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Key Points
1. Suspect DKA or HHS in an ill patient with
hyperglycemia (usually) – medical emergency
2. DKA = ketoacidosis is prominent
3. HHS = ECFV contraction + hyperosmolarity
4. Rx = FLUIDS, POTASSIUM, INSULIN (DKA)
5. Treat precipitating cause
6. Prevention is critical
2013
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Hyperglycemic Emergencies
• DKA = Diabetic Ketoacidosis
• HHS = Hyperosmolar Hyperglycemic State
• Common features:
– Insulin deficiency hyperglycemia urinary loss of water
and electrolytes
Volume depletion + electrolyte deficiency +
hyperosmolarity
– Insulin deficiency (absolute) + glucagon
Ketoacidosis (in DKA)
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DKA
• Ketoacidosis
• ECFV contraction
• Milder hyperosmolarity
• Normal to high glucose
• May haveLOC
• Beware hypokalemia
• Must use insulin
• Absolute insulin deficiency +
glucagon
HHS
• Minimal acid-base problem
• ECFV contraction
• Hyperosmolarity
• Marked hyperglycemia
• Marked LOC
• Beware hypokalemia
• May need insulin
• Relative insulin deficiency
ECFV = extracellular fluid volume; LOC = level of consciousness
Suspect DKA or HHS in an ILL Patient with
Hyperglycemia (usually)
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• pH ≤7.3
• Bicarbonate ≤15 mmol/L
• Anion gap >12 mmol/L
= (sodium + potassium) – (chloride + bicarbonate)
• Positive serum or urine ketones
• Plasma glucose ≥14 mmol/L (but may be lower)
• Precipitating factor
Suspect DKA if……
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Be Aware of Conditions that may make DKA
Diagnosis Difficult
• Mixed acid base disorder (eg. vomiting may raise the
bicarbonate)
• Pregnancy normal to minimally elevated glucose
levels
• Normal AG due to loss of ketones from osmotic
diuresis
• Negative serum ketones due to β-hydroxybutarate
AG + negative serum ketones = order serum
β-hydroxybutarate
Always order both urine and serum ketones
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Fluids, Potassium, Acidosis are the Pillars of
Treatment
IV fluids AcidosisSerum
Potassium
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Replace Potassium: Hypokalemia is an
avoidable cause of death in DKA
Correct K+ first
THEN
start insulin
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Management of Acidosis with Insulin
Insulin should
be maintained
until the anion
gap normalizes
Insulin used to
treat the
acidosis, not
the glucose!
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Identify and Treat the Precipitating Factor
• Insulin omission – MOST COMMON CAUSE of DKA
• New diagnosis of diabetes
• Infection / Sepsis
• Myocardial infarction
– Small rise in troponin may occur without overt ischemia
– ECG changes may reflect hyperkalemia
• Thyrotoxicosis
• Drugs
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PREVENTION of DKA / HHS
• Type 1 diabetes
– Education around sick day management
– Continuation of insulin even when not eating
– Frequent monitoring when ill
• Type 2 diabetes
– Education around sick day management
– Frequent monitoring when ill
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1. In adult patients with DKA, a protocol should be
followed that incorporates the following principles of
treatment [Grade D, Consensus]
a) Fluid resuscitation
b) Avoidance of hypokalemia
c) Insulin administration
d) Avoidance of rapidly falling serum osmolality
e) Search for precipitating cause
(See figure 1)
Recommendation 1
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2. In adult patients with HHS, a protocol should be
followed that incorporates the following principles of
treatment [Grade D, Consensus]:
a) Fluid resuscitation
b) Avoidance of hypokalemia
c) Avoidance of rapidly falling serum osmolality
d) Search for precipitating cause
e) Possibly insulin to further reduce hyperglycemia
(See figure 1)
Recommendation 2
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3. Point-of-care capillary beta-hydroxybutyrate, if
available, may be measured in the hospital in
patients with T1DM with capillary glucose >14
mmol/L to screen for DKA and a beta-
hydroybutyrate >1.5 mmol/L warrants further
testing for DKA [Grade C, level 2]
Recommendation 3 2013
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4. In individuals with DKA, IV 0.9% sodium chloride
should be administered initially at 500 mL/hour for 4
hours, then 250 mL/hour for 4 hours [Grade B, Level 2]
with consideration of a higher initial rate (1–2 L/hour)
in the presence of shock [Grade D, Consensus]
For persons with HHS, IV fluid administration
should be individualized based on the patient’s
needs [Grade D, Consensus]
Recommendation 4
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5. In individuals with DKA, an infusion of short-acting
IV insulin of 0.10 U/kg/hour should be used [Grade B,
Level 2]
The insulin infusion rate should be maintained until
the resolution of ketosis [Grade B, Level 2] as measured
by the normalization of the plasma anion gap [Grade D,
Consensus]
Once the plasma glucose concentration reaches
14.0 mmol/L, IV dextrose should be started to avoid
hypoglycemia [Grade D, Consensus]
Recommendation 5
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CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
http://diabetes.ca – for patients
Editor's Notes DKA or HHS must be suspected in all patients with diabetes presenting with hyperglycemia. With insulin deficiency, hyperglycemia causes urinary losses of water and electrolytes (sodium, potassium, chloride) and the resultant extracellular fluid volume (ECFV)
depletion.
Potassium is shifted out of cells (looks high but in fact depletion)
Ketoacidosis occurs as a result of elevated glucagon levels and absolute insulin deficiency (in the case of type 1 diabetes) or high catecholamine levels suppressing insulin release (in the case of type 2 diabetes).
In DKA, ketoacidosis is prominent while, in HHS, the main features are ECFV depletion and hyperosmolarity.
3 urgent priorities: restoring ECF volume, resolution of acidosis, replacement of potassium and electrolyte balance
Monitoring of volume status (including fluid intake and output), vital signs, neurologic status, plasma concentrations of electrolytes, anion gap, osmolality, and glucose need to be monitored closely, initially as often as every 2 hours Phosphate repletion if severe hypophosphatemia
No insulin bolus ; some cases of HHS may respond to initial volume (no insulin needed)
Do not tailor insulin to glucose: once BG <14, add D5W to solution
Can use continuous IV insulin or q1-2 hourly SC insulin: no difference in resolution of ketoacidosis or hypoglycemia risk