This document discusses the challenges of managing diabetic emergencies like diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) in patients with heart failure. Aggressive fluid resuscitation is typically needed for DKA/HHS but can worsen heart failure, requiring cautious fluid administration and monitoring. Goals of treatment include managing hemodynamics, fluid balance, metabolic derangements like acidosis/electrolyte imbalances, and preventing complications like acute kidney injury or thromboembolism. Careful attention to fluid intake and output as well as electrolyte and acid-base status is important when treating hyperglycemic crises in patients with heart failure.

1. Double trouble: managing diabetic
emergencies in patients with heart
failure
Dr.Rahatul Quadir
MD Thesis student
NHFRI
rahatul.quadir@gmail.com

2. Introduction
• Heart failure and diabetes frequently coexist
• Although the management of heart failure in patients with stable
glycaemia is relatively straightforward, the management of the two
conditions becomes difficult during diabetic ketoacidosis (DKA) or
hyperosmolar hyperglycaemic state (HHS).
• Recently, it has become apparent that the relationship between
heart failure and diabetes is more bidirectional in nature rather
than just diabetes leading to heart failure

3. Introduction
• One postulated theory is that the decreased physical activity in
heart failure patients may lead to decreased insulin sensitivity.
• Furthermore, neuro-humoral activation, including increased
catecholamine levels and sympathetic activity stimulate
gluconeogenesis and glycogenolysis leading to hyperglycaemia.
• Poor cardiac output and increased venous congestion can cause
hypoperfusion of the pancreas and the liver thereby weakening
their potential to regulate metabolic homeostasis

4. Management of hyperglycaemic
emergencies in patients with heart failure
• Diuretics and fluid restriction are essential components of heart failure
management while aggressive intravenous fluid replacement is indicated
in DKA and HHS
• If they have concomitant heart failure, managing these patients may well
pose many challenges:
1. managing haemodynamic compromise
2. fluid management
3. managing associated metabolic derangement such as kidney function,
associated acidaemia and base excess.

5. Management
• The mainstay of treatment of these diabetic emergencies is insulin,
fluids and electrolyte correction
• ideally, these patients should also be managed in a high-care setting
• There are no specific guidelines to date on specific management of
hyperglycaemic emergencies in heart failure although UK guidelines
suggest that ‘fluid replacement may need to be modified’.

6. History
• It is important to take a focused history from the patient or
their family
• Last HbA1c
• Latest Echo
• Previous admission history
• Last weight
• Current cardiac medication
• Fluid status

7. Examination
• Assessing volume status in these patients can be difficult.
• Heart failure patients can have peripheral oedema
• Patients are often intravascularly depleted during the
hyperglycaemic state while appearing peripherally
overloaded.
• Therefore care should be taken while examining and
interpreting volume status.

8. Look for
• JVP
• Extent of edema
• Lung congestion
• IVC size & collapsibility
• CVP
• Thirst & mucous membrane
• Mean arterial pressure
• Urine output
• Conscious level
• Capillary refill time

9. Investigation
• Blood glucose
• Troponin
• Seum osmolarity
• Blood ketone
• ECG
• ABG
• Previous RFT

10. Specefic Mx:Fluid balance
• The average fluid deficit is approximately 5–7 litres in DKA but may be as
much as 22 litres in HHS
• Normal saline with potassium is the fluid of choice
• A more cautious approach of giving 1–1.5 litres of normal saline over 1–2
hours with frequent haemodynamic and clinical monitoring could be
attempted as initial resuscitation in patients with heart failure
• Fluid resuscitation should be tailored to patients’ clinical status and
response. If there are signs of worsening haemodynamics, then this might
warrant use of vasoactive drugs and escalation of treatment to a critical
care setting

11. Fluid balance
• In DKA, once glucose has fallen to target levels but where
ketones/ acidosis have not yet resolved, a 10% dextrose
infusion is usually commenced to prevent hypoglycaemia.
• In patients with heart failure where fluid overload is
becoming a worry, this can be substituted with 20% dextrose
to maintain glycaemic targets with only half of the volume
infused

12. Renal impairment
• It may be necessary to withhold some of the prognostic heart
failure medications such as ACE-i ,ARNI and MRAs and adjust
diuretics to aid patients’ recovery from the acute phase.
• Measuring urine output and recording daily weights.

13. Metabolic derangement
• Acidosis can be seen in HHS and DKA patients
• Withhold metformin
• Care be taken in correcting acidosis gently, if
hyperglycaemia is the primary cause of the acidosis
• Bicarbonate should not be given to correct the metabolic
derangement as it can worsen central nervous system
acidosis and precipitate cerebral oedema

14. Electrolyte imbalance
• Abnormalities in sodium and potassium are common
• low sodium with hyperglycaemia is real in order to preserve osmolality
• normal or high measured serum sodium in this setting indicates a severe
state of dehydration
• Renal impairment and heart failure medications such ACE-i, ARBs and
MRAs can cause hyperkalaemia.
• A low potassium level therefore suggests severe total body potassium
depletion

15. Thromboembolic state
• During the acute phase of a hyperglycaemic emergency, patients
are at risk of clot formation due to the associated hyper-viscosity of
blood.
• Therefore thromboembolism prophylaxis should be administered in
all patients unless there is a significant contraindication

16. THANK YOU
ALL