Diabetic emergency management

1. Diabetic Emergency Management
RYAN CHENG

2. 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

3. Overview
DKA HHS
Mild Moderate Severe
Plasma glucose >13.9 >13.9 >13.9 >33.3
Arterial pH 7.25 to 7.30 7.00 to 7.24 <7.00 >7.30
Serum bicarbonate
(mEq/L)
15 to 18 10 to <15 <10 >18
Urine ketones Positive Positive Positive Small
Serum ketones -
Nitroprusside reaction
Positive Positive Positive ≤ Small
Effective serum
(mOsm/kg)
Variable Variable Variable >320
Anion gap >10 >12 >12 Variable
Alteration in sensoria or
mental obtundation
Alert Alert/drowsy Stupor/coma Stupor/coma

4. DKA - Assessment
 Dx: ketones, BSL, U+E, V/ABG
 Root cause?
 Bloods, CXR, UA, cultures, bHCG, ECG
 Endocrinology disposition: ward vs HDU vs ICU

5. 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+

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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)

13. 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

14. 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

15. 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

16. HDU/ICU
Consider if:
1. Osmolality >350 mosmol/kg
2. BP < 90mmHg
3. Na > 160mmol/l
4. HR <60 or >100
5. pH <7.1
6. Hypo/hyperkalemia
7. Urine output <0.5 ml/kg/hr
8. GCS <12
9. O2 < 92% RA
10. Other serious co-morbidities

17. 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.