Hyperglycemic Emergencies Therapeutics

Hyperglycemic emergencies

Life-threatening complications of diabetes mellitus including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)

Diabetic ketoacidosis (DKA) definition

State of absolute or relative insulin deficiency leading to hyperglycemia, ketosis, and metabolic acidosis

Hyperosmolar hyperglycemic state (HHS) definition

State of severe hyperglycemia, hyperosmolarity, and dehydration with little or no ketosis

Diabetes type most associated with DKA

Type 1 diabetes mellitus

Diabetes type most associated with HHS

Type 2 diabetes mellitus

Onset of DKA

Rapid onset (usually <24–48 hours)

Onset of HHS

Gradual onset (often >5 days)

Pathophysiology of DKA

Insulin deficiency combined with increased counter-regulatory hormones

Counter-regulatory hormones in DKA

Glucagon, catecholamines, cortisol, growth hormone

Effect of insulin deficiency in DKA

Increased hepatic glucose production and decreased peripheral glucose utilization

Effect of counter-regulatory hormones in DKA

Stimulate gluconeogenesis, glycogenolysis, and lipolysis

Lipolysis in DKA

Breakdown of triglycerides into free fatty acids

Ketone body formation in DKA

Free fatty acids converted to ketone bodies in the liver

Ketone bodies produced in DKA

B-hydroxybutyrate, acetoacetate, acetone

Result of ketone accumulation in DKA

Metabolic acidosis with increased anion gap

Effect of hyperglycemia in DKA

Osmotic diuresis leading to polyuria and dehydration

Electrolyte loss in DKA

Loss of sodium, potassium, chloride, and magnesium in urine

Total body potassium in DKA

Depleted despite normal or elevated serum potassium

Volume depletion in DKA

Leads to hypotension and possible shock

Clinical symptoms of DKA

Polyuria, polydipsia, weight loss, nausea, vomiting, abdominal pain

Respiratory pattern in DKA

Kussmaul respirations (deep, rapid breathing)

Breath odor in DKA

Fruity odor due to acetone

Severe DKA findings

Altered mental status and coma

Diagnostic criteria for DKA

Glucose >250 mg/dL, pH <7.3, bicarbonate <15 mEq/L, ketones present

Definition of ketonemia

B-hydroxybutyrate ≥3.0 mmol/L

Definition of ketonuria

Urine ketones ≥2+

Euglycemic DKA definition

DKA with blood glucose <200 mg/dL

Causes of euglycemic DKA

SGLT-2 inhibitors, pregnancy, starvation, alcohol use, liver disease

Initial fluid therapy in DKA

0.9% normal saline intravenous (total 6–9 liters)

Insulin therapy in DKA

Continuous intravenous regular insulin infusion (0.1 units/kg/hour)

Potassium requirement before insulin in DKA

Potassium must be ≥3.3 mEq/L before insulin is started

Effect of insulin on potassium in DKA

Drives potassium into cells causing hypokalemia

Potassium replacement in DKA

10–20 mEq/L during treatment

Glucose management in DKA

Add dextrose when blood glucose <250 mg/dL

Goal of insulin therapy in DKA

Suppress ketogenesis and resolve metabolic acidosis

Use of bicarbonate in DKA

Not recommended unless pH ≤6.9

Pathophysiology of HHS

Relative insulin deficiency prevents ketosis but not hyperglycemia

Hyperglycemia in HHS

Extreme elevation of blood glucose leading to osmotic diuresis

Dehydration in HHS

Severe fluid loss resulting in hyperosmolar state

Ketone production in HHS

Minimal or absent

Diagnostic criteria for HHS

Glucose >600 mg/dL, pH >7.3, bicarbonate >15 mEq/L, osmolarity >320 mOsm/kg

Clinical features of HHS

Severe dehydration and altered mental status

Neurologic manifestations in HHS

Confusion, seizures, coma

Glucose levels in DKA vs HHS

DKA moderately elevated; HHS extremely elevated

Ketones in DKA vs HHS

DKA present; HHS minimal or absent

pH in DKA vs HHS

DKA decreased; HHS normal

Mental status in DKA vs HHS

DKA mild changes; HHS severe neurologic impairment

Treatment priority in HHS

Aggressive intravenous fluid replacement

Insulin therapy in HHS

Intravenous insulin infusion after fluid resuscitation

Electrolyte management in HHS

Monitor and replace potassium and other electrolytes

Common precipitating factors of DKA and HHS

Infection, insulin omission, myocardial infarction, stroke, physiologic stress

Monitoring in DKA

Glucose, ketones, pH, electrolytes

Monitoring in HHS

Glucose, osmolarity, electrolytes, fluid status

Medication associated with euglycemic DKA

SGLT-2 inhibitors

Prevention of SGLT-2 related DKA

Hold SGLT-2 inhibitors 3–4 days before surgery