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Hyperglycemic Emergencies DKA/HONC. William Harper, MD, FRCPC Endocrinology & Metabolism Assistant Professor of Medicine, McMaster University. DKA. A collection of severe and potentially life-threatening metabolic disturbances: Hyperglycemia  Osmotic diuresis

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hyperglycemic emergencies dka honc

Hyperglycemic EmergenciesDKA/HONC

William Harper, MD, FRCPC

Endocrinology & Metabolism

Assistant Professor of Medicine, McMaster University

slide2
DKA

A collection of severe and potentially life-threatening metabolic disturbances:

  • Hyperglycemia  Osmotic diuresis
      • Urinary loss of fluids & electrolytes
      • ECFv contraction
      • Depletion of total body K+ stores

(even though may be hyperkalemic 2° to cell shift)

  • Ketone production  Metabolic acidosis
      • Compensatory Respiratory alkalosis (hopefully!)
  • Uncontrolled lipolysis  severe  TG
dka pathophysiology

fat cell

TG

DKA: Pathophysiology

Insulin -

Ketoacids

Glucose

HSL

FFA

Insulin

+ PFK

Liver Cell

Pyruvate

Fatty

Acyl-CoA

Acetyl-CoA

+

Kreb’s

Glucagon

Insulin

+

VLDL (TG)

dka pathophysiology1

fat cell

TG

DKA: Pathophysiology

Insulin -

Ketoacids

Glucose

HSL

FFA

Insulin

+ PFK

Liver Cell

Pyruvate

Fatty

Acyl-CoA

Acetyl-CoA

+

Kreb’s

Glucagon

Insulin

+

VLDL (TG)

dka risk factors
DKA risk factors
  • T1DM
      • 1st presentation
      • Acute-illness
      • Insulin omission (inappropriate sick-day management, noncompliance, Eating Disorders)
  • T2DM
      • During stress
      • Ethnicity: African-American, Hispanic
  • Extremes of age
  • Poor glycemic control
  • MDI with CSII
dka precipitating factors
DKA: Precipitating Factors

Acute illness

(MI, GIB, trauma,

10-20%

pancreatitis)

20-38%

New-onset DM

5-39%

Insulin omission

33%

Infections

dka diagnosis
DKA: Diagnosis
  • Symptoms & Signs:
      • Polyuria, polydipsia, weight-loss
      • Fatigue
      • N/V, abdominal pain
      •  ECFv, Kussmaul’s, Acetone breath, mild impairment in cognition
  • Laboratory:
      • pH < 7.3, serum HCO3 < 15 mEq/L, AG > 14 mM
      • Raised serum ketones (and urine ketones)
      • BS > 14 mM (occasionally normal or only mild  BS)
dka management
DKA: Management
  • Monitoring
  • IV Fluid Resuscitation (3-9L deficit)
  • Potassium (“no pee no K”)
      • K+ deficit 3-5 mEq/Kg
  • IV insulin
  • Identify & Rx underlying cause
      • Noncompliance, infection, MI, etc.
dka monitoring
DKA: Monitoring
  • Consider ICU:
      • pH < 6.9, inadequate respiratory compensation
      • decreased LOC
      • Severe K+ disturbance (K+ < 3.0 or > 6.0 mEq/L)
  • Stepdown/Telemetry: all others
  • Ward:
      • Only very mild DKA!
      • pH > 7.2, serum HCO3 > 20, AG < 14
      • ECFv near normal
      • Not elderly, no hi-risk DKA precipitant (ex. MI)
dka monitoring1
DKA: Monitoring
  • CBG q1-2h on IV insulin gtt
  • q2h: Serum lytes, creatinine, glucose
  • q4-6h:
      • pH > 7.2, HCO3 > 20, AG < 15
      • ECFv stable and IV fluids @ maintenance rates
      • normal K+
  • Calcium profile:
      • Initially, then q12-24h unless abnormal
      • Phospate levels can be high at 1st but drop with Rx of DKA
  • Flowcharts to record biochemical parameters shown to be useful
dka monitoring2
DKA: Monitoring
  • EKG, cardiac enzymes: r/o ACS (silent MI)
  • Septic w/up: cultures, CXR, urinalysis, etc.
  • Consider pulmonary embolism?
dka iv fluids
DKA: IV Fluids
  • IV NS 0.5-1L/h x 1-2h or longer so no more tachycardia, hypotension, orthostatic changes, low JVP.
  • Then change to 1/2 NS:
      • 200-500 cc/h over 12h in order to replace ½ estimated deficit
      • Then lower to 100-150 cc/h until deficit restored and eating/drinking well
  • If hypotension recalcitrant to fluids consider AI (Schmidt PGAS II) and send stat plasma cortisol and ACTH, then give solucortef 100 mg IV q8h.
dka mortality
DKA: Mortality
  • Adults 2-4%
      • Hypokalemia
      • MI, CVA, pneumonia, pulm. embolism, etc.
  • Kids 0.2-0.4%
      • Cerebral edema
dka potassium
DKA: Potassium
  • K+ defecit: 3-5 mEq/Kg (350 mEq for 70Kg)
  • Normal to high serum K+

Ketoacidosis

H+

H+

K+

K+

Insulin

dka potassium1
DKA: Potassium
  • K+ deficit 3-5 mEq/kg (350 mEq 70kg)
  • Need K with initial IV fluid & insulin Rx unless:
      • Anuric
      • K > 5.5 mEq/L or hyperkalemic ECG changes

> 20 mEq/h:

Cardiac monitor

> 60 mEq/L:

Central line

dka iv insulin
DKA: IV Insulin
  • Might delay starting IV insulin for a few hours if K+ severely low (< 3.0 mEq/L) and metabolic acidosis not severe (pH > 7.0)
  • Humulin R or Novolin Toronto
  • Bolus 0.1-0.2 U/kg IV
  • Then IV gtt @ 0.1-0.2 U/kg/h

(50 U of regular insulin in 500cc D5W; 1U/10cc)

  • Aim is to demonstrate correction of Anion Gap (AG) and decrease in BS 4.4 mM/L/h
  • Monitoring serial serum ketones NOT useful as most assays measure Acetoacetate only:

ßHß (not detected) DKA Rx Acetoacetate (detected)

dka iv insulin1
DKA: IV Insulin
  • Using insulin to treat 2 different and separate metabolic disturbances in DKA:
      • Ketoacidosis
      • Hyperglycemia
dka iv insulin2
DKA: IV Insulin
  • If AG not correcting and/or BS not decreasing then increase IV gtt rate 1.5-2X
  • If BS < 13 but AG still not corrected do NOT decrease insulin IV gtt.
  • Instead start IV glucose gtt:
      • D5W-D10W @ 100-200 cc/h
  • Once AG corrected than titrate IV insulin to BS
  • When BS < 13 and AG normal: reduce IV insulin gtt to 1-2 U/h and add IV glucose if not already done.
dka switch to s c insulin
DKA: Switch to S.C. insulin
  • Can consider switch to SC insulin when:
      • AG normalized
      • BS < 15 mM
      • Insulin IV gtt requirements < 2U/h
      • Patient able to eat
  • Overlap insulin IV gtt with 1st SC insulin by 2-4h to avoid recurrent ketosis
  • T2DM patients with DKA:
      • Don’t necessarily have to be d/c on insulin SC (I often do!)
      • Once acute stress resolved, many do well on OHA
dka other rx
DKA: Other Rx
  • Bicarbonate
      • May exacerbate hypokalemia
      • Only give if pH < 6.9 AND evidence of cardiovascular instability (arrythmia, CHF, hypotension)
      • 1-2 amps bicarb in 1L D5W IV with 10-20 mEq of added KCl given over 2h or until pH > 7.1
  • Phosphate
      • Routine IV not recommended
      • Rx symptomatic hypophosphatemia (rhabdo, unexplained CHF or respiratory failure, severe confusion)
      • 10cc K Phos soln (3.0mEq Pi and 4.4 mEq K/cc) in 1L NS IV over 8-12h
dka other rx1
DKA: Other Rx
  • Cerebral Edema
      • Usually only kids
      • Persistent decreased LOC despite standard Rx of DKA
      • CT scan to confirm diagnosis
      • Decadron 10 mg IV
      • Mannitol 25 mg IV
dka management1
DKA: Management
  • Monitoring
      • ICU: pH < 6.9, severe K (< 3, > 6), decr LOC
  • IV Fluid Resuscitation (3-9L deficit)
  • Potassium (“no pee no K”)
  • IV insulin
  • Identify & Rx underlying cause
      • Noncompliance, infection, MI, etc.
dka rx ebm
DKA Rx: EBM
  • In patients not in shock, recovery is more rapid with slower rates of IV fluids (500 mL/h x 4h, then 250 mL/h)
      • RCT: Adrogue et al, 1989, JAMA: 262:2108-13
  • Low-dose insulin (0.1-0.2 U/Kg bolus, then rate of 0.1-0.2 U/Kg/h) has similar rate of recovery and less hypokalemia than high-dose insulin (50-150 U/h)
      • RCT: Kitabchi et al, 1976, Ann Intern Med: 84:633-8
      • RCT: Heber et al, 1977, Arch Intern Med: 137:1377-80
  • No clinical benefit to giving IV HCO3
      • RCT: Gamba et al, 1991, Rev Invest Clin: 43:234-48
  • No benefit to giving IV phosphate
      • RCT: Fischer et al, 1983, JCEM:57:177-80
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