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'''For more information about DKA, click [[DKA|here]].'''
'''For more information about DKA, click [[DKA|here]].'''


{{CMG}}; {{AE}} {{HK}}, {{HS}}
{{CMG}}; {{AE}} {{HK}}, {{HS}},{{SSW}}
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Revision as of 02:13, 17 January 2018


For more information about DKA, click here.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2], Husnain Shaukat, M.D [3],Sargun Singh Walia M.B.B.S.[4]

Hyperglycemic crises Resident Survival Guide Microchapters
Overview
Classification
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life threatening complications of untreated or inadequately treated diabetes mellitus. HHS is characterized by hyperglycemia, hyperosmolarity and dehydration; whereas DKA is characterized by hyperglycemia, acidosis, and ketosis.[1]

Causes

Life Threatening Causes

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

Common Causes

Common causes of hyperosmolar hyperglycemic state (HHS) include:

Management

The diagnostic approach and management management of HHS and DKA are based on the ADA guidelines published in 2009.[1]

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)
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 HHS:

❑ 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
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 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 200 and 300 mg/dL until
resolution of HHS (200-300 mg/dL for HHS)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Check glucose every 3-4 hours until stable
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirm resolution of HHS 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 HHS
 
 
 
 
 
 
 
 
 
 
 

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 subcutaneous 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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