lions and tigers and bears: diabetic ketoacidosis, pump ...€¦ · lions and tigers and bears:...

Lions and Tigers and Bears:

Diabetic Ketoacidosis, Pump

Mangement and Other

Challenges in Pregnancy

Karin A. Fox, M.D., M.Ed.

Division of Maternal-Fetal Medicine,

Department of Obstetrics and Gynecology

Critical Care Conference

Feb 27, 2017

OBJECTIVES

Describe etiologies of and differences among the 3 major

diabetic emergencies: Diabetic Ketoacidosis (DKA),

Hyperosmolar Hyperglycemic State (HHS) and

Hypoglycemia

Formulate a basic treatment plan for each of the above

Understand the basics of pump management

Counsel patients and healthcare trainees about diagnosis

and management of the above metabolic emergencies.

I have no conflicts of interest to declare

We will discuss briefly insulin management, including

various forms of insulin

HOUSEKEEPING

SIZE AND SCOPE OF THE ISSUE

National Diabetes Statistics Report, National Center for Chronic Disease Prevention and Promotion, Division of Diabetes Translation, CDC, 2012

SIZE AND SCOPE OF THE ISSUE

Menke A,Casagrande S, Geiss L, Cowie C. Prevalence and Trends in Diabetes Among Adults in the United States 1988-201. JAMA. 2015;314(10):1021-1029.

~50% of adults in USA are diabetic or prediabetic Prevalence of diabetes: 12-14% Up to 25% of adults with diabetes are undiagnosed Prevalence increased among all ethnic groups

Center for Disease Control. Overweight and Obesity: Adult Obesity Facts. http://www.cdc.gov/obesity/data/adult.html

SIZE AND SCOPE OF THE ISSUE

NORMAL PHYSIOLOGIC STATE

TYPE 1 DIABETES (T1DM)

Elevated blood glucose

TYPE 2 DIABETES (T2DM)

Elevated blood glucose

Insulin receptor

DIABETIC KETOACIDOSIS (DKA)

A state of absolute or relative insulin deficiency

aggravated by hyperglycemia, dehydration, and

acidosis-producing derangements in intermediary

metabolism (intracellular starvation)

Ketone body formation

Can occur in both Type I Diabetes and Type II

Diabetes

In type II diabetics with insulin

deficiency/dependence

The presenting symptom for ~ 25% of Type I

Diabetics.

KETONES

Prolonged starvation:

Ketone bodies = 70% energy requirements of the

brain.

Normal conditions:

Kidneys excrete about 20 mg of ketone bodies/day.

Blood levels ~1 mg ketone bodies/100 mL of blood.

O O

OH

Acetoacetic acid

OH

OH O

3-b-Hydroxybutyrate

CH3

O

CH3

Acetone

1:10 in

DKA

H+ K+

HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS)

An acute metabolic complication of diabetes

mellitus characterized by impaired mental

status and elevated plasma osmolality in a

patient with hyperglycemia.

Occurs predominately in Type II Diabetics

A few reports of cases in type I diabetics.

The presenting symptom for 30-40% of Type II

diabetics.

Mild DKA Moderate DKA Severe DKA HHS

Plasma glucose (mg/dL) > 250 > 250 > 250 > 600

Arterial pH 7.25-7.30 7.00-7.24 < 7.00 > 7.30

Sodium Bicarbonate

(mEq/L)

15 – 18 10 - <15 < 10 > 15

Urine Ketones Positive Positive Positive Small

Serum Ketones Positive Positive Positive Small

Serum Osmolality

(mOsm/kg)

Variable Variable Variable > 320

Anion Gap > 10 > 12 > 12 variable

Mental Status Alert Alert/Drowsy Stupor/Coma Stupor/Coma

METABOLIC FINDINGS IN DKA/HHS

CAUSES OF DKA

Stressful precipitating event that results in increased catecholamines, cortisol, glucagon.

Infection (pneumonia, UTI)

Alcohol, drugs

Stroke

Myocardial Infarction

Pancreatitis

Trauma

Medications (steroids, thiazide diuretics)

Non-compliance with insulin

New Diagnosis of Diabetes

Pregnancy

PHYSIOLOGIC CHANGES IN PREGNANCY

Increased catecholamines, cortisol, glucagon, Human Placental Lactogen, growth hormone Hyperglycemia

Nausea and Vomiting of Pregnancy

Physiologic Alkalosis of Pregnancy (decreased buffering capacity)

PHYSIOLOGIC CHANGES IN PREGNANCY

SYMPTOMS OF DKA/HHS

Polyuria

Polydypsia

Blurry vision

Nausea/Vomiting

Abdominal Pain

Fatigue

Confusion

Obtundation/Coma

PHYSICAL EXAM FINDINGS

Hypotension

Tachycardia

Kussmaul breathing (deep, labored

breaths)

Fruity odor to breath (acetone)

Dry mucus membranes

Confusion

Abdominal tenderness

OUTCOMES - DKA

Fetal loss rates with single episode of

DKA approx 10-25%

Rare maternal mortality if recognized and

treated, actual incidence unknown

Prompt recognition and treatment key

TREATMENT

MATERNAL- Complete H&P

- Monitor VS and SaO2

- Seek source of infection/stressor

- Evaluate compliance

- Serum glucose, B-OH butyrate,

electrolytes

FETAL- Leftward tilt

- Confirm Viability

- Fetal Heart Monitor if > 24

weeks

FLUID STATUS- Start 0.9% NS 1,000ml/hr

x 2h

- After 2h, switch to 0.45%

NS at 250ml/hr

- When BG< 250mg/dL,

switch to D5/0.45%NS at

250ml/hr

- Total: 6-10 L/24h

- Foley catheter

- Maintain UOP > 50ml/hr

INSULIN- IV bolus 10-15 units

(REGULAR insulin)

- Start IV insulin infusion 0.1

unit/kg/hr

- Double rate if BG does not

decrease by 50mg/dL in 1st

hr

- Decrease to 0.05

units/kg/hr when BG <

200mg/dL

-Target: 100-150 mg/dL

POTASSIUM

- Serum K < 3.3,

hold insulin

infusion

- K >5.3, repeat

q1-2h until < 5.3

- If K 3.3-5.3, add

20-30 mEq K to

each L IVF

-Goal: 4-5 mEq/L

TREATMENT (Continued)

BICARBONATE- Avoid NaCHO3 if maternal pH >7.0

- If pH < 7.0, give 1 amp NaCHO3

- Repeat every 1-2h until pH >7.0

Once patient is stable and tolerating oral intake,

resume subcutaneously dosed insulin

Adapted from: de Veciana M. Diabetes ketoacidosis in pregnancy. Semin Perinatol. 2013Aug;37(4):267-73..

HYPOGLYCEMIA

Of patients with diabetes who die as a

direct result of diabetic complications,

what percentage die from hypoglycemia?

10%

HYPOGLYCEMIA- SYMPTOMS

Shakiness

Weakness

Sudor

Confusion/irritability

Obtundation/Coma

HYPOGLYCEMIA- TREATMENT

GLUCOSE

If able to eat/drinkgive 4 oz juice

(preferred) or soda, continue until BG > 70

If unable Glucagon 1mg IM OR D50 ½

to 1 amp IV

Recheck BG frequently (q15-30min)

Continue to monitor if active insulin on

board, at risk for further hypoglycemia

INSULIN

Basal: Long or intermediate acting(covers gluconeogenesis/periods of fasting)

Bolus: Short or Intermediate acting (covers mealtime glucose boluses from food)

40% TDD

60% TDD

Adjust by 10-20% up or down as needed, may adjust every 2-3 days

INSULIN

Example:Newly dx’d 60 kg patient at 12 weeks:

Same pt dx’d at 20 weeks:

At 32 weeks:

42 units

48 units

54 units

INSULIN DOSING

TDD: Total Daily Dose the total number of units used in 24h

Fixed Dose Regimen: Long acting dose (fixed)Fixed dose of rapid acting insulin with meals Consistent carbs, dose based on time

Carb-counting Regimen: Long acting dose (fixed)Flexible dose of rapid acting insulinFixed ratio of insulin to grams of carbs eatenICR (insulin-to-carb ratio)Correction factor (mg/dL drop with 1 unit)TargetMuch more flexible, but requires counting

Pump regimen: Similar concepts to carb-counting, but uses acontinuous infusion of rapid acting insulin

INSULIN DOSING – CARB COUNTING

Premeal Target BG: 90-110

Insulin to Carb Ratio: Estimated by the “Rule of 500”Divide 500 by TDD

Correction Factor: How much 1 unit will drop BG in mg/dLEstimated by “Rule of 1500”Divide 1500 by TDD

If the premeal BG is 172, and the patient plans to eat 60g carbs at her meal, how much insulin should she give herself?

500/42 = 11.9 1:12

1500/42 = 35.7 36

7 units

INSULIN DOSING – PUMP

Programmable: TargetBasal rate (may set multiple, based on time of day)Insulin-to-carb ratio (ICR) (may be different for each meal)Correction Factor

Patient then has to: Change insertion site q3d while pregnantTroubleshoot tubing/pump and refill reservoirType in premeal BG pump wizard calculates and doses!

*Check BG 8-10x daily (fasting, premeal, postmeal and prn)

Modern pumps communicate with continuous glucose monitors, can alarm when BG low/high, suspend

TAKE-HOME MESSAGES

- Not all diabetes is alike

- Every patient has a unique sensitivity to insulinMUST titrate

- In DKA Treat the underlying cause and mother to aid fetus

- Insulin helps glucose get into the cells, where it can be metabolized

- No matter what the insulin regimen, aim for ~50/50 or 40/60 split of long-acting (basal) to rapid-acting (bolus)

- Extremes of glucose levels are dangerous aim for steady state- watch for signs/symptoms and treat early!

QUESTIONS/COMMENTS