Hyperglycemic Crises in Diabetes MellitusYoshiaki UdaICU Training

Hyperglycemic Crises in DM

DKAHHS (previously HONK)Absolute insulin deficiencyRelative insulin deficiencyPredominantly T1DMYounger adultsPredominantly T2DMElderly, debilitated +/- dementiaHigher mortality Ketonemia, acidosis, hyperglycemia (usually BSL56), DehydrationEarly presentation (24/24)Late presentation (several days, week)HyperglycemiaPolyphagia, polydypsia, polyuriaKetoacidosisAbdo pain, n+v, Kussmaul breathing, Fruity breathDehydrationAltered conscious stateHyperglycemiaPolyuria Severe DehydrationDiuretic use, reduced access to water, impaired thirst perceptionHyperosmilalityAltered conscious state (Osm>320)Focal neurological signs, seizure, visualRisk of thromboembolic complicationGI symptom rare

DKA and HHS TriggerInfectionInsulin omissionCVAPancreatitisMIETOH/drug abusePregnancyEating disorder (recurrent DKA)Substance abuse

Medication affecting carbohydrate metabolism corticosteroid, thiazide, beta-blocker, second generation antipsychoticRestricted water intake from illness, immobilization, altered thirst mechanism in the elderly (HHS)Mechanical problems with insulin pump (DKA)

DKA and HHS: Diagnostic CriteriaAmerican Diabetes association 06

Confounding acid-base disturbancese.g. Metabolic alkalosis from vomitting/diuretic usee.g. Lactic acidosis from hypoperfusion

Testing for Ketone

Insulin required to suppress lipolysis is 1/10th of that required to promote glucose utilization

Pathogenesis Spectrum of diseaseKitabchi et alKetosis and acidosisExtreme hyperglycemia without ketosis/acidosis

Kitabchi et alLeukocytosisRaised lipase, amylase

Beware of pseudohyponatremia/pseudohypo-normoglycemia that can occur in severe hyperlipidaemia

Corrected serum NaCorrected serum Na is used to estimate the magnitude of water loss that has occurred in the development of hyperglycemia

Elevated corrected sodium concentration means dehydrationNormal corrected sodium concentration means either patients maintained adequate water intake or the onset of hyperglycemia was very acuteMeasured sodium level should rise as glucose fall

Measured sodium should be used in calculating plasma osmolality or anion gap

Corrected serum Na =Lawrence 2001

DKA and HHS management goalsImproving circulatory volume and tissue perfusionDecreasing serum glucose and plasma osmolality towards normal levelsClearing the serum and urine ketones at a steady stateCorrecting electrolyte imbalancesIdentifying and treating precipitating cause

Fluid therapyIn DKA and HHS, all of intravascular, interstitial, and intracellular compartments are contracted.

Estimated typical water deficit DKA 100ml/kg (~6 to 7L)HHS up to 200ml/kg (up to 10-12L) It is recommended to start fluid resus with 0.9% NaCl. (No K) This willRestore intravascular volume to restore tissue perfusionDecrease counter-regulatory hormones and lower blood glucoseBy improving hyperosmolar state, insulin therapy become more effectiveK+ level can be obtained in the meantimeOnce intravascular volume is restored, some experts switch to half normal saline (hypotonic solution) depending on corrected serum Na values

Fluid therapyKitabchi 2009HHSDKA

Insulin therapy

Insulin therapyKitabchi 2009

Insulin therapy

PotassiumKitabchi 2009

?Bicarbonate in DKAKitabchi 2009Prospective randomized studies so far has not shown advantage of alkali therapy in terms of neuro, cardiovascular function or rate of recovery of ketoacidosis

No prospective randomized study concerning use of bicarbonate in DKA with pH

Transition to SC insulinKitabchi 2009

Other important points

Complications from therapyHypoglycemiaHypokalaemiaHyperchloraemic metabolic acidosisCerebral oedema

ReferenceKitabchi, AE, Umpierrez, GE, Miles, JM, Fisher, JN. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care 2009; 32:1335Kitabchi, AE, Nyenwe EA, Hyperglycemic Crisis in Diabetes Mellitis: diabetoc Ketoacidosis and Hyperglycemic Hyperosmolar State. Endocrinol Metab Clin N Am 23 (2006) 725-751Hillman, K, Fluid resuscitation in diabetic emergencies a reappraisal. Intensive Care Med 1987: 13:4Brenner ZR, Management of hyperglycemic emergencies. AACN Clin Issues 2006: 17: 56-65Scherer Clinical Communications 2005: Management of Diabetic Ketoacidodsis and Hyperosmolar Hyperglycemic State American Diabetes Association: Hyperglycemic Crises in patients with diabetes mellitusSouthern Health Protocol: Management of Diabetic Ketoacidosis in Adults Protocol

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