Diabetic Emergency ManagementRYAN CHENG

Overview

Diabetic ketoacidosis Characteristically DM1 Young <65yo patients 4.6-13.4 per 1000 diabetic cases/year Near absolute insulinopenia

Hyperosmotic hyperglycemic nonketotic state: HHS, formerly HONK Older >65yo patients Sufficient insulin to prevent lipolysis and ketogenesis but not

adequate to cause glucose utilization

Overview

  DKA HHSMild Moderate Severe

Plasma glucose (mmol/L) >13.9 >13.9 >13.9 >33.3Arterial pH 7.25 to 7.30 7.00 to 7.24 <7.00 >7.30Serum bicarbonate (mEq/L) 15 to 18 10 to <15 <10 >18Urine ketones Positive Positive Positive SmallSerum ketones - Nitroprusside reaction

Positive Positive Positive ≤ Small

Effective serum osmolality (mOsm/kg)

Variable Variable Variable >320

Anion gap >10 >12 >12 VariableAlteration in sensoria or mental obtundation

Alert Alert/drowsy Stupor/coma Stupor/coma

DKA - Assessment

Dx: ketones, BSL, U+E, V/ABG Root cause?

Bloods, CXR, UA, cultures, bHCG, ECG Endocrinology disposition: ward vs HDU vs ICU

DKA - Management

Fluid resuscitation 1L first 30min 1L next hour 1L over next 2 hours Then fluids to rehydrate Fluids fluids fluids!

If Na rise >2.4mmol/l for each 5.5mmol/l fall in BSL = insufficient fluid replacement No evidence for Hartmann’s, nil evidence to support benefit compared to NS Needs regular review to avoid overload Shouldn’t delay giving K+

DKA - Management

Insulin 50iu actrapid in 500mL NS @ 40ml/hr Aim for 3-5 mmol/L per hour drop in BSL 10% dextrose when BSL 10-15mmol

Maintain infusion until acidosis corrected Stop when eating normally and change to S/C

To be stopped 1hr after s/c dose administered and meal ingestion BSL rising with tx likely is related to pump failure

DKA - Management

Cochrane Review re: S/C vs IV insulin for DKA (21/1/16)

5 RCTs, n = 201 Time to resolution of DKA between s/c and IV did not differ

substantially Hypoglycaemic episodes similar between groups

http://onlinelibrary.wiley.com.qelibresources.health.wa.gov.au/doi/10.1002/14651858.CD011281.pub2/full

DKA - Management

Potassium K <3.5 = 40mmol/l per hour K 3.5-5.5 = 20mmol/l per hour K > 5.5 = hold

If nil urine output, refrain from administering K+ Insulin mediated potassium uptake

DKA - Management

Bicarbonate Controversial Has been associated with hypokalemia, decreased tissue oxygen

uptake, cerebral oedema, delay to resolution of DKA pH <6.9 may benefit to avoid adverse effects of severe acidosis,

such as impaired myocardial contractility 100mmol in 400ml NS with 20mEq KCl @ 200ml/hr for 2 hours until pH

>7

Not recommended in HHS Isn’t in SCGH’s protocol

DKA - Monitoring

Fluid balance chart with hourly urine output IDC if unable to reliably measure

NGT if vomiting and drowsy Repeat labs

Check 1 hour after therapy initation, then 2-6 hourly until fixed BSL/VBG/ketones

Hourly obs

HHS - Assessment

Dx: nil ketones, BSL, serum osmolality >340 mosm/l, bicarb 2 (Na+ + K+) + Urea + Glucose (in mmol/l)

Root cause? Bloods, CXR, UA, cultures, bHCG, ECG

Endocrinology disposition: ward vs HDU vs ICU

HHS - Management

Fluid resuscitation 1L first 2hrs 1L next 2-4hrs 1L over 4-6hrs Then fluids to rehydrate Careful not to overhydrate!

Avoid overhydration and too rapid of a fall of BSL (hypotension)

HHS - Management

Insulin 50iu actrapid in 500mL NS @ 40ml/hr Aim for 3-5 mmol/L per hour drop in BSL 10% dextrose when BSL 10-15mmol

FSH protocol Treat hyperglycemia with IVF only When BSL stops falling with IVF or if ketonemia >1mmol/L,

commence insulin

HHS - Management

Potassium K < 5.4 = 40mmol/l per hour K >5.4 = hold

Anticoagulation Higher risk of thromboembolic adverse events

Severe dehydration/hypertonicity results in disruption of endothelial cells Release of thromboplastins, elevated vasopressin = enhanced coagulation

Overall incidence 1.7% (modestly lower than in ortho sx) Anticoagulation unless contraindicated – prophylaxis vs tx dose

HHS - Monitoring

Fluid balance chart with hourly urine output IDC if unable to reliably measure

NGT if vomiting and drowsy Repeat labs

Check 2 hours after initiation of tx then 6 hourly for first 24hrs BSL/VBG

Hourly obs If osmolality increases (or falls <3mosmol/kg/hr) and Na increasing check fluid balance

If inadequate: increase infusion rate If adequate: consider changing to 0.45% saline at same rate

If osmolality falling > 8mosmol/kg/hr consider Reducing rate of IVF Reduce rate of insulin infusion

HDU/ICU

Consider if:1. Osmolality >350 mosmol/kg2. BP < 90mmHg3. Na > 160mmol/l4. HR <60 or >1005. pH <7.16. Hypo/hyperkalemia7. Urine output <0.5 ml/kg/hr8. GCS <129. O2 < 92% RA10. Other serious co-morbidities

References

Pasquel FJ, Umpierrez GE. Hyperosmolar Hyperglycemic State: A Historic Review of the Clinical Presentation, Diagnosis, and Treatment. Diabetes Care. 2014;37(11):3124-3131. doi:10.2337/dc14-0984.

SCGH Guidelines for the Management of Diabetic Ketoacidosis SCGH Guidelines for the Management of Hyperosmolar Non-Ketotic Hyperglycemia (HONK) FSH Adult Diabetic Ketoacidosis (DKA) Guidelines and Management Record FSH Adult Hyperosmolar Hyperglycaemic State (HHS – formerly known as HONK) Guidelines and Management

Record Dunning, T. 2005 Diabetic ketoacidosis - prevention, management and the benefits of ketone tesing. Director

Endocrinology and Diabetes Nursing Research. St Vincent’s Health & the University of Melbourne. Available URL:www.reedexhibitions.net.auGPS2006/S11A.ppt-Supplement Result

http://onlinelibrary.wiley.com.qelibresources.health.wa.gov.au/doi/10.1002/14651858.CD011281.pub2/full Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic Crises: Diabetic Ketoacidosis (DKA), And

Hyperglycemic Hyperosmolar State (HHS) [Updated 2015 May 19]. In: De Groot LJ, Chrousos G, Dungan K, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www-ncbi-nlm-nih-gov.qelibresources.health.wa.gov.au/books/NBK279052/

Scott AR. Management of hyperosmolar hyperglycaemic state in adults with diabetes. Diabet Med. 2015;32(6):714-24.

Nyenwe EA, Kitabchi AE. Evidence-based management of hyperglycemic emergencies in diabetes mellitus. Diabetes Res Clin Pract. 2011;94(3):340-51.