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1. ACUTE METABOLIC COMPLICATIONS
OF DIABETES
PHUNG HUY HOANG, MD
RESIDENT IN INTERNAL MEDICINE
PHAM NGOC THACH UNIVERSITY OF MEDICINE
MAY, 2017

2. • Hyperglycemic states:
• Diabetic ketoacidosis (DKA)
• Hyperglycemic hyperosmolar state (HHS)
• Lactic acidosis
• Hypoglycemia

3. HYPERGLYCEMIC STATES
• DIABETIC KETOACIDOSIS (DKA)
• HYPERGLYCEMIC HYPEROSMOLAR STATE (HHS)
PHUNG HUY HOANG, MD
RESIDENT IN INTERNAL MEDICINE
PHAM NGOC THACH UNIVERSITY OF MEDICINE
MAY, 2017

4. • Acute, severe
• Depending on: patient, rapidity and duration of severe
hyperglycemia
• DKA – T1DM (2/3), HHS – T2DM  both could overlap!
• Characteristics:
• Insulin deficiency
• Volumn depletion
• Acid-base abnormalities
Gale E., Anderson J. (2012), Kumar & Clark’s Clinical Medicine, Parveen Kumar , Michael Clark, Editors, Elsevier, pp. 1001-1046

5. Yates A., Laing I. (2011), Clinical Biochemistry, Nessar Ahmed, Editor, Oxford University Press, pp. 338-76

6. Lieberman M., Marks A., Peet A. (2013), Marks’ Basic Medical Biochemistry A Clinical
Approach, Susan Rhyner, Editor, Lippincott Williams & Wilkins, pp. 477-492

7. Nelson D. L., Cox M. M. (2013), Lehninger Principles of Biochemistry, W. H. Freeman and Company, pp. 667-693
Conditions that promote gluconeogenesis (untreated
diabetes, severely reduced food intake) slow the citric
acid cycle (by drawing off oxaloacetate) and enhance
the conversion of acetyl-CoA to acetoacetate. The
released coenzyme A allows continued β-oxidation of
fatty acids

8. PATHOPHYSIOLOGY DKA
• Insulin deficiency (relative or absolute) + counterregulatory hormone excess (glucagon,
catecholamines, cortisol, GH).
• ↓ insulin/glucagon:
• ↑ Gluconeogenesis
• ↑ Glycogenolysis
• ↑ Ketone body formation
• ↑ substrate delivery from fat and muscle (free fatty acids, amino acids)  liver.
• ↓ insulin:
• impair glucose uptake (skeletal muscle, fat) ~ GLUT4
• ↓ intracellular glucose metabolism
• ↑ lipolysis  ↑ free fatty acid
• ↑ free fatty acid:
• ↑ ketone body formation
• Hypertriglyceridemia, ↑ VLDL, LDL
• Transient insulin resistance (as well becauses hormone imbalance)
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Powers A. C. (2016), Harrison's Principles of Internal Medicine, Dennis L. Kasper, Anthony S. Fauci, Stephen L. Hauser, Editors, McGraw Hill Education, pp. 2407-2421

9. Wyckoff J., Abrahamson M. J. (2005), Joslin’s Diabetes Mellitus, C. Ronald Kahn, Gordon C. Weir, George L. King, Editors, Lippincott Williams and Wilkins, pp. 887-901

10. Kitabchi A. E., Umpierrez G. E., Murphy M. B. (2015), International Textbook of Diabetes Mellitus, Ralph A. DeFronzo, Ele Ferrannini, Paul Zimmet, Editors, Wiley Blackwell, pp. 799-
814

11. Pearson E. R., McCrimmon R. J. (2014), Davidson’s Principles and Practice of Medicine, Brian R. Walker, Nicki R. Colledge, Stuart H. Ralston, Editors, Churchill Livingstone Elsevier, pp.
797-836

12. Wyckoff J., Abrahamson M. J. (2005), Joslin’s Diabetes Mellitus, C. Ronald Kahn, Gordon C. Weir, George L. King, Editors, Lippincott Williams and Wilkins, pp. 887-901

13. PATHOPHYSIOLOGY HHS
• Relative insulin deficiency + inadequate fluid intake
• Hyperglycemia + inadequate fluid replacement  osmotic diuresis  intravascular volume
depletion.
• Absence of ketosis:
• Relative insulin deficiency = inadequate to facilitate glucose utilization >< adequate to prevent lipolysis
and subsequent ketogenesis
• Lower levels of couterregulatory hormones and free fatty acids
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Powers A. C. (2016), Harrison's Principles of Internal Medicine, Dennis L. Kasper, Anthony S. Fauci, Stephen L. Hauser, Editors, McGraw Hill Education, pp. 2407-2421

14. PRECIPITATING FACTORS
• Acute illness
• Acute infection (most common)
• Stroke, myocardial infarction, acute pancreatitis, acute pulmonary edema, intestinal obstruction, mesenteric thrombosis,
renal failure, heat stroke, hypothermia, subdural hematoma, severe burns…
• Endocrine
• Acromegaly
• Thyrotoxicosis
• Cushing syndrome
• Drugs/therapies
• Corticosteroids
• Thiazides
• Sympathomimetic agents
• Pentamidine
• Pregnancy
• Discontinuation of or inadequate insulin therapy (fear of weight gain, fear of hypoglycemia, rebellion, stress
of chronic disease)
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Kitabchi A. E., Umpierrez G. E., Murphy M. B. (2015), International Textbook of Diabetes Mellitus, Ralph A. DeFronzo, Ele Ferrannini, Paul Zimmet, Editors, Wiley Blackwell, pp. 799-
814

15. CLINICAL FEATURES (1)
• Development:
• DKA: over 24h
• HHS: days to weeks history
DKA
• Situation:
• Initial symptom leading to T1DM diagnosis
• Established diabetes (more frequent)
• Nausea, vomiting, abdominal pain (severe, can resemble acute pancreatitis/ruptured viscus)
• Hyperglycemia  glucosuria, volume depletion, tachycardia.
• Hypotension: volume depletion + peripheral vasodilatation
• Kussmaul respirations, fruity odor: metabolic acidosis, increased acetone)
• Lethargy, central nervous system depression, coma (also evaluation other reasons, e.g., infection,
hypoxemia)
• Signs of precipitators.

16. CLINICAL FEATURES (2)
Powers A. C. (2016), Harrison's Principles of Internal Medicine, Dennis L. Kasper, Anthony S. Fauci, Stephen L. Hauser, Editors, McGraw Hill Education, pp. 2407-2421

17. HHS
• Classic scenery:
• Elderly
• T2DM
• Several-week history: polyuria, weight loss, diminished oral intake
• Mental confusion, lethargy, coma.
• Profound dehydration, hyperosmolality, hypotension, tachycardia.
• Absence: Nausea, vomiting, abdominal pain, Kussmaul respirations (≠ DKA)
• Focal neurologic signs (hemianopia, hemiparesis), seizures (focal/generalized).
CLINICAL FEATURES (3)

18. Wyckoff J., Abrahamson M. J. (2005), Joslin’s Diabetes Mellitus, C. Ronald Kahn, Gordon C. Weir, George L. King, Editors, Lippincott Williams and Wilkins, pp. 887-901

19. • Plasma glucose
• BUN, Creatinine
• Electrolytes, anion gap
• Osmolality
• Serum and urinary ketones
• Urinalysis
• Arterial blood gases
• Complete blood count
• ECG, CXR, urine, sputum or blood cultures
• …
LABORATORY

20. • Characteristics: hyperglycemia, ketosis, metabolic acidosis ↑ AG.
• Potassium:
• Total-body potassium deficit
• Serum potassium may ↑ mildly/at presentation (acidosis)
• Sodium, chloride, phosphorus, magnesium:
• ↓
• Not accurate: due to hypovolemia, hyperglycemia
• BUN, serum creatinine: ↑ (intravascular volumn depletion).
• Leukocytosis
• Hypertriglyceridemia, Hyperlipiproteinemia
• Hyperamylasemia: amylase/DKA = salivary origin  only suggest pancreatitis  serum lipase.
• Severe inflammatory state (both DKA+HHS): cytokines, CRP,…
LABORATORY DKA(1)

21. • Ketone bodies = β-hydroxybutyrate, acetoacetate, acetone.
• Commonly used ketosis dection reagent: nitroprusside 
preferentially detect acetoacetate (semiquantitative)  high
sensitive, under estimate the severity.
• β –hydroxybutyrate >> in DKA  serum or plasma assays for
β-hydroxybutyrate: more accurately reflect
• False-positive reaction: captopril, penicillamine.
LABORATORY DKA(2)
Pearson E. R., McCrimmon R. J. (2014), Davidson’s Principles and Practice of Medicine, Brian R. Walker, Nicki R. Colledge, Stuart H. Ralston, Editors, Churchill Livingstone Elsevier, pp.
797-836

22. Wyckoff J., Abrahamson M. J. (2005), Joslin’s Diabetes Mellitus, C. Ronald Kahn, Gordon C. Weir, George L. King, Editors, Lippincott Williams and Wilkins, pp. 887-901

23. • Marked hyperglycemia
• Hyperosmolality: positive linear relationship between osmolality and mental obtundation
• Prerenal azotemia
LABORATORY HHS

24. Powers A. C. (2016), Harrison's Principles of Internal Medicine, Dennis L. Kasper, Anthony S. Fauci, Stephen L. Hauser, Editors, McGraw Hill Education, pp. 2407-2421

25. Kitabchi A. E., Umpierrez G. E., Murphy M. B. (2015), International Textbook of Diabetes Mellitus, Ralph A. DeFronzo, Ele Ferrannini, Paul Zimmet, Editors, Wiley Blackwell, pp. 799-
814

26. • Corrected serum sodium = measured serum sodium + 1.6mg/dL for each 100 mg/dL of glucose
above 100 mg/dL
Osmotic flux of water from intracellular  extracellular space (hyperglycemia)
[Na]c= [Na]s + 0.6 x
[glucose]s −100
100
• Effective osmolality: not take urea concentration (freely permeable + accumulation does not
induce major changes in intracellular volume or osmotic gradient across the cell membrane)
Normal range: 280-290 mOsM/kg
OSMe=2 x Na (m 𝐸𝑞/L)+
[Glucose](mg/dL)
18
CORRECTED EQUATIONS
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43

27. • Correction of:
• Dehydration
• Hyperglycemia
• Electrolyte imbalances
• Identification of comorbid precipitating events
Careful monitoring and frequent reassenssment
TREATMENT GOAL
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Powers A. C. (2016), Harrison's Principles of Internal Medicine, Dennis L. Kasper, Anthony S. Fauci, Stephen L. Hauser, Editors, McGraw Hill Education, pp. 2407-2421

28. • Necessary for frequent monitoring
• pH < 7.00
• Unconcious
ICU ADMISSION
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Powers A. C. (2016), Harrison's Principles of Internal Medicine, Dennis L. Kasper, Anthony S. Fauci, Stephen L. Hauser, Editors, McGraw Hill Education, pp. 2407-2421

29. Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43

30. • Goal:
• Replete intravascular (circulating volume)  replenish interstitial, intracellular volume (total body water deficit)
• Estimate fluid deficit = current weight – recent dry weight
• Restore renal perfusion (contribute to correct hyperglycemia  excrete glucose in urine)
• Varies based on: age, weight, hemodynamics, comorbidities.
• Aim for over 12-24h
• Generally depleted 3-6L (DKA), 8-12L (HHS)
• Monitor: urine output, HR, BP, respiratory status.
• Careful: CHF, kidney disease.
FLUID THERAPY (1)
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Rometo D. A., Kollef M. H., Tobin G. S. (2012), The Washington Manual of Critical Care Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 239-244
Herrick C. J., McGill J. B. (2016), The Washington Manual of Medical Therapeutics, Pavat Bhat, Alexandra Dretler, Mark Gdowski, Editors, Wolters Kluwer, pp. 730-757

31. • 1-1.5L Natri clorua 0.9% over first 30-60 min  An addition 1-2L q30-60 min (15-20 mL/kg/h) until
haemodynamically stable + urine output ↑
• Serum Na high/normal: Natri clorua 0.45%, 250-500 mL/h
• Serum Na low: Natri clorua 0.9%, 250-500 mL/h
• When BG reach mean 250 mg/dL (DKA 200, HHS 300)  add dextrose 5%, ↓ to 150-250 mL/h
• Prevent hypoglycemia
• Hyperglycemia is corrected faster than ketoacidosis  add dextrose to allow continued insulin
administration until ketonemia is controlled.
FLUID THERAPY (2)
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Rometo D. A., Kollef M. H., Tobin G. S. (2012), The Washington Manual of Critical Care Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 239-244
Herrick C. J., McGill J. B. (2016), The Washington Manual of Medical Therapeutics, Pavat Bhat, Alexandra Dretler, Mark Gdowski, Editors, Wolters Kluwer, pp. 730-757

32. Wyckoff J., Abrahamson M. J. (2005), Joslin’s Diabetes Mellitus, C. Ronald Kahn, Gordon C. Weir, George L. King, Editors, Lippincott Williams and Wilkins, pp. 887-901

33. Delayed until [K+] > 3.3 mEq/L
• Regular insulin/continuous intravenous infusion
• Short half-life  easy titration
(a) 0.1 U/kg bolus  0.1 U/kg/h
(b) 0.14 U/kg/h (no bolus)
• Frequent subcutaneous or intramuscular injections
 Effective regardless of the route of administration
INSULIN THERAPY (1)
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Rometo D. A., Kollef M. H., Tobin G. S. (2012), The Washington Manual of Critical Care Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 239-244
Herrick C. J., McGill J. B. (2016), The Washington Manual of Medical Therapeutics, Pavat Bhat, Alexandra Dretler, Mark Gdowski, Editors, Wolters Kluwer, pp. 730-757

34. BG MONITORING
• Initial: q1h
• Stable (3 consecutive values decreased in target range): q2h
• Resume to q1h for each change in insulin infusion rate
INSULIN THERAPY (2)
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Rometo D. A., Kollef M. H., Tobin G. S. (2012), The Washington Manual of Critical Care Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 239-244
Herrick C. J., McGill J. B. (2016), The Washington Manual of Medical Therapeutics, Pavat Bhat, Alexandra Dretler, Mark Gdowski, Editors, Wolters Kluwer, pp. 730-757

35. TITRATING INSULIN INFUSION RATE
• GOAL: decrease 50-75 mg/dL/hr.
• BG decreased by > 100 mg/dL/hr : ↓ Insulin 50%/hr
• BG decreased by < 50 mg/dL/hr: ↑ Insulin 50%/hr
• When BG reach: (// dextrose addition)  decrease Insulin rate to 0.0.2-0.05U/kg/h
• 200mg/dL DKA (Goal: 150-200)
• 300mg/dL HHS (Goal: 200-300)
INSULIN THERAPY (3)
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Rometo D. A., Kollef M. H., Tobin G. S. (2012), The Washington Manual of Critical Care Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 239-244
Herrick C. J., McGill J. B. (2016), The Washington Manual of Medical Therapeutics, Pavat Bhat, Alexandra Dretler, Mark Gdowski, Editors, Wolters Kluwer, pp. 730-757

36. START SC INSULIN
• When ketoacidosis resolve:
• BG < 200 mg/dL
• 2 of 3:
• [HCO3
-] ≥ 15 mEq/L
• venous pH > 7.3
• Calculated AG ≤ 12 mEg/L
• When HHS resolve:
• Normal osmolality
• Regain of normal mental status
Allow an overlap of 1-2hr between IV and SC  prevent recurrence/relapse of hyperglycemia or
ketoacidosis.
Patient able to eat
INSULIN THERAPY (4)
DOSES:
1. Known DM: may use doses receiving before
onset of DKA, closely monitor
2. Insulin-naïve: multidose (0.5-0.8/kg/day)
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Rometo D. A., Kollef M. H., Tobin G. S. (2012), The Washington Manual of Critical Care Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 239-244
Herrick C. J., McGill J. B. (2016), The Washington Manual of Medical Therapeutics, Pavat Bhat, Alexandra Dretler, Mark Gdowski, Editors, Wolters Kluwer, pp. 730-757

37. POTASSIUM
Wyckoff J., Abrahamson M. J. (2005), Joslin’s Diabetes Mellitus, C. Ronald Kahn, Gordon C. Weir, George L. King, Editors, Lippincott Williams and Wilkins, pp. 887-901
Kitabchi A. E., Umpierrez G. E., Murphy M. B. (2015), International Textbook of Diabetes Mellitus, Ralph A. DeFronzo, Ele Ferrannini, Paul Zimmet, Editors, Wiley Blackwell, pp. 799-814

38. BICARBONATE THERAPY
• Severe metabolic acidosis consequences:
• Impaired myocardial contractility
• Cerebral vasodilatation
• Coma
• Gastrointestinal complications
• Indications:
• pH < 6.9
• HCO3 < 5-10 mEq/L
• Cardiac/respiratory dysfunction
• Severe hyperkalemia
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Rometo D. A., Kollef M. H., Tobin G. S. (2012), The Washington Manual of Critical Care Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 239-244
Herrick C. J., McGill J. B. (2016), The Washington Manual of Medical Therapeutics, Pavat Bhat, Alexandra Dretler, Mark Gdowski, Editors, Wolters Kluwer, pp. 730-757

39. • BP, pulse, respirations, mental status, fluid balance: q1-4hr
• Capillary glucose: q1-2hr
• Electrolytes (esp K+, bicarbonate, phosphate), AG, pH: q4hr/first 24hr.
MONITORING
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Rometo D. A., Kollef M. H., Tobin G. S. (2012), The Washington Manual of Critical Care Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 239-244
Herrick C. J., McGill J. B. (2016), The Washington Manual of Medical Therapeutics, Pavat Bhat, Alexandra Dretler, Mark Gdowski, Editors, Wolters Kluwer, pp. 730-757

40. • Natural:
• Shock: hypovolemia…
• Lactic acidosis
• Kidney injury
• Embolism
• Iatrogenic:
• Hypoglycemia
• Hypokalemia
• Pulmonary edema
• Cerebral edema
COMPLICATIONS
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
Herrick C. J., McGill J. B. (2016), The Washington Manual of Medical Therapeutics, Pavat Bhat, Alexandra Dretler, Mark Gdowski, Editors, Wolters Kluwer, pp. 730-757

41. • Symptoms and signs:
Headache, Gradual deterioration in level of consciousness, seizures, sphincter incontinence,
pupillary changes, papilledema, bradycardia, elevation BP, respiratory arrest
• Proposed mechanism
• Cerebral ischemia/hypoxia
• Generation of various inflammatory mediators
• Increased cerebral blood flow
• Disruption of cell membrane ion transport
• Rapid shift in extracellular and intracellular fluids  changes in osmolality
CEREBRAL EDEMA (1)
Rometo D. A., Kollef M. H., Tobin G. S. (2012), The Washington Manual of Critical Care Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 239-244

42. • ICU admission
• ↑ head of the bed
• ↓ 1/3 rate of fluid administration
• Mannitol 0.5-1 g/kg IV, 20 min  repeat if there is no initial response in 30min-1hr.
• Hypertonic saline (3%), 5-10 mL/kg, 30 min (may be alternative to mannitol if no initial response)
• Intubation  airway protection, impending respiratory failure
• Brain CT  differential diagnosis.
CEREBRAL EDEMA (2)
Rometo D. A., Kollef M. H., Tobin G. S. (2012), The Washington Manual of Critical Care Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 239-244

43. • Death:
• Metabolic complications of hyperglycemia or ketoacidosis
• Underlying precipitating illness
• Poor:
• Extremes of age in the presence of coma
• Hypotension
• Severe comorbidities.
PROGNOSIS
Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43

44. • 21-79% of patients with DKA1
• Acidemia (arterial pH ≤7.32) may have spurious elevations in serum amylase2
• Differentiate with other conditions, esp acute pancreatitis
• Serum lipase determination may be beneficial in differenial diagnosis of pancreatitis
Hyperamylasemia
1. Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), Diabetes Care, 32 (7), pp. 1335-43
2. Conwell D. L., Banks P., Greenberger N. J. (2016), Harrison's Principles of Internal Medicine, Dennis L. Kasper, Anthony S. Fauci, Stephen L. Hauser, Editors, McGraw Hill Education, pp. 2090-2102

45. LACTIC ACIDOSIS
PHUNG HUY HOANG, MD
RESIDENT IN INTERNAL MEDICINE
PHAM NGOC THACH UNIVERSITY OF MEDICINE
MAY, 2017

46. • MALA (Metformin-associated Lactic Acidosis): most severe adverse effect of biguanide
therapy
• Can be fatal in up to 50% of cases
• Phenformin >> metformin (difference is due to the lipophilic side chain of phenformin  allows
the drug to penetrate lipid + mitochondrial membranes + more potently inhibit NADH-dependent
respiration; partially metabolized in the liver through hydroxylation + 1 in 10 people have a genetic
polymorphism that slows hydroxylation, reducing drug clearance)
• Vast majority of cases of LA with metformin therapy: had concurrent illnesses and
precipitate the reaction
OVERVIEW
Samson S. L., Garber A. J. (2015), International Textbook of Diabetes Mellitus, Ralph A. DeFronzo, Ele Ferrannini, Paul Zimmet, Editors, Wiley Blackwell, pp. 641-656

47. Samson S. L., Garber A. J. (2015), International Textbook of Diabetes Mellitus, Ralph A. DeFronzo, Ele Ferrannini, Paul Zimmet, Editors, Wiley Blackwell, pp. 641-656

48. • Renal insuffciency
• may be safely used in patients with eGFR as low as 30 mL/min/1.73 m2
• dose reduction to a maximum daily dose of 1000 mg (eGFR <50 mL/minute/1.73m2; avoidance
when eGFR < 30 mL/minute/1.73m2)
• Congestive heart failure requiring pharmacologic treatment (potential for hypoxia)
• Hepatic impairment (lactate accumulation)
• Acute or chronic metabolic acidosis
• Alcoholism
• Hypoxemia, dehydration, or sepsis
CONTRAINDICATIONS TO BIGUANIDES
• Samson S. L., Garber A. J. (2015), International Textbook of Diabetes Mellitus, Ralph A. DeFronzo, Ele Ferrannini, Paul Zimmet, Editors, Wiley Blackwell, pp. 641-656
• Cefalu W. T., Bakris G., Blonde L. (2017), Diabetes Care, 40 (Supplement 1), pp. S64-S74.
• George J. T., McKay G. A. (2008), Diabetic Medicine, 25 (5), pp. 636-637.

49. • > 60 years
• Decreased cardiac, hepatic or renal function
• Diabetic ketoacidosis
• Surgery
• Respiratory failure
• Ethanol intoxication
• Fasting
RISK FACTORS
Luft F. C. (2001), J Am Soc Nephrol, 12 Suppl 17, pp. S15-9

50. • Arterial blood pH <7.35
• Elevated lactate levels (> 4–5 mEq/L or mmol/)
• An anion gap
DEFINITION
Samson S. L., Garber A. J. (2015), International Textbook of Diabetes Mellitus, Ralph A. DeFronzo, Ele Ferrannini, Paul Zimmet, Editors, Wiley Blackwell, pp. 641-656

51. COHEN & WOODS CLASSIFCATION
• Type A-Poor tissue perfusion: circulatory insufficiency (shock, cardiac failure), severe anemia,
mitochondrial enzyme defects, and inhibitors (carbon monoxide, cyanide)
• Type B-Aerobic disorders: malignancies, nucleoside analogue reverse transcriptase inhibitors in
HIV, diabetes mellitus, renal or hepatic failure, thiamine deficiency, severe infections (cholera,
malaria), seizures, or drugs/toxins (biguanides, ethanol, methanol, propylene glycol, isoniazid, and
fructose)
CLASSIFICATION OF LA
Thomas D. DuBose J. (2016), Harrison's Principles of Internal Medicine, Dennis L. Kasper, Anthony S. Fauci, Stephen L. Hauser, Editors, McGraw Hill Education, pp. 315-24

52. CLASSIFICATION OF LA
Morgan T. J. (2014), Oh’s Intensive Care Manual, Andrew D Bersten , Neil Soni, Editors, Elsevier,
pp. 937-948

53. • 15–20 mmol/kg/day lactate from glycolysis and
deamination of alanine to be converted to pyruvate in the
liver
• Lactic acid production from the gut and other tissues
• Biguanide:
• inhibition of the mitochondrial respiratory chain 
increase in glycolysis which can result in increased
lactate production
• decrease hepatic uptake and utilization of lactate for
gluconeogenesis
PHYSIOLOGIC ASPECT
• Samson S. L., Garber A. J. (2015), International Textbook of Diabetes Mellitus, Ralph A. DeFronzo, Ele Ferrannini, Paul Zimmet, Editors, Wiley Blackwell, pp. 641-656
• Bailey C. J., Krentz A. J. (2010), Textbook of Diabetes, Richard I.G. Hol, Clive S. Cockram, Allan Flyvbjerg, Editors, Wiley Blackwell, pp. 452-477

54. • Reduced myocardial contractility, tachy- and bradydysrhythmias, systemic arteriolar
dilatation, venoconstriction, centralisation of blood volume
• Pulmonary vasoconstriction, hyperventilation, respiratory muscle failure
• Reduced splanchnic and renal blood flow
• Increased metabolic rate, catabolism, reduced ATP synthesis, reduced 2,3-DPG synthesis,
accelerated aerobic glycolysis
• Confusion, drowsiness
• Increased iNOS expression, pro-inflammatory cytokine release
• Hyperglycemia, hyperkalaemia
• Cell membrane pump dysfunction
• Bone loss, muscle wasting
ADVERSE EFFECT OF METABOLIC ACIDOSIS
Morgan T. J. (2014), Oh’s Intensive Care Manual, Andrew D Bersten , Neil Soni, Editors, Elsevier, pp. 937-948

55. DIFFERENTIATION
Juran P., Cheng S. (2012), The Washington Manual of Critical Care Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 209-221

56. • Diagnose and correct the underlying condition
• Restore adequate tissue oxygen delivery
• Hyperventilation
• Bicarbonate
• Dialysis/hemofiltration
TREATMENT
Cooper D. J., Higgins A. M., Nichol A. D. (2014), Oh’s Intensive Care Manual, Andrew D Bersten , Neil Soni, Editors, Elsevier, pp. 158-164

57. • Recommended in severe metformin poisoning (1D)
• ECTR is recommended if:
• Lactate concentration > 20 mmol/L (180 mg/dL) (1D)
• Blood pH ≤ 7.0 (1D)
• Standard therapy (supportive measures, bicarbonate, etc.) fails (1D)
• ECTR is suggested if
• Lactate concentration is 15–20 mmol/L (135–180mg/dL) (2D)
• Blood pH 7.0–7.1 (2D)
• Comorbid conditions that lower the threshold for initiating ECTR
• Impaired kidney function (1D)
• Shock (1D)
• Decreased level of consciousness (2D)
• Liver failure (2D)
EXTRACORPOREAL TREATMENT
Calello D. P., Liu K. D., Wiegand T. J., et al. (2015), Crit Care Med, 43 (8), pp. 1716-30

58. • Cessation of ECTR is indicated when
• Lactate concentration is < 3 mmol/L (27mg/dL)
• and pH > 7.35 (1D)
• Choice of ECTR
• As an initial ECTR, intermittent HD with bicarbonate buffer is preferred (1D), but CRRT is an
acceptable alternative if HD is not available (2D)
• After the initial ECTR session, either HD (1D) or CRRT (1D) is appropriate if necessary
EXTRACORPOREAL TREATMENT
Calello D. P., Liu K. D., Wiegand T. J., et al. (2015), Crit Care Med, 43 (8), pp. 1716-30

59. PHUNG HUY HOANG, MD
RESIDENT IN INTERNAL MEDICINE
PHAM NGOC THACH UNIVERSITY OF MEDICINE
MAY, 2017
HYPOGLYCEMIA
Lieberman M., Marks A., Peet A. (2013), Marks’ Basic Medical Biochemistry A
Clinical Approach, Susan Rhyner, Editor, Lippincott Williams & Wilkins, pp. 477-
492

60. GLUCOSE METABOLISM
Intestinal absorbtion
1
Glycogenolysis
2
Glyconeogenesis
3

61. Hussain K. (2016), Goldman-Cecil Medicine, Lee Goldman , Andrew I. Schafer, Editors, Elsevier Saunders, pp. 1548-1555

62. GLUCOSE BALANCE
• Plasma glucose-lowering hormone (regulatory): insulin
• Plasma glucose-raising hormones (counterregulatory): glucagon, epinephrine,
cortisol, GH
70-110 mg/dL
Cryer P. E. (2016), Williams Textbook Of Endocrinology, Henry M. Kronenberg, et al.,
Editors, Elsevier, pp. 1582-1607

63. Hussain K. (2016), Goldman-Cecil Medicine, Lee Goldman , Andrew I. Schafer, Editors, Elsevier Saunders, pp. 1548-1555

64. Cryer P. E. (2016), Williams Textbook Of Endocrinology, Henry M. Kronenberg, et al., Editors, Elsevier, pp. 1582-1607

65. Cryer P. E., Davis S. N. (2016), Harrison's Principles of Internal Medicine, Dennis L. Kasper, Anthony S. Fauci, Stephen L. Hauser, Editors, McGraw Hill Education, pp. 2403-2434

66. Cryer P. E. (2010), Textbook of Diabetes, Richard I.G. Hol, Clive S. Cockram, Allan Flyvbjerg, Editors, Wiley Blackwell, pp. 528-545

67. Cryer P. E. (2016), Williams Textbook Of Endocrinology, Henry M. Kronenberg, et al., Editors, Elsevier, pp. 1582-1607

68. “All episodes of abnormally low plasma glucose concentration that
expose the individual to potential harm”
American Diabetes Association
Endocrine Society
Cefalu W. T., Bakris G., Blonde L. (2017), Diabetes Care, 40 (Supplement 1), pp. S48-S56

69. (International Hypoglycaemia Study Group)
Cefalu W. T., Bakris G., Blonde L. (2017), Diabetes Care, 40 (Supplement 1), pp. S48-S56

70. • Threshold: dynamic
• Clinical manifestation
o Autonomic: adrenergic, cholinergic
o Neuroglycopenic
o Transient focal neurologic deficits
• WHIPPLE TRIAD
o Symptoms and/or signs consistent with
hypoglycemia
o Low plasma glucose concentration
o Resolution of symptoms and signs after plasma
glucose concentration is raised
• Asymtomatic (unawareness) hypoglycemia: beta-
blockers usage, elderly, recurrent hypoglycemia episodes
DIAGNOSIS
Pearson E. R., McCrimmon R. J. (2014), Davidson’s Principles and Practice of Medicine, Brian R. Walker, Nicki R. Colledge, Stuart H. Ralston, Editors, Churchill Livingstone Elsevier, pp.
797-836

71. Masharani U., Gitelman S. E. (2011), Greenspan's Basic and Clinical
Endocrinology, David G. Gardner , Dolores Shoback, Editors, McGraw
Hill, pp. 657-674

72. Masharani U., Gitelman S. E. (2011), Greenspan's Basic and Clinical Endocrinology, David G. Gardner , Dolores Shoback, Editors,
McGraw Hill, pp. 657-674

73. RISK FACTORS
Cryer P. E. (2016), Williams Textbook Of Endocrinology, Henry M. Kronenberg, et al., Editors, Elsevier, pp. 1582-1607

74. Amiel S. A. (2015), International Textbook of Diabetes Mellitus, Ralph A. DeFronzo, Ele
Ferrannini, Paul Zimmet, Editors, Wiley Blackwell, pp. 783-798

75. Cryer P. E. (2010), Textbook of Diabetes, Richard I.G. Hol, Clive S. Cockram, Allan Flyvbjerg, Editors, Wiley Blackwell, pp. 528-545

76. Mordes J. P., Malkan S. (2014), Irwin & Rippe’s Manual of Intensive Care Medicine, Richard S. Irwin, Craig M. Lilly, James M. Rippe, Editors, Lippincott Williams & Wilkins, pp. 627-
636

77. Mordes J. P., Malkan S. (2014), Irwin & Rippe’s Manual of Intensive Care Medicine, Richard S. Irwin, Craig M. Lilly, James M. Rippe, Editors, Lippincott Williams & Wilkins, pp. 627-
636

78. CONSEQUENCE AND OUTCOME
• Lethargy, obtundation, seizures, coma
• SVT, VT, AFib, junctional dysrhythmias (due to catecholamine storms).
• Hypothermia
• Respiratory failure
 death

79. MANAGEMENT
Orally
Parenteral

80. MANAGEMENT
Orally
• Conscious patients.
• Ingestion of glucose (preferred to other form of carbohydrate) or carbohydrates that
contains flucose.
• Use only glucose when acarbose related.
• Reasonable dose: 15-20g glucose.
• Clinical improvement occurs in 15-20 minutes.
• Once SMBG returns to normal  consume a meal or snack to prevent recurrence
of hypoglycemia
• Cryer P. E. (2016), Williams Textbook Of Endocrinology, Henry M. Kronenberg, et al., Editors, Elsevier, pp. 1582-1607
• Cefalu W. T., Bakris G., Blonde L. (2017), Diabetes Care, 40 (Supplement 1), pp. S48-S56

81. MANAGEMENT
Parenteral
Unconscious; Unable to eat
• Glucagon
• IV glucose
• Diazoxide, octreotide
 Start oral feedings as soon as consciousness is restored
Cryer P. E. (2016), Williams Textbook Of Endocrinology, Henry M. Kronenberg, et al., Editors, Elsevier, pp. 1582-1607
Masharani U., Gitelman S. E. (2011), Greenspan's Basic and Clinical Endocrinology, David G. Gardner , Dolores Shoback, Editors, McGraw Hill, pp. 657-674

82. GLUCAGON
• 1.0 mg – SC or IM
• Often cause substantial, albeit, transient hyperglycemia
• Nausea, vomiting
• For all individuals at increased risk of clinically
significant hypoglycemia (> 54 mg/dL= 3.0 mmol/L)*
• Should not be given if due to sulfonylurea use (can
stimulate insulin secretion  worsen hypoglycemia)
• Cryer P. E. (2016), Williams Textbook Of Endocrinology, Henry M. Kronenberg, et al., Editors, Elsevier, pp. 1582-1607
• Masharani U., Gitelman S. E. (2011), Greenspan's Basic and Clinical Endocrinology, David G. Gardner , Dolores Shoback, Editors, McGraw Hill, pp. 657-674
• (*) Cefalu W. T., Bakris G., Blonde L. (2017), Diabetes Care, 40 (Supplement 1), pp. S48-S56

83. IV GLUCOSE
• 25g = 20-50 mL Glucose 50%
80-100 mL Glucose 30%
• Long- or intermediate-acting insulin; long-acting sulphonylurea: infusion of 10% glucose,
titrated to patient’s blood glucose  prevent recurrence
Cryer P. E. (2016), Williams Textbook Of Endocrinology, Henry M. Kronenberg, et al., Editors, Elsevier, pp. 1582-1607
Masharani U., Gitelman S. E. (2011), Greenspan's Basic and Clinical Endocrinology, David G. Gardner , Dolores Shoback, Editors, McGraw Hill, pp. 657-674

84. DIAZOXIDE, OCTREOTIDE
• Have taken massive overdoses of sylfonylureas
• Diazoxide 150-300 mg (may cause hypotension)
• Octreotide 100 µg
Cryer P. E. (2016), Williams Textbook Of Endocrinology, Henry M. Kronenberg, et al., Editors, Elsevier, pp. 1582-1607
Masharani U., Gitelman S. E. (2011), Greenspan's Basic and Clinical Endocrinology, David G. Gardner , Dolores Shoback, Editors, McGraw Hill, pp. 657-674

85. MONITORING
• Cognitive
• Vital signs
• Blood glucose
Cryer P. E. (2016), Williams Textbook Of Endocrinology, Henry M. Kronenberg, et al., Editors, Elsevier, pp. 1582-1607
Masharani U., Gitelman S. E. (2011), Greenspan's Basic and Clinical Endocrinology, David G. Gardner , Dolores Shoback, Editors, McGraw Hill, pp. 657-674

86. PREVENTION
• Alert for “hypoglycemia unawareness”:
• Exacerbated by frequent hypoglycemic episodes
• Medications (eg, BBlocker)
• Long-standing DM  blunting of counterregulation, increased sensitivity to fast-
acting insulin
• Education
• Appropriate adjustment to medication, diet, exercise regimen, glycemic target
Cryer P. E. (2016), Williams Textbook Of Endocrinology, Henry M. Kronenberg, et al., Editors, Elsevier, pp. 1582-1607
Masharani U., Gitelman S. E. (2011), Greenspan's Basic and Clinical Endocrinology, David G. Gardner , Dolores Shoback, Editors, McGraw Hill, pp. 657-674

87. Cryer P. E. (2010), Textbook of Diabetes, Richard I.G. Hol, Clive S. Cockram, Allan Flyvbjerg, Editors, Wiley Blackwell, pp. 528-545

88. SU DOSES REPLACEMENT
"Kimberley Standard Drug List“, 2016

89. REFERENCES
1. Amiel S. A. (2015), "Hypoglycemia and other complications of insulin therapy", International Textbook of Diabetes Mellitus,
Ralph A. DeFronzo, Ele Ferrannini, Paul Zimmet, Editors, Wiley Blackwell, pp. 783-798.
2. Bailey C. J., Krentz A. J. (2010), "Oral Antidiabetic Agents", Textbook of Diabetes, Richard I.G. Hol, Clive S. Cockram, Allan
Flyvbjerg, Editors, Wiley Blackwell, pp. 452-477.
3. Calello D. P., Liu K. D., Wiegand T. J., et al. (2015), "Extracorporeal Treatment for Metformin Poisoning: Systematic Review and
Recommendations From the Extracorporeal Treatments in Poisoning Workgroup", Crit Care Med, 43 (8), pp. 1716-30.
4. Cefalu W. T., Bakris G., Blonde L. (2017), "6. Glycemic Targets", Diabetes Care, 40 (Supplement 1), pp. S48-S56.
5. Cefalu W. T., Bakris G., Blonde L. (2017), "8. Pharmacologic Approaches to Glycemic Treatment", Diabetes Care, 40
(Supplement 1), pp. S64-S74.
6. Cooper D. J., Higgins A. M., Nichol A. D. (2014), "Lactic acidosis", Oh’s Intensive Care Manual, Andrew D Bersten , Neil Soni,
Editors, Elsevier, pp. 158-164.
7. Cryer P. E. (2016), "Hypoglycemia", Williams Textbook Of Endocrinology, Henry M. Kronenberg, et al., Editors, Elsevier, pp.
1582-1607.
8. Cryer P. E. (2010), "Hypoglycemia in Diabetes", Textbook of Diabetes, Richard I.G. Hol, Clive S. Cockram, Allan Flyvbjerg,
Editors, Wiley Blackwell, pp. 528-545.
9. Cryer P. E., Davis S. N. (2016), "Hypoglycemia", Harrison's Principles of Internal Medicine, Dennis L. Kasper, Anthony S. Fauci,
Stephen L. Hauser, Editors, McGraw Hill Education, pp. 2403-2434.
10. Gale E., Anderson J. (2012), "Diabetes mellitus and other disorders of metabolis", Kumar & Clark’s Clinical Medicine, Parveen
Kumar , Michael Clark, Editors, Elsevier, pp. 1001-1046.
11. George J. T., McKay G. A. (2008), "Establishing pragmatic estimated glomerular filtration rate thresholds to guide metformin
prescribing: careful assessment of risks and benefits is required", Diabetic Medicine, 25 (5), pp. 636-637.
12. Herrick C. J., McGill J. B. (2016), "Diabetes Mellitus and Related Disorders", The Washington Manual of Medical Therapeutics,
Pavat Bhat, Alexandra Dretler, Mark Gdowski, Editors, Wolters Kluwer, pp. 730-757.

90. REFERENCES
13. Hussain K. (2016), "Hypoglycemia and Pancreatic Islet Cell Disorders", Goldman-Cecil Medicine, Lee Goldman , Andrew I.
Schafer, Editors, Elsevier Saunders, pp. 1548-1555.
14. Juran P., Cheng S. (2012), "Metabolic Acid–Base Disorders", The Washington Manual of Critical Care Marin H. Kollef ,
Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 209-221.
15. Kitabchi A. E., Umpierrez G. E., Miles J. M., et al. (2009), "Hyperglycemic crises in adult patients with diabetes", Diabetes Care,
32 (7), pp. 1335-43.
16. Kitabchi A. E., Umpierrez G. E., Murphy M. B. (2015), "Diabetic ketoacidosis and hyperosmolar state", International Textbook
of Diabetes Mellitus, Ralph A. DeFronzo, Ele Ferrannini, Paul Zimmet, Editors, Wiley Blackwell, pp. 799-814.
17. Lieberman M., Marks A., Peet A. (2013), "Basic Concepts in the Regulation of Fuel Metabolism by Insulin, Glucagon, and
Other Hormones", Marks’ Basic Medical Biochemistry A Clinical Approach, Susan Rhyner, Editor, Lippincott Williams & Wilkins,
pp. 477-492.
18. Luft F. C. (2001), "Lactic acidosis update for critical care clinicians", J Am Soc Nephrol, 12 Suppl 17, pp. S15-9.
19. Masharani U., Gitelman S. E. (2011), "Hypoglycetic Disorders", Greenspan's Basic and Clinical Endocrinology, David G.
Gardner , Dolores Shoback, Editors, McGraw Hill, pp. 657-674.
20. Mordes J. P., Malkan S. (2014), "Hypoglycemia", Irwin & Rippe’s Manual of Intensive Care Medicine, Richard S. Irwin, Craig M.
Lilly, James M. Rippe, Editors, Lippincott Williams & Wilkins, pp. 627-636.
21. Morgan T. J. (2014), "Acid–base balance and disorders", Oh’s Intensive Care Manual, Andrew D Bersten , Neil Soni, Editors,
Elsevier, pp. 937-948.
22. Nelson D. L., Cox M. M. (2013), "Fatty Acid Catabolism", Lehninger Principles of Biochemistry, W. H. Freeman and Company,
pp. 667-693.
23. Pearson E. R., McCrimmon R. J. (2014), "Diabetes mellitus", Davidson’s Principles and Practice of Medicine, Brian R. Walker,
Nicki R. Colledge, Stuart H. Ralston, Editors, Churchill Livingstone Elsevier, pp. 797-836.

91. REFERENCES
24. Powers A. C. (2016), "Diabetes mellitus: management and Therapies", Harrison's Principles of Internal Medicine, Dennis L.
Kasper, Anthony S. Fauci, Stephen L. Hauser, Editors, McGraw Hill Education, pp. 2407-2421.
25. Rometo D. A., Kollef M. H., Tobin G. S. (2012), "Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State", The
Washington Manual of Critical Care Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 239-244.
26. Samson S. L., Garber A. J. (2015), "Metformin and other biguanides: pharmacology and therapeutic usage", International
Textbook of Diabetes Mellitus, Ralph A. DeFronzo, Ele Ferrannini, Paul Zimmet, Editors, Wiley Blackwell, pp. 641-656.
27. Seaquist E. R., Anderson J., Childs B., et al. (2013), "Hypoglycemia and Diabetes: A Report of a Workgroup of the American
Diabetes Association and The Endocrine Society", Diabetes Care, 36 (5), pp. 1384-1395.
28. Thomas D. DuBose J. (2016), "Acidosis and Alkalosis", Harrison's Principles of Internal Medicine, Dennis L. Kasper, Anthony S.
Fauci, Stephen L. Hauser, Editors, McGraw Hill Education, pp. 315-24.
29. Wyckoff J., Abrahamson M. J. (2005), "Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State", Joslin’s Diabetes
Mellitus, C. Ronald Kahn, Gordon C. Weir, George L. King, Editors, Lippincott Williams and Wilkins, pp. 887-901.
30. Yates A., Laing I. (2011), "Diabetes mellitus and hypoglycaemia", Clinical Biochemistry, Nessar Ahmed, Editor, Oxford
University Press, pp. 338-76.

92. ACUTE METABOLIC COMPLICATIONS
OF DIABETES
PHUNG HUY HOANG, MD
RESIDENT IN INTERNAL MEDICINE
PHAM NGOC THACH UNIVERSITY OF MEDICINE
MAY, 2017