hyperglycemic crises

HyperglycemicCrisisDKA, HHSLactic AcidosisHypoglycemia

DKA is a l i fe-threatening complication in Pt. with DM

DKA occurs mostly in type 1 DM frequently presented to hospitals with DKA for the first time at onset

DKA is less common in type 2 DM, but it may occur in situations of physiologic stress. Search a cause?

Definit ion

PATHOGENESIS

Osmotic Diuresis

Renal Hypoperfusion

Impaired Excretion ofKetones & Hydrogen ions

Fluid & Electrolyte Depletion

Vomiting

AcidosisHyperglycemia

Glycosuria

Glucose Ketones

Ketoacidosis is a state of

uncontrolled catabolism associated with

insulin deficiency.

 1. Hyperglycemia : gluconeogenesis, glycogenolysis , glucose uptake into ↓cell (underutilization) 

2. Ketosis (acidosis) : lipolysis, ketogenesis ,

↓ Peripheral tissue uptake ketone -- ketonemia 3. Hypertriglyceridemia  : ↑free fatty acid 

4. Osmotic diuresis ,dehydration : hyperglycemia -- ) renal loss glucose, Na & K -- )electrolyte imbalance 5. Volume depletion  : hyperglycemia, glucosuria & osmotic diuresis -- dehydration6. Insulin resistance FA,Acidosis , Counter Reg hormones7.Increase coagulability8. Increase Proinflammatory cytokines

Pathophysiology

CLINICAL FEATURES

• Polyuria leading to Oliguria

• Dehydration, Thirst

• Hypotension, Tachycardia,

• Peripheral circulatory failure

• Ketosis

• Hyperventilation

• Vomiting

• Abdominal pain (acute abdomen)

• Drowsiness, Coma

1. Glucose & ketone in serum & urine 2. Serum electrolyte, BUN, Cr, Ca, PO4,Mg 3. Blood gas : capillary or arterial blood gas ABG4. EKG : hypo/ hyperkalemia5. CBC ,UA 6.Consider the ppt factors cardiac enzyme, bld culture ect….

Lab

DDiagnosisiagnosisSevere HyperglycemiaSevere Hyperglycemia1.1. Serum glucose > ~300 mg/dlSerum glucose > ~300 mg/dl

DD< euglycemic Ketosis> pregnancy, alcolhol drinking, stravation >

ASSESSMENT OF ABG1.1. Acidosis : serum HCO3 < 15 mEq/ml or pH < Acidosis : serum HCO3 < 15 mEq/ml or pH <

7.257.25 severity of DKA Mild : HCO3 > 15-18 mq/L & pH > 7.3 Alert

2. Moderate : HCO3 10-15 mq/L & pH 7.1-7.3 ~

3. Severe : HCO3 < 10 mq/L & pH < 7.1

< wide anion gap: >15 mEq/L>

DKA1.1. Ketone : positive ketone in urine Ketone : positive ketone in urine

and / orand / or serum serum B hydroxybutyrateB hydroxybutyrate

Anion gapaverage anion gap for healthy adults is 8-12 mEq/L The concentrations are expressed in units of

milliequivalents/liter (mEq/L) or in millimoles/litre (mmol/L).[edit] With potassiumIt is calculated by subtracting the serum concentrations of

chloride and bicarbonate (anions) from the concentrations of sodium plus potassium (cations):= ( [Na+]+[K+] ) − ( [Cl−]+[HCO3−] )

[edit] Without potassium (Daily practice)However, the potassium is frequently ignored because

potassium concentrations, being very low, usually have little effect on the calculated gap. This leaves the following equation:= ( [Na+] ) − ( [Cl−]+[HCO3−] )

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DKA- Monitoring Admission ? Observation, ?Home, ?Ward and ? ICU2 IV’s, Oxygen, cardiac monitor, continuous vitals, pulse oxFoley to monitor I &OInitially blood work every 1-2 hours If pH is less that 6.9 be frightenedNasogastric, AnticoagulantAntibiotic

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DKA- MonitoringStandard blood work

Glucose, lytes with calculated anion,ABG, MagBun & creatinine, calculate GFRBeta-hydroxybutyrate or serum ketonesUACBCEKG Infection-cultures,chest xrayCardiac status-cardiac enzymes

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Diabetic Ketoacidosis: Treatment involves 5 key components:

MonitoringFluid resuscitation / Electrolyte repletionInsulinTreating underlying cause

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DKA- Fluids Deficits are typically 100 ml per kg Fluid replacement will lower glucoseInitial Tx usually fluid, fluid, fluidInitial resuscitation 15-20 ml/kg stat for severe

dehydration with normal saline 1l,1l,1l,then 500ml X4 hours, reassess/reassess Once glucose below 250, switch to D5W/.45% N saline or D5W/.9% saline (separate or

Mix)

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InsulinDelay insulin if Hypokalemic until corrected

??? 10 units R Insulin IV, .15 units/kg , Not Recommended Only if pharmacy delay infusionInsulin infusion pump, most

protocols 5-7 units per hour, .1 units/kg/hr adjusted every 1 or 2 hours

Patient to ICUStop insulin drip when sugar is less

than 250

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Electrolytes- KWhole body potassium deficits exist. (3-5 mmol/kg)Acidosis increases KGlucose + Insulin lowers KStart K with K less than 5 mmol and adequate urine

outputIf initial K less than 3.3 mmol replete, and then start insulin when K above 3.3

mmol/L

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Electrolytes- KCommonly under repleted

Resident mistakenly uses the replacement of potassium protocol, which vastly under repletes potassium

Watch like a hawk!!!!Replace/repete/replace/repeteHco3 potentiate electrolyte defecit not recommeded

except in deep coma or severe acidosisPhosphate replaced with K as K phosphate of ~ effect

Bicarbonate Beneficial ONLY if patient is

severely acidotic or nearing cardiorespiratory collapse

HCO3 + H = carbonic acid = H2O + CO2 in ECF

CO2 readily enters cells, where reverse reaction occurs, i.e., H is produced intracellularly, leading to intracellular acidosis

HypokalemiaParadoxical acidosis of CSFAdverse effects on oxyHb

dissociation curve: tissue hypoxia

Overshoot alkalosisAcceleration of ketogenesis by

raising pHCerebral edemaLocal necrosis

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Electrolytes- Mg A serum deficit usually exists of .5-1 mmol per L

Consider repleting if less than 1.8 mg/dL

•Hypoglycemia •Electrolyte imbalance •Hyperglycemia •Metabolic acidosis •Cerebral edema•Hypoxemia,ARDS•Thrombotic events:CVA,MI

Complication

HHSMild Type 2 DiabeticOld agePolyurea from Hyperglycemia and from Impaired

renal functionSevere dehydration CNS Manifestation very evident (cellular

dehydration)Insulin is enough to inhibit ketosis but not

hyperglycemiaCritical and prognosis is badSame management as DKA

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Dx Criteria for HHS

Glucose > 600

Arterial pH <7.30Serum bicarb <15 mEq Urine and Serum ketones- smallB-hydroxybutyrate- n or elevatedAnion gap-variablePatient is stupor/comaOsmalality >320 mOsm/kgOsmolality = (2 x (Na + K)) + (BUN /

2.8) + (glucose / 18)Trachtenbarg David, Diabetic Ketoacidosis, American Family Physician, 2005;71:1705-1714

Lactic acidosis

Diabetic type 2 receiving BIGUANIDE (metformin)Suffering from IHD,Chr resp impairement,heart

failure,liver impairement,renal impairement and severe anemia (Metabolite accumulation &increase lactic acid)

Same line of management of DKA

Thank you