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 mental status ❑ Fever ❑ Kussmaul breathing ❑ Vomiting Identify precipitating factors: ❑ Infections ❑ Insulin deficiency ❑ Myocardial infarction ❑ New onset DM type 1 ❑ Pregnancy ❑ Stress

Examine the patient

Consider alternative diagnosis: ❑ Starvation ketosis ❑ Alcoholic ketoacidosis ❑ Drug abuse (salicylate, methanol, ethylene glycol) ❑ Lactic acidosis ❑ Other causes of high anion gap metabolic acidosis

Order tests: ❑ Serum glucose ❑ ABG ❑ CBC ❑ Electrolytes ❑ Serum & urinary ketones ❑ Urinalysis ❑ BUN ❑ Creatinine ❑ Plasma osmolality ❑ EKG ❑ CXR ❑Urine, sputum, blood cultures (not routine)

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

IV fluid therapy ❑ Check hydration status ❑ Mild dehydration ❑ Evaluate for corrected Na+levels ❑ High/Normal Na+levels ❑ Switch to 0.45% NaCl (250-500mL/hr) ❑ Low Na+ levels ❑Continue to 0.9% NaCl (250-500mL/hr) ❑ Check blood glucose levels ❑ At serum glucose levels ~ 200 mg/dL, switch to 5% dextrose with 0.45% NaCl (150-250 ml/hr) ❑ Severe dehydration ❑ Start 0.9% NaCl (1L/hr) initially ❑ Cardiogenic shock ❑ Pressors/ Monitor hemodynamics

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 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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