1. H YPERGLYCEMIC E MERGENCIES IN A DULTS Rohit Gandhi PGY-2 Family Medicine September 2015

2. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association H YPERGLYCEMIC E MERGENCIES DKA = Diabetic Ketoacidosis Type 1 DM HHS = Hyperosmolar Hyperglycemic State Type 2 DM Relative Insulin Deficiency

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association DKA AND HSS Pathophysiology / Common Features: Insulin deficiency  hyperglycemia  urinary loss of water and electrolytes  Volume depletion + electrolyte deficiency + hyperosmolarity Insulin deficiency (absolute)  breakdown of FFA  Ketoacidosis (in DKA)  Common Symptoms: Abdominal Pain (unusual HSS), N/V Polyurea, Polydipsia, Polyphagia Signs of dehydration

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association o Medication (insulin) Non-Compliance o Infection (pneumonia and UTI) o New diagnosis of DM I o Drugs o Thyrotoxicosis o Stroke o MI DKA AND HSS: CAUSES

5. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Ketoacidosis ECFV contraction Milder hyperosmolarity Normal to high glucose May have  LOC Beware hypokalemia Must use insulin Absolute insulin deficiency + glucagon Rapid Evolution Minimal acid-base problem ECFV contraction Hyperosmolarity (more severe hyperglycemia) Marked hyperglycemia Marked  LOC Beware hypokalemia May need insulin Relative insulin deficiency Insidious onset DKA HHS DKA VS HHS

6. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association S USPECT DKA IF : pH ≤7.3 Bicarbonate ≤15 mmol/L Anion gap >12 mmol/L = (Na + K) – (Cl + HCO3) Positive serum or urine ketones Plasma glucose ≥14 mmol/L (but may be lower) Precipitating factor

7. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association B E A WARE OF C ONDITIONS THAT MAY MAKE DKA D IAGNOSIS D IFFICULT 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

8. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association I NITIAL E VALUATION Airway, breathing, and circulation (ABC) status Mental status Precipitating events (eg, source of infection, myocardial infarction) Volume status

9. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association W HAT TO O RDER Serum glucose Serum electrolytes (with calculation of the anion gap), blood urea nitrogen (BUN), and plasma creatinine Complete blood count (CBC) with differential Urinalysis and urine ketones by dipstick Plasma osmolality Serum ketones (if urine ketones are present) Arterial blood gas if the serum bicarbonate is substantially reduced or hypoxia is suspected Electrocardiogram

10. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association H YPONATREMIA AND H YPERKALEMIA Hyponatremia Due to osmotic diuresis induced by glycosuria Corrected plasma [ Na +] = Measured [ Na +] + [ 3 / 10 × ([ Glucose (mmol/L)] − 5)] Hyperkalemia K+ / H+ exchanger Total body K+ can be low (but not very commonly)

11. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association M ANAGEMENT OF DKA IN A DULTS

12. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association F LUIDS, P OTASSIUM, A CIDOSIS ARE THE P ILLARS OF T REATMENT IV fluids Acidosis Serum Potassium Always get and ECG/CK/TNI to rule out MI ECG changes may reflect hyperkalemia

13. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association R EPLACE F LUIDS WITH IV 0.9% N A C L UNTIL E UVOLEMIC Start with 1-2 L bolus, avg deficit 7-8L

14. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association O NCE E UVOLEMIC, CONSIDER PLASMA N A + AND GLUCOSE TO DETERMINE IV FL UID TYPE

15. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association R EPLACE P OTASSIUM : H YPOKALEMIA IS AN AVOIDABLE CAUSE OF DEATH IN DKA Correct K+ first THEN start insulin

16. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association M ANAGEMENT OF A CIDOSIS WITH I NSULIN Correct K+ before Insulin Insulin should be maintained until the anion gap normalizes Insulin used to treat the acidosis, not the glucose! 0.1U/Kg bolus to start

17. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association I NSULIN I NFUSION P ARAMETERS Glucoscans q1h <5.1: never hold Insulin, give D5W 5.1 – 10.0 and AG > 12: give D5W and consider small decrease in IV insulin dose 10.1 – 15.0 and AG > 12: give D5W with IV insulin 15.1-20: increase insulin 1U/h 20.1 – 25.0: increase insulin 2U/h GOAL: 10-14 in DKA Switch to SC insulin when AG and pH are normal and patient wants to eat / can tolerate PO Transition with Lantus, give SC 2h before DC IV pH can still be elevated from fluids (hypercloeremic acidosis), but will have a Normal Anion Gap

18. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association DKA IN P EDIATRICS #1: Fluids Never bolus, risk of cerebral edema Give 1.5 maintenance #2: K+ Similar guidelines as adults #3: Insulin Started by end of initial fluid resuscitation Bolus not indicated in Pediatrics, 0.1U/kg/h until acidosis corrected No Bicarb – never indicated in kids HyperNa+ – indicates significant fluid loss, correct for Glucose

19. 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

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

21. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association R ECOMMENDATION 2 2.In adult patients with HHS, a protocol should be followed that incorporates the following principles of treatment [Grade D, C onsensus]: a) F luid resuscitation b) A voidance of hypokalemia c) A voidance of rapidly falling serum osmolality d) S earch for precipitating cause e) P ossibly insulin to further reduce hyperglycemia (See figure 1)

22. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association R ECOMMENDATION 3 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] 2013

23. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association R ECOMMENDATION 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 (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]

24. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association R ECOMMENDATION 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]

25. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CDA C LINICAL P RACTICE G UIDELINES http://guidelines.diabetes.cahttp://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca http://diabetes.ca – for patients

26. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association K EY P OINTS 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