ca hyper glycemic emergencies

7/28/2019 CA Hyper Glycemic Emergencies

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Canadian Diabetes Association

Clinical Practice Guidelines

Hyperglycemic Emergencies in

Adults

Chapter 15

Jeannette Goguen, Jeremy Gilbert


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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Copyright 2013 Canadian Diabetes Association

Key Points

1. Suspect DKA or HHS in an ill patient with

hyperglycemia (usually) medical emergency

2. DKA = ketoacidosis is prominent3. HHS = ECFV contraction + hyperosmolarity

4. Rx = FLUIDS, POTASSIUM, INSULIN (DKA)

5. Treat precipitating cause6. 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

MarkedLOC

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 -hydroxybutarate

AG + negative serum ketones = order serum

-hydroxybutarate

Always order both urine and serum ketones


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Management of DKA in Adults


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Fluids, Potassium, Acidosis are the Pillars of

Treatment

IV fluids AcidosisSerumPotassium


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Once euvolemic, consider plasma Na+ and

glucose to determine IV fluid type


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Replace Potassium: Hypokalemia is an

avoidable cause of death in DKA

Correct K+ firstTHEN

start insulin


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Management of Acidosis with Insulin

Insulin should

be maintained

until the aniongap normalizes

Insulin used to

treat theacidosis, 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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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 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 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 resuscitationb) 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 (12 L/hour)

in the presence of shock [Grade D, Consensus]

For persons with HHS, IV fluid administration

should be individualized based on the patientsneeds [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/hourshould be used [Grade B,Level 2]

The insulin infusion rate should be maintained untilthe 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
http://guidelines.diabetes.ca/http://diabetes.ca/http://diabetes.ca/http://guidelines.diabetes.ca/

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