Hyperglycemic crises resident survival guide

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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

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:

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

Management: Potassium

Management: Bicarbonate

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

  1. 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)
  2. 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.
  3. 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)
  4. 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)
  5. Umpierrez, GE.; Kitabchi, AE. (2003). "Diabetic ketoacidosis: risk factors and management strategies". Treat Endocrinol. 2 (2): 95–108. PMID 15871546.
  6. 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)
  7. 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)


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