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], Rim Halaby, M.D. [3]

Overview

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life threatening complications of untreated or inadequately treated diabetes mellitus. DKA is characterized by hyperglycemia, acidosis and ketosis; whereas HHS is characterized by hyperglycemia, hyperosmolarity, and dehydration without ketosis.

Causes

Life Threatening Causes

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

Common Causes

Low insulin

• Failure of pump therapy
• Inadequate treatment of DM
• Insulin deficiency

Iatrogenic

• Medications (corticosteroid, pentamidine, thiazide diuretics, clozapine)

Ischemia

• MI
• Cerbrovascular accident
• Ischemic bowel disease

Inflammation

• Pancreatitis
• Cholecystitis

Infection

• Pneumonia
• UTI

Intoxication

• Alcohol
• Drug intoxication

Miscellaneous

• Pregnancy
• Surgery
• Dehydration

Management

The diagnostic approach and management management of DKA and HHS are based on the 2009 Diabetic Care recommendations.

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)
Diagnostic criteria Mild DKA Moderate DKA Severe DKA HHS Plasma glucose >250 mg/dL >250 mg/dL >250 mg/dL >600 mg/dL Arterial pH 7.25-7.30 7.00 to <7.24 <7.00 >7.30 Serum bicarbonate (mEq/l) 15-18 10 to <15 <10 >18 Urine ketone Positive Positive Positive Small Serum ketone Positive Positive Positive Small Effective serum osmolality Variable Variable Variable >320 mOsm/kg Anion gap >10 >12 >12 Variable Mental status Alert Alert/drowsy Stupor/coma Stupor/coma
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 DKA: ❑ 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

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 200 mg/dL in DKA (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+>3.3 mEq/L ❑ 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 200 mg/dL for DKA (300 mg/dL for 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 and 200 mg/dL until resolution of DKA (200-300 mg/dL for HHS)

❑ Check glucose every 3-4 hours until stable

❑ Confirm resolution of DKA 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 DKA

Management: Bicarbonate

❑ Assess pH

pH≥6.9

pH<6.9

❑ No HCO3-

❑ 100 mmol HCO3- in 400 mL H20 and 20 mEq KCl infusion for 2 hours

❑ Repeat every 2 hours until pH≥7 ❑ Monitor serum K+ every 2 hours

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.
• 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 SC 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.
• Do not supplement phosphate excessively, clinical trials have not shown any benefits. Supplement phosphate only if there is an actual deficit.

References

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