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

General Approach

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
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
Start the management of the following SIMULTANEOUSLY: (Check the algorithms below for more details) ❑ IV fluids ❑ Insulin ❑ Potassium ❑ Bicarbonate
Check the following every two hours until the patient is stable: ❑ Electrolytes ❑ BUN ❑ Venous pH ❑ Creatinine ❑ Glucose
Determine the resolution of DKA/HHS: Management after the resolution of DKS/HHS: Vidit was here!! ;-)

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)

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.
• 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 3.5 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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