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, usually Type 1 but sometimes also seen in Type 2. It is a metabolic abnormality with hypoglycemia, metabolic acidosis and ketonuria/ketonemia. It is seen when there is lack of insulin in body, so that instead of sugars, fats are burned as fuel.

Causes

It sometimes occurs as an initial presentation in undiagnosed cases of type 1 DM, however it can also occur in people with type 2 DM. In both the types it may be precipitated by one or more of the following causes.

• Intercurrent illnesses - such as infections, is the most common risk factor precipitating DKA. Urinary tract infection's and Pneumonia being the 2 most common.

• Inadequate dosage or complete lack of insulin, such as in non-compliant cases and those with newly diagnosed type 1 DM.

• Myocardial infarction.

• Pregnancy.

• Stress such as that caused from surgery, infections etc which leads to a release of stress hormones , which are counter-regulatory to insulin.

• Dehydration.

• Medications such as corticosteroid, pentamidine, clozapine.

• Failure of pump therapy - This has been recognized as a potential adverse effect of pump use and hence incidence has reduced.

Complications

These include the following:

• Hypogylcemia
• Hypokalemia
• Cerebral edema - most life threatening complication of DKA especially in children.
• Respiratory distress
• Sepsis
• Acute gastric dilation

Management

DKA

H/o - vomiting abdominal pain drowsiness altered mentation fever malaise. Precipitating factors - Insulin deficiency, Intercurrent illness, stress, MI, Pregnancy, new onset DM type 1.

Check labs - CBC, Chem 7, ABG, EKG, CXR, urine dipstick & routine

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

i.v fluid therapy

Insulin

Need for K+ replacement?

Need for bicarbonate replacement?

Check hydration status

i.v.

s.c. 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 K+ per L of fluid.

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.

Continous infusion @ 0.1 U/kg/Hr

s.c. insulin 0.2 U/kg every 2 Hrs.

Recheck

High Na+ levels

Normal Na+ levels

Low Na+ levels

Double insulin infusion if blood sugar doesnt 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 i.v. insulin to 0.02-0.05 U/kg/Hr or s.c. insulin @ 0.1 U/kg every 2 hrs. Target blood sugar - 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, once pt. tolerates oral feeds transition to s.c. insulin @ 0.8 U/kg/day. Stop i.v. insulin gradually.

Look out for following complications.

The managment protocol is based on the recommendations given by American Diabetes Association (ASA) and other sources.

Do's

• Check labs initially and every 2-4 hours.
• Check urine for ketones immediately with dipstick and send urine to lab for analysis.
• Initiate i.v. insulin as soon as the patient arrives and satisfies criteria for DKA.
• Assess to understand what precipitated DKA and treat the cause.
• Admit the patient. If pH < 7.0, pt unconscious admit to ICU else may be shifted directly to floor.
• Assess hydration status of the patient, treat aggressively.
• switch to Dextrose with normal saline once blood sugar falls to 200 mg/dL.
• Check for complications from the condition itself as well as those developing due to therapy.

Don'ts

• DO not stop i.v. insulin until DKA has resolved.
• Do not stop i.v. insulin, as soon as s.c. insulin is administered, as it needs time to kick in.
• DO not give insulin if K+ levels are below 3.5 mEq/l, may further cause hypokalemia.
• Do not use 0.9% NaCl if corrected Na+ levels > 145 mEq/l, use 0.45% instead.

• Do not supplement phosphate overzealously, clinical trials have not shown any benefits. Give only if there is am actual deficiency.

References

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