You are on page 1of 20

Canadian Diabetes Association Clinical Practice Guidelines Hyperglycemic Emergencies in Adults

Chapter 15 Jeannette Goguen, Jeremy Gilbert

Key Points

2013

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

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

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)

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Suspect DKA or HHS in an ILL Patient with Hyperglycemia (usually)


DKA

HHS

Ketoacidosis ECFV contraction Milder hyperosmolarity Normal to high glucose May haveLOC Beware hypokalemia Must use insulin Absolute insulin deficiency + glucagon

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


guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Suspect DKA if

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

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

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 -hydroxybutarate
AG + negative serum ketones = order serum -hydroxybutarate Always order both urine and serum ketones

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Management of DKA in Adults

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Fluids, Potassium, Acidosis are the Pillars of Treatment

IV fluids

Serum Potassium

Acidosis

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Replace Fluids with IV 0.9% NaCl until Euvolemic

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Once euvolemic, consider plasma Na+ and glucose to determine IV fluid type

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Replace Potassium: Hypokalemia is an avoidable cause of death in DKA

Correct K+ first THEN start insulin


guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Management of Acidosis with Insulin

Insulin should be maintained until the anion gap normalizes Insulin used to treat the acidosis, not the glucose!
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

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

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

PREVENTION of DKA / HHS

Type 1 diabetes

Education around sick day management Continuation of insulin even when not eating Frequent monitoring when ill Education around sick day management Frequent monitoring when ill

Type 2 diabetes

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Recommendation 1
1. In adult patients with DKA, a protocol should be followed that incorporates the following principles of treatment
[Grade D, Consensus]

a) b) c) d) e)

Fluid resuscitation Avoidance of hypokalemia Insulin administration Avoidance of rapidly falling serum osmolality

Search for precipitating cause (See figure 1)

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Recommendation 2
2. In adult patients with HHS, a protocol should be followed that incorporates the following principles of treatment [Grade D, Consensus]:
a) b) c) d) e)

Fluid resuscitation Avoidance of hypokalemia Avoidance of rapidly falling serum osmolality Search for precipitating cause

Possibly insulin to further reduce hyperglycemia (See figure 1)

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Recommendation 3

2013

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 betahydroybutyrate >1.5 mmol/L warrants further testing for DKA [Grade C, level 2]

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Recommendation 4
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 (12 L/hour) in the presence of shock [Grade D, Consensus] For persons with HHS, IV fluid administration should be individualized based on the patients needs [Grade D, Consensus]

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Recommendation 5
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]
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

CDA Clinical Practice Guidelines


http://guidelines.diabetes.ca for professionals 1-800-BANTING (226-8464) http://diabetes.ca for patients

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

You might also like