Hyperglycemic crises resident survival guide: Difference between revisions

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==Life Threatening Causes==
==Life Threatening Causes==
 
Diabetic ketoacidosis is a life-threatening condition and must be treated as such irrespective of the causesLife-threatening conditions may result in death or permanent disability within 24 hours if left untreated.
* '''Inadequate dosage or complete lack of insulin''', such as in non-compliant cases and those with newly diagnosed type 1 DM.<ref name="Wolfsdorf-2009">{{Cite journal  | last1 = Wolfsdorf | first1 = J. | last2 = Craig | first2 = ME. | last3 = Daneman | first3 = D. | last4 = Dunger | first4 = D. | last5 = Edge| first5 = J. | last6 = Lee | first6 = W. | last7 = Rosenbloom | first7 = A. | last8 = Sperling | first8 = M. | last9 = Hanas | first9 = R. | title = Diabetic ketoacidosis in children and adolescents with diabetes. | journal = Pediatr Diabetes | volume = 10 Suppl 12 | issue = | pages = 118-33 | month = Sep | year = 2009 | doi = 10.1111/j.1399-5448.2009.00569.x | PMID = 19754623 }}</ref><ref name="Wolfsdorf-2006">{{Cite journal  | last1 = Wolfsdorf | first1 = J. | last2 = Glaser | first2 = N. | last3 = Sperling | first3 = MA. | title = Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. | journal = Diabetes Care | volume = 29 | issue = 5 | pages = 1150-9 | month = May | year = 2006 | doi = 10.2337/diacare.2951150| PMID = 16644656 }}</ref>
 
* '''Myocardial infarction'''.  


==Most Common Causes==
==Most Common Causes==

Revision as of 21:40, 26 November 2013

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. It is a life-threatening condition in itself.

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.

Most Common 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.[1]
  • Stress such as that caused from surgery, infections etc which leads to a release of stress hormones , which are counter-regulatory to insulin.[3]
  • Dehydration.
  • Medications such as corticosteroid, pentamidine,[4] clozapine. [5]
  • Failure of pump therapy - This has been recognized as a potential adverse effect of pump use and hence incidence has reduced. [6][7]

Management

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diabetic ketoacidosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 criteriaBlood 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.
Hypogylcemia
Hypokalemia
Cerebral edema
Respiratory distress
Sepsis
Acute gastric dilation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

The managment protocol is based on the recommendations given by American Diabetes Association (ASA) and other sources.[8]

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

  1. Umpierrez, GE.; Kitabchi, AE. (2003). "Diabetic ketoacidosis: risk factors and management strategies". Treat Endocrinol. 2 (2): 95–108. PMID 15871546.
  2. Parker, JA.; Conway, DL. (2007). "Diabetic ketoacidosis in pregnancy". Obstet Gynecol Clin North Am. 34 (3): 533–43, xii. doi:10.1016/j.ogc.2007.08.001. PMID 17921013. Unknown parameter |month= ignored (help)
  3. MacGillivray, MH.; Bruck, E.; Voorhess, ML. (1981). "Acute diabetic ketoacidosis in children: role of the stress hormones". Pediatr Res. 15 (2): 99–106. doi:10.1203/00006450-198102000-00002. PMID 6789292. Unknown parameter |month= ignored (help)
  4. Lambertus, MW.; Murthy, AR.; Nagami, P.; Goetz, MB. (1988). "Diabetic ketoacidosis following pentamidine therapy in a patient with the acquired immunodeficiency syndrome". West J Med. 149 (5): 602–4. PMID 3150636. Unknown parameter |month= ignored (help)
  5. Ai, D.; Roper, TA.; Riley, JA. (1998). "Diabetic ketoacidosis and clozapine". Postgrad Med J. 74 (874): 493–4. PMID 9926128. Unknown parameter |month= ignored (help)
  6. Rosenbloom, AL. (2010). "The management of diabetic ketoacidosis in children". Diabetes Ther. 1 (2): 103–20. doi:10.1007/s13300-010-0008-2. PMID 22127748. Unknown parameter |month= ignored (help)
  7. Baird, JS. (2009). "Relapse of diabetic ketoacidosis secondary to insulin pump malfunction diagnosed by capillary blood 3-hydroxybutyrate: a case report". Cases J. 2: 8012. doi:10.4076/1757-1626-2-8012. PMID 19918445.
  8. Nyenwe, EA.; Kitabchi, AE. (2011). "Evidence-based management of hyperglycemic emergencies in diabetes mellitus". Diabetes Res Clin Pract. 94 (3): 340–51. doi:10.1016/j.diabres.2011.09.012. PMID 21978840. Unknown parameter |month= ignored (help)


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