin level, hyperglycemia, acidosis and ketosis.

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
• Cholecystitis
• Cerbrovascular accident
• Dehydration
• Drug intoxication
• Failure of pump therapy
• Inadequate treatment of DM
• Insulin deficiency
• Medications (corticosteroid, pentamidine, thiazide diuretics, clozapine)
• MI
• Pancreatitis
• Pneumonia
• Pregnancy
• Surgery
• UTI

Management

Characterize the symptoms: ❑ Abdominal pain ❑ Altered mentation/Drowsiness ❑ Fever ❑ Kussmaul breathing ❑ Vomiting Precipitating factors: ❑ Infections ❑ Insulin deficiency ❑ Myocardial infarction ❑ New onset DM type 1 ❑ Pregnancy ❑ Stress

Examine the patient

Consider alternative diagnosis: ❑ Severe hypoglycemia ❑ Hyperosmolar nonketotic coma ❑ Acute pancreatitis

Order 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----❑ IV - Complicated DKA:❑ Regular insulin (0.1 U/kg) bolus:❑ Continuous infusion (0.1 U/kg/hr)----❑ SC - Uncomplicated DKA:❑ Rapid action insulin 0.3 U/kg then 0.2 U/kg after 1 hr:❑ SC insulin 0.2 U/kg every 2 hrs----❑ Double insulin infusion if blood sugar doesn't fall by 50-70 mg/dL in first 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

'Need for K+replacement?----❑ < 3.3 mEq/dL:❑ Hold insulin:❑ supplement K+ (20-30 mEq/hr) till K+ > 3.3 mEq/L----❑ 3.3-5.3 mEq/dL:❑ Administer 20-30 mEq/L K+----❑ >5.3 mEq/dL:❑ Don't supplement, check 2 hourly

Need for bicarbonate replacement?----❑ pH < 6.9:❑ Dilute NaHCo3(100 mmol) in 400 ml H2O with 20 mEq KCl infused over 2 hrs:❑ Reassess----❑ pH > 7.0:❑ No bicarbonate needed

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

Template:WikiDoc Sources