Diabetic EmergenciesClay Wu, DO

Brett Lindgren, DO

Last updated: August 19, 2019

Content

• Epidemiology

• Differentials

• Pathophysiology

• Precipitating Factors

• Diagnostic Criteria

• Treatment

• HHS

Content

• Epidemiology

• Differentials

• Pathophysiology

• Precipitating Factors

• Diagnostic Criteria

• Treatment

• HHS

Epidemiology

• Most common hyperglycemic emergency in patients with diabetes mellitus

• Hospital admissions• 8-29 % due to DKA

• < 1 % due to HHS

• 4-8 episodes/1000 pt admissions with DM

• 115,000 admissions in 2003 in the US

• Average cost: $13,000 per patient

A: Incidence of DKA

B: Mortality Rate of DKA

Content

• Epidemiology

• Differentials

• Pathophysiology

• Precipitating Factors

• Diagnostic Criteria

• Treatment

• HHS

Differential Diagnoses of DKA

DKA

Hyperglycemia Acidosis

Ketosis

Other Hyperglycemic states:Uncontrolled DMHHSStress Hyperglycemia

Other Metabolic Acidotic states:Lactic acidosisHyperchloremic acidosisSalicylismUremic acidosis

Other Ketotic states:Ketotic hypoglycemiaAlcoholic ketosisStarvation ketosisIsopropyl alcoholHyperemesis

Note that DKA needs to have all 3 components of hyperglycemia, ketosis, and acidosis

Content

• Epidemiology

• Differentials

• Pathophysiology

• Precipitating Factors

• Diagnostic Criteria

• Treatment

• HHS

Content

• Epidemiology

• Differentials

• Pathophysiology

• Precipitating Factors

• Diagnostic Criteria

• Treatment

• HHS

Precipitating Factors

• Infection (UTI, pneumonia, etc)

• Myocardial ischemia

• Medications (corticosteroids, sympathomimetics, atypical antipsychotics)

• Pancreatitis

• Trauma

• Surgery

• Psychological stress

• Non-compliance with insulin therapy

Content

• Epidemiology

• Differentials

• Pathophysiology

• Precipitating Factors

• Diagnostic Criteria

• Treatment

• HHS

Content

• Epidemiology

• Differentials

• Pathophysiology

• Precipitating Factors

• Diagnostic Criteria

• Treatment

• HHS

Basics to Consider

• Fluids

• Insulin

• Electrolyte Repletion

• Treating Underlying Cause

Intravenous fluids

• Initial 1-2 L 0.9% NaCl over 1-2 hrs

• Continue 0.9% NaCl @ 250-500 mL/hr• Can switch to 0.45% NaCl depending on serum sodium

• Adjust rate based on hemodynamics (i.e. HR, BP)

• When BG level 200-250 mg/dL, change to D5 0.45% NaCl• This is done to avoid hypoglycemia and risk of cerebral edema

Insulin

• Regular insulin IV bolus of 0.1 U/kg optional

• Continuous insulin infusion at 0.1 U/kg/h

• BG checks every 1 hour

• When BG < 250 mg/dL, reduce insulin rate to 0.05 U/kg/h

• Thereafter, adjust rate to maintain glucose level ~ 200 mg/dL

• Subcutaneous rapid-acting insulin (i.e. aspart or lispro) can be an alternative to intravenous insulin in patients with mild-to-moderate DKA.

SubQ insulin for DKA treatment

• Studied regimen:

• Loading dose: 0.3 U/kg SQ rapid-acting insulin

• 0.1 U/kg/h until the BG was < 250 mg/dL.

• Reduce dose to 0.05 U/kg/h until the DKA resolved.

• Studies have show no difference in length of stay or total insulin needed

Potassium

• Monitor every 2-3 hrs

• K+ level > 5.0 mEq/L• No supplement required

• K+ level 3.3-5 mEq/L• Add 20-40 KCl to intravenous fluids

• K+ level < 3.3 mEq/L• HOLD INSULIN

• Replete potassium until > 3.3 mEq/L

Bicarbonate

• Repletion not routinely recommended.

• If pH < 6.9 consider bicarbonate increase pH > 7.0

• pH < 6.9• 88 mEq/L over 2 hours

• pH 6.9-7.0• 44 mEq/L over 1 hour

Resolution of DKA

• BG is < 200 mg/dL

• Bicarb level ≥ 15 mEq/L

• Venous pH > 7.3

• Calculated AG ≤ 12 mEq/L

Transition to Subcutaneous Insulin

• Insulin infusion continues until resolution of ketoacidosis

• Continue IV insulin for 2-4 hours after long-acting subcutaneous insulin given

• For patients treated with insulin before admission, restart previous insulin regimen and adjust doses as needed.

• For patients with newly diagnosed diabetes mellitus, start total daily insulin dose at ~0.6 U/kg/d along with meal-time and sliding scale.

Content

• Epidemiology

• Differentials

• Pathophysiology

• Precipitating Factors

• Diagnostic Criteria

• Treatment

• HHS

Hyperglycemic Hyperosmolar State (HHS)

• Overlap of DKA and HHS however differs by degree of dehydration, ketosis, and metabolic acidosis.

Hyperglycemic Hyperosmolar State (HHS)

• DKA and HHS differ by degree of dehydration, hyperglycemia, ketosis, and metabolic acidosis.

• Unlike in DKA, there is adequate insulin to restrain lipolysis and ketogenesis.

More hyperglycemia, less acidosis, less ketosis, less dehydration

DKA

Treatment of HHS

• Fluids

• Insulin

• Electrolyte Repletion

• Treating Underlying Cause

Same as DKA

Sample Case

HPI

• 58 y/o woman with history of IDDM diagnosed age 16 who presents with 20 hours of nausea, vomiting, and abd pain. Denies sick contacts, weakness, recent travel, fevers. She checked her finger stick at home and it was 690 mg/dL.

• Her IDDM was diagnosed at age 16 when she presented with thirstand weight loss. She has been on her home insulin and has been wellsince then. She reports her fasting glucose varies from 75-125, with her last A1c 7.8%

Objective

• On examination she had a blood pressure of 95/60 mmHg, orthostatic hypotension, a pulse rate of 140/min and cold extremities. She had a deep, sighing respiration. She weighs 50 kg.

• The elevated blood glucose was confirmed on admission (890 mg/dl lab result), and was found to be associated with marked ketonuria.

Labs

ABGpH 7.21pCO2 22pO2 89

126 95 40

5.5 16 1.5

445

UA with positive ketones

Case continued

• She is admitted to the ICU after being given 2 L NS bolus in the ED, started on NS @ 250 mL/hr.

• She was also given an insulin bolus of 5 units and started on a drip of 5 U/hr.

• Glucose, ketones, electrolytes ordered every 2-4 hours.

1 hour later…

Questions

• What does this EKG finding represent?

• What’s the pathophysiology behind why this happened?

• What changes should be made in management?

EKG Changes in Hypokalemia

• Prolonged PR

• T wave flattening and inversion

• ST depression

• U waves

• Increased risk of torsades de pointes

Acidosis and Insulin Effects of Potassium

• Initial hyperkalemia seen with diabetic ketoacidosis• In actuality, patient is total body potassium deficient

• Acidosis promotes H+/K+ leading to pseudohyperkalemia• Thus most patients present with “potassium”

• Insulin administration lowers potassium by enhancing activity of Na-K-ATPase driving potassium into skeletal muscle• Can precipitate hypokalemia and arrhythmias

Case Continued.

• Patient found to have a potassium of 2.7.

• Insulin drip was stopped with addition of potassium to IV fluids.

• When potassium level reached greater than 3.3, insulin drip was restarted.

• Upon resolution of her DKA, she was transitioned to her home dose lantus and mealtime insulin.