1. Diabetic Emergencies
Andjela Drincic M.D.

2. Diabetic Emergencies Case Presentation
Pt is a 32yo female with a hx of type 1 DM who presents with a cc of N/V, and diffuse abdominal pain for 24 hours
What other questions would you like to ask

3. Diabetic Emergencies Case Presentation
Pt denies F/C, URI symptoms, urinary symptoms except for frequency
Pt also states that she has been using her insulin correctly, but she had not taken any insulin for the last 24 hours because she wasn’t able to eat anything

4. Diabetic Emergencies Case Presentation
PMHx: Diagnosed with DM after episode of DKA approx 7 years ago.
Meds: Insulin 70/30 28UqAM, 16UqPM
NKMA
SHx: Single, no children, (+) Tob 1ppd for 12 years, occ EtOH use, no recreational drugs
FHx: (+) HTN
What are pertinent findings on physical exam?

5. Diabetic Emergencies Physical Exam Gen: Mild distress but A&O x 3
97.4, 120, 34, 132/88
HEENT: WNL
Heart: RR Lungs: CTA-B
Abd: (+) BS, diffuse tenderness, no rebound
Ext: WNL Neuro: WNL
What Lab Data would you like to obtain?

6. Diabetic Emergencies Case Presentation Lab Data
WBC 15.7, H/H 15/45 Plt 229
NA 132, K 5.2, CL 96, HCO 11, BUN 10, Cr 1.0 Glucose 612, Ca 12.1, Phos 6.6, Mg 2.1

7. Diabetic Emergencies Case Presentation Lab Data Analysis
NA 132, K 5.2, CL 96, HCO 11, BUN 10, Cr 1.0 Glucose 612, Ca 12.1, Phos 6.6, Mg 2.1
What is the anion gap?
What is the actual serum sodium?
What is the differential diagnosis for wide anion gap metabolic acidosis?

8. Formulas you may need sOsm = 2 (Na + K ) + Glu/18 + BUN/2.8 + ETOH/4.6
AG = Na - ( Cl + HCO3)
Na = Na x (Glu - 100)/100

9. Diabetic Emergencies Case Presentation Lab Data (Continued)
UA: Protein 3+, Large ketones
Serum ketones were 1:16
Serum osmolarity was 323mOsm/kg

10. Diabetic Ketoacidosis (DKA)
Life-threatening emergency
Gross insulin deficiency is the predominant problem of DKA
Most common in patients with type 1 diabetes
Can occur in patients with type 2 diabetes due to progressive loss of β-cell reserve
Mortality is ~5%–10%
In the absence of insulin to facilitate glucose entry into cells, the body metabolizes fat instead of glucose for energy, which results in an abnormally elevated concentration of ketones in the blood and urine. The accumulation of ketones leads to acidity, which can result in diabetic ketoacidosis (DKA), a life-threatening emergency. Although DKA is characteristic of type 1 diabetes, it can occur in type 2 diabetes under stress conditions or with progression to insulinopenia.
Fishsbein H, Palumbo PJ. Acute metabolic complications in diabetes. In: National Diabetes Data Group. Diabetes in America. Bethesda (MD): National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases: 1995:

11. Signs, Symptoms, and Treatment of Diabetic Ketoacidosis
Blurred vision
Increased thirst
Increased urination
Nausea/vomiting
Confusion
Loss of consciousness
Signs
Deep respirations
Fruity breath
Dehydration
Hyperglycemia
Ketosis
Acidosis
Treatment
Give insulin in a sufficient amount
Attention to the potassium level is also important
Hydration

12. Type 1 DM hormonal pathophysiology
- Insuln deficiency:
decreased glucose utilization
- Elevations in counterregulatory hormones:
increased lipolysis in adipose tissue
increased proteolysis in muscle
increased glycogenolysis
increased gluconeogenesis
hepatic ketogenesis
Leading to DKA

13. Hyperosmolar Hyperglycemic State (HHS)
Life-threatening emergency
Occurs in patients with type 2 diabetes
Characterized by very high blood glucose levels without ketones
insulin secretion is maintained to prevent peripheral lipolysis , liver able to metabolize FFA in a nonketogenic manner
relative insulin deficiency : decreased peripheral uptake and increased hepatic gluconeogenesis
hyperglycemia, hyperosmolality
osmotic diuresis and volume and electrolyte depletion

14. DKA/HHS not mutually exclusive ! Criteria for DKA
hyperglycemia ( glu>250 mg/dl)
ketosis
acidemia ( pH <7.3)

15. Pathophysiology of DKA/HHS
Insulin Deficiency
Increased Lipolysis
Hyperglycemia
Increased ketogenesis
Osmotic Diuresis
Ketoacidosis
Hyperosmolality
Pure Diabetic Ketoacidosis
Pure Hyperosmolar State

16. DKA
Absolute insulin deficiency and counter-regulatory hormones promote lipolysis
shift in hepatic lipid metabolism of incoming fatty acids due to high ratio of glucagon to insulin in portal flow - fall in malonyl co A levels and disinhibition of CPT
CPT catalizes beta oxidative pathway- fatty acids are oxidized to form ketone bodies rather than re-esterified into TG

17. Physiology of DKA 3 hydroxybutyrate Acetone Triglyceride
Insulin glucagon
Triglyceride
Free Fatty Acids
Fatty Acyl Co A
Acetyl Co A
HMA Co A
Acetoaceteate
Hormone Sensitive Lipase
Adipocyte
Serum
Glucagon
Malonyl Co A
Hepatocyte
Carnitine palmitoyl transferase 1
Mitochondria
3 hydroxybutyrate
Acetone

18. Evaluation of patient history of DM , medications and symptoms
history of complications
utilization of medications
social history ( including alcohol)
vomiting
precipitating factor - pregnancy, infection, omission of insulin, MI, CVA
asses hemodynamic status
examine for infection

19. Laboratory Evaluation
BMP
CBC
serum ketones
calculate serum osmolality and AG
measure serum osmolality if ingestion of osmotically active substance other than glucose suspected
UA and culture
consider blood culture
CXR
consider HCG
ABG if indicated clinically
HbA1c

20. “Euglycemic ketoacidosis “
Glu < 300 mg/dl
HCO3 < 10 mEq/l
Usually in pump pts ( no “back-up insulin)

21. Other expected labs in DKA
Hyponatermia unless pt is dehydrated
Hyperkalemia due to cellular shift
Leukocytosis in the absonce of infection
Elevation of amylase and lipase in the absence of pancreatitis

22. “Serum Ketone Negative DKA”
Alcoholic ketoacidosis
Hypoxia
Beta hydroxybutirate is the dominant ketone
Not detected by nitroprusside reaction

23. Gudelines ofr therpay of DKA/HHS
addapted from Joslin’s Diabetes Mellitus 14th edtion , 2005

24. Suggested Fluid Replacement in DKA/HHS
Administer NS as indicated to maintain hemodynamic status than follow general guidelines:
NS for first 4 hours
consider 1/2 NS thereafter
Change to D5 1/2 NS when BG < 259 mg/dl
may need to adjust type and rate of fluid administration in the elderly and in patients with CHF and CRF

25. Suggested fluid replacement in DKA /HHS
1st hour : 1 l
2nd hour : 1 l
3rd hour : ml - 1 l
4th hour: ml - 1 l
5th hour : ml - 1 l
Total 1st - 5th hour l
6th - 12th hour : ml/hr

26. Guidelines for Insulin Management in DKA/ HHS
regular insulin 10U I.v. stat ( for adults) or U/kg I.v. stat
start regular insulin infusion 0.1 u /kg per hour or 5 U per hour
Increase insulin by 1 U per hour every 1-2 hours if less than 10 % decrease in glucose or no improvement in acid - base status
decrease insulin by 1-2 U/hr when BG < 250 mg/dl and/or progressive improvement in clinical status with decrease in glucose >75 mg/dl /hr
do not decrease insulin infusion to < 1 u /hr
maintain BG mg/dl
if BG < 80 mg/dl , stop insulin infusion for no more than 1 hour and restart the infusion
if BG drops consistently to <100 mg/dl , change I.V. fluids to D 10 to maintain BG mg/dl

27. Insulin Infusion Algorithm
1. Discontinue all subcutaneous insulin use
2. Measure blood glucose every hour
measure urine ketones after each void every 4 hours
3. Give D5%W iv via insulin infusion pump
4. Make insulin solution using regular insulin to a concentration of 0.5 U/ml

28. Insulin Infusion Algorithm Newton et al:Arch Intern Med 164,sept 27, 2004

29. Guidelines for K replacement in DKA/HHS
Do not administer K if serum K > 5.5 mEq/l or if patient is anuric
Use KCl but alternate with KPO4 if there is severe phosphorus depletion and patient is unable to take phosphorus by mouth
Add I.V. KCl to each liter of fluid administered unless contraindicated

30. Guidelines for K replacement in DKA/HHS
serum K ( mEq/L) Additional K required
< mEq/L
mEq/L
mEq/L
> Stop K infusion

31. Guidelines for Bicarbonate Therapy in DKA
PRO: severe acidosis is associated with adverese effects:hypotension, decreased cardiac output decreased peripheral vascular resistance, increased pulmonary arterterial resistance , bardycardia, arrhytimas , renal and mesenteric ischemia, cerebral vasodilatation
CONS: no studies have shown any benefit of bicarbonate if pH is
SIDE EFF : overshoot alkalosis, paradoxical CSF acidosis , hypokalemia, volume overload, overproduction of ketoacids

32. Guidelines for Bicarbonate Therapy in DKA
Use clinical judgement in deciding if bicarbonate therapy is indicated
if pH is < 7.0 consider 100 ml HCO3 over 45 min
( mix 100 ml NaHCO3 with 400 ml sterile water and administer at rate of 200 ml/hr)
check ABG 30 min later

33. Phosphate replacement
Phos depletion is common: renal loss, intracellular uptake during insulin Rx
problem: low cardiac output, respiratory muscle weakness, rhabdomyolisis , CNS deppression , seizures , coma, renal failure
CAVE : iv Phos leads to hypocalcemia
no benefit in routine replacement
reserve replacement Rx if phos < 1.5 mg/dl AND in whom Ca is normal
use of small amount of Kphos and KCL iv is safe and effective
but oral replacement preferred to I.V.

34. Monitoring of RX BG hourly
electrolytes and acid base status every 2-4 hours
ok to check venous pH if you can’t get art line ( 0.03 unit less than arterial )
frequent measurement of ketones may be misleading (  hydroxybutirate is converted to acetoacetate)
consider using bedside measurement of ß hydroxybutirate
repeat CXR after 4 l fluids administered

35. Complications of RX hypoglycemia hypokalemia hypophosphatemia
hyperchloremia and hyperchloremic acidosis - chloride losses are less severe than sodium losses but replacement solutions have equal par tof Na and Cl
hypoalcemia
cerebral edema - children
DVT/PE ( dehydration as a risk factor)

36. DKA - is it always type 1 DM?
Arch Int Med :2317 -
epidemiology of pts admitted for DKA : type 1 DM in
80 % of whites
53% of African Americans
34 % of Hispanics
no difference in electrolytes,glu, pH, AG, pOsm or level of ketosis
majority of pts with type 2 , no preciptating event !

37. A” Real Life “ case 55 y/o AAF no previous h/o DM
comes with polyuria,, polydipsia, fatigue
Vitals: 96.9, 130, 24, 122/63
Labs: WBC 19, BS 502, K 6.0, Na 128, CO2 5

38. Orders Dx DKA IVF NS 3l bolus than 200 cc/hour 2 amps HCO3
blood cultures, sputum cultures,accucheck q 1hour
diabetic education in am
cbc , bmp in am
bmp q 2hours x 4, UA
Mg, PO4 levels

39. Insulin gtt: U/hour 0-50 off 70 - 100 0.3 101- 129 0.4 130 - 170 0.5
>

40. Orders - cont 4 hours later - K 3.0 , BS 347 order : 40 mEq KCl now
change IVF to D5 NS with 40 KCl at 200 cc/hour
6 hours later: phos 1.2
order : 40 mEq K phos IV
soft diet for pt
24 hours later , BS 350

41. Diabetic Emergencies Hypoglycemia Whipple Triad
Consistent signs and symptoms
Low blood glucose
Relief with supplemental glucose
Two categories of hypoglycemia
Reactive
Nonreactive

42. Diabetic Emergencies Hypoglycemia Reactive Hypoglycemia
Develops in response to a nutrient challenge
Seen in pts with type 2 DM (???) and post GI surgery pts
Idiopathic form
Nonreactive Hypoglycemia
Iatrogenic
Fasting/Factious

43. Diabetic Emergencies Hypoglycemia Fasting/Factious Hypoglycemia
3 main causes
Factitious taking of oral hypoglycemics/insulin
Autoimmune etiology
Insulinoma from an islet cell tumor
Heavy EtOH can also cause hypoglycemia
Three tests for workup of nonreactive hypoglycemia
Serum insulin
C-peptide
Urinary sulfonylurea test

44. Diabetic Emergencies Hypoglycemia C-peptide Insulin levels
Elevated indicates endogenous insulin secretion and is low if there is factitious insulin injection
High levels seen in autoimmune hypoglycemia, insulinoma, and sulfonylurea ingestion
Urinary sulfonylurea test will rule in or out oral hypoglycemic use
Insulin levels
< 100 suggest insulinoma
> 100 suggest autoimmune