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Hyperglycemic Crises

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Hyperglycemic Crises

  1. 1. Hyperglycemic Crises<br />
  2. 2. Hyperglycemic Crises<br />Diabetic Ketoacidosis<br />Hyperglycemia, Ketonemia, Metabolic Acidosis<br />Mortality rate: <5%<br />Hyperosmolar Hyperglycemic State<br />Mortality rate: ~11%<br />
  3. 3.
  4. 4. Pathogenesis<br />Reduction in net effective action of circulating insulin<br />Elevation of counterregulatory hormones: glucagon, catecholamines, cortisol and growth hormone<br />
  5. 5. Pathogenesis<br />
  6. 6. Diagnostic Criteria<br />
  7. 7. Diagnostic Criteria – DKA<br />Serum glucose > 250 mg/dl<br />Arterial pH < 7.3<br />Serum Bicarbonate < 18 mEq/L<br />Moderate ketonuria or ketonemia<br />
  8. 8. Diagnostic Criteria - HHS<br />Serum glucose > 600 mg/dl<br />Arterial pH > 7.3<br />Serum Bicarbonate > 15 mEq/L<br />Minimal ketonuria or ketonemia<br />
  9. 9. Diagnostic Criteria<br />
  10. 10. Diagnostic Criteria<br />
  11. 11. Precipitating Factors<br />Inadequate/inappropriate insulin therapy<br />Infection<br />Pancreatitis <br />Myocardial infarction<br />Cerebrovascular accident<br />Drugs (corticosteroids, thiazides, sympathomimetics, 2nd gen antipsychotics)<br />New onset Type 1 DM<br />Discontinuation of Insulin in Type 1 DM<br />
  12. 12. Diagnosis<br />
  13. 13.
  14. 14. History<br />Polyuria<br />Polydipsia<br />Weight loss<br />Vomiting<br />Abdominal pain<br />Dehydration<br />Weakness<br />Mental status change<br />Coma<br />
  15. 15. Physical Findings<br />Poor skin turgor<br />Kussmaul respirations<br />Tachycardia<br />Hypotension<br />Alteration in mental status<br />Shock<br />Coma<br />
  16. 16. Laboratory Exams<br />Plasma glucose<br />Blood Urea Nitrogen<br />Creatinine<br />Serum ketones<br />Electrolytes (with calculated anion gap) <br />Urinalysis, urine ketones<br />Arterial blood gases<br />Complete blood count<br />
  17. 17. Laboratory Exams – if indicated<br />12-L ECG<br />Chest xray<br />Urine, blood, or sputum cultures<br />HBA1c<br />
  18. 18. Laboratory Findings<br />Hyperglycemia, ketonemia, metabolic acidosis<br />Leukocytosis proportional to blood ketones<br />Low serum sodium<br />Elevated serum potassium<br />Elevated amylase<br />
  19. 19. Treatment<br />
  20. 20. Treatment<br />Correction of dehydration<br />Correction of hyperglycemia<br />Correction of electrolyte imbalances<br />Identification of precipitating events<br />Frequent patient monitoring<br />
  21. 21. Fluid Therapy<br />
  22. 22.
  23. 23. Fluid Therapy<br />0.9 % NaCl at 15-20 ml/kg/hr (1L) (1st hour)<br />Evaluate corrected Na⁺<br /><ul><li>If corrected serum Na⁺ is normal or elevated, then start 0.45% NaCl at 4-14 ml/kg/hr
  24. 24. If corrected serum Na⁺ is low, then start 0.9% NaCl at similar rate</li></ul>When serum glucose reaches 200 mg/dl, then change to 5% dextrose with 0.45% NaCl at 150-250 ml/hr<br />
  25. 25. Serum Na in Hyperglycemia<br />Translational hyponatremia in Hyperglycemia <br />Corrected Sodium <br /> = Sodium + {[(glucose - 100)/100] x 1.6}<br /> = Sodium + 0.016 x (glucose - 100)<br />*for every 100 mg/dl glucose > 100 mg/dl, add 1.6 mEq to Sodium value<br />
  26. 26. Fluid Therapy - Monitoring<br />Blood pressure monitoring<br />Fluid input/output monitoring<br />Laboratory values<br />Clinical examination<br /><ul><li>Fluid replacement should correct estimated deficits within the first 24 hours.</li></li></ul><li>
  27. 27. Insulin Therapy<br />IV regular insulin is the treatment of choice<br />May give SC rapid-acting insulin if uncomplicated or mild/moderate DKA<br />Check potassium first before starting insulin therapy<br /><ul><li>If serum potassium is < 3.3 mEq/L, hold insulin and give 20-30 mEq K⁺ until potassium > 3.3 mEq/L</li></li></ul><li>Insulin Therapy (IV)<br />Give Regular Insulin 0.1 u/kg BW as IV bolus<br />Continuous insulin infusion at 0.1 u/kg BW/hr<br />If plasma glucose does not decrease by 50-75 mg/dl after 1 hour, insulin infusion may be doubled every hour until a steady glucose decline is achieved.<br />
  28. 28. Insulin Therapy (IV)<br />When plasma glucose reaches 200 mg/dl in DKA or 300 mg/dl in HHS, decrease infusion to 0.05-0.1 u/kg/hr.<br />Keep glucose level between 150-200 mg/dl (DKA) until resolution of DKA. <br />In HHS, keep glucose level between 250-300 mg/dl until plasma osmolality is ≤ 315 mOsm/kg and patient is mentally alert.<br />
  29. 29. Insulin Therapy (SC)<br />Give rapid acting insulin 0.2 u/kg followed by 0.1 u/kg every hour <br /> OR<br /> 0.3 u /kg followed by 0.2 u/kg every 2 hours<br /> until glucose reaches < 250 mg/dl<br />If serum glucose does not fall by 50-70 mg/dl in the first hour, then double SC bolus<br />Decrease insulin to 0.05 or 0.1 u/kg given every 1-2 hours until resolution of DKA.<br />
  30. 30. Fluid Therapy<br />
  31. 31. Potassium<br />Establish adequate renal function<br />If K⁺ < 3.3 mEq/L,<br />Hold insulin<br />Give 20-30 mEq K⁺/hr until K⁺ > 3.3 mEq/L<br />If K⁺ > 5.3 mEq/L,<br />Do not give K⁺, check serum K⁺ every 2 hours<br />If K⁺ is between 3.3 and 5.3 mEq/L, give 20-30 mEq per liter of IV fluid to keep K⁺ between 4-5 meq/L.<br />
  32. 32. Fluid Therapy<br />
  33. 33. Bicarbonate<br />At pH > 7.0, insulin administration blocks lipolysis and resolves ketoacidosis.<br />If pH< 6.9,<br />Dilute NaHCO₃ (100 mmol/L) in 400 ml H2O with 20 mEqKCl and infuse for 2 hours<br />Repeat NaHCO₃ administration every 2 hours until pH > 7.0<br />Monitor serum potassium<br />
  34. 34. Bicarbonate<br />If pH = 6.9 to 7.0,<br />Dilute NaHCO₃ (50 mmol/L) in 200 ml H2O with 10 mEqKCl and infuse over 1 hour<br />Repeat NaHCO₃ administration every 2 hours until pH > 7.0<br />Monitor serum potassium<br />If pH > 7.0 = no NaHCO₃ <br />
  35. 35. Fluid Therapy<br />
  36. 36. Phosphate<br />Phosphate decreases with insulin therapy<br />No beneficial effect in routine phosphate replacement<br />Indicated in patients with cardiac dysfunction, anemia and respiratory depression or if serum PO₄ < 1.0 mg/dl,<br />Add 20 – 30 mEq/L potassium phosphate<br />
  37. 37. Monitoring<br />Check electrolytes, BUN, creatinine, glucose, and venous pH (for DKA) every 2-4 hours until stable.<br />After resolution of DKA/HHS and patient is able to eat, initiate SC multidose insulin regimen<br />Continue IV insulin infusion for 1-2 hours after SC insulin to ensure adequate plasma levels<br />Insulin-naïve patients, start at 0.5-0.8 u/kg/day<br />Resume previous dose in patients already on insulin<br />
  38. 38. Criteria for Resolution of DKA<br />Glucose < 200 mg/dl<br />Serum Bicarbonate ≥ 18 mEq/l<br />Venous pH > 7.3 <br />
  39. 39. Complications<br />Iatrogenic Hypoglycemia<br />Iatrogenic Hypokalemia<br />Hyperglycemia<br />Hypochloremic Acidosis<br />Cerebral edema (rare)<br />
  40. 40. Prevention<br />Proper patient education<br />Blood glucose goals<br />Use of short or rapid acting insulin during illness<br />Importance of managing infections<br />Initiation of easily digestable liquid diet containing carbohydrates and salt<br />Importance of continuous insulin therapy <br />

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