1. Canadian Diabetes Association Clinical Practice Guidelines Hyperglycemic Emergencies in Adults Chapter 15 Jeannette Goguen, Jeremy Gilbert

2. 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 prominent 3.HHS = ECFV contraction + hyperosmolarity 4.Rx = FLUIDS, POTASSIUM, INSULIN (DKA) 5.Treat precipitating cause 6.Prevention is critical 2013

3. 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)

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association DKA Ketoacidosis ECFV contraction Milder hyperosmolarity Normal to high glucose May have  LOC Beware hypokalemia Must use insulin Absolute insulin deficiency + glucagon HHS 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 Suspect DKA or HHS in an ILL Patient with Hyperglycemia (usually)

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

6. 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 β-hydroxybutarate   AG + negative serum ketones = order serum β-hydroxybutarate  Always order both urine and serum ketones

7. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Management of DKA in Adults

8. 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 Acidosis Serum Potassium

9. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Replace Fluids with IV 0.9% NaCl until Euvolemic

10. 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

11. 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

12. 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!

13. 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

14. 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 Type 2 diabetes – Education around sick day management – Frequent monitoring when ill

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

16. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2.In adult patients with HHS, a protocol should be followed that incorporates the following principles of treatment [Grade D, Consensus]: a) Fluid resuscitation b) 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

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

18. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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 (1–2 L/hour) in the presence of shock [Grade D, Consensus] For persons with HHS, IV fluid administration should be individualized based on the patient’s needs [Grade D, Consensus] Recommendation 4

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

20. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CDA Clinical Practice Guidelines http://guidelines.diabetes.cahttp://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca http://diabetes.ca – for patients