Hyperglycemic Crises (Exam #2)

Diabetic Ketoacidosis (DKA)

Reduced effective insulin + increased counterregulatory hormones leading to:

+ Hyperglycemia as a result of:

- Increased gluconeogenesis

- Accelerated glycogenolysis

- Impaired glucose utilization by tissues

+ Ketosis as a result of:

- Lipolysis from adipose tissues

- Hepatic fatty acid oxidation to ketone bodies (ß hydroxybutyrate, acetoacteate)

Hyperosmolar Hyperglycemic State (HHS)

Relative insulin deficiency + increased counterregulatory hormones leading to:

+ Hyperglycemia

- Causes osmotic diuresis, dehydration, and impaired renal function

+ Hyperosmolarity:

- Increased intravascular osmolarity

**Insulin levels in HHS are sufficient to prevent lipolysis**

Diabetic Ketoacidosis (DKA) Precipitating Factors

- New onset DM type 1

- Omitting Insulin

- Acute Illness

- Infection

Diabetic Ketoacidosis (DKA) Onset

Rapid (Hours to Days)

Diabetic Ketoacidosis (DKA) Clinical Presentation

- Abdominal pain, Nausea, Vomiting

- Dehydration

- Kussmaul Respirations (Deep, rapid respirations)

- Possible altered mental status

Hyperosmolar Hyperglycemic State (HHS) Precipitating Factors

• Prolonged hyperglycemia (more common in older patients with DM Type 2)

• Acute illness

• Infection

Hyperosmolar Hyperglycemic State (HHS) Onset

Days to weeks

Hyperosmolar Hyperglycemic State (HHS) Clinical Presentation

• Polyuria (Urination)

• Polydipsia (Thirst)

• Fatigue, weakness

• Dehydration

• Possible altered mental status

Euglycemic diabetic ketoacidosis (EDKA) Labs

• Euglycemia (serum glucose <250 mg/dL)

• Metabolic acidosis (serum bicarbonate <18 mEq/L and pH < 7.3)

• Ketosis

What class of oral medications have increased the recognition & incidence of EDKA in recent years?

SGLT2i

Hyperosmolar Hyperglycemic State (HHS) Glucose

> 600

Low arterial pH < 7.3 & Low sodium bicarbonate < 18 indicates

Diabetic Ketoacidosis

Fluid Replacement for DKA & HHS

Isotonic saline (0.9% NaCl) bolus:

+ 500-1000 ml/hr x 2-4 hrs, followed by:

- 9% NaCl 250-500 ml/hr infusion,

OR

- 0.45% NaCl 250-500 ml/hr infusion

+ Once serum glu is < 200 mg/dL for DKA or < 300 mg/dL for HHS:

Change to 5% dextrose/0.45% NaCl @ 150-250 ml/hr

+ Rationale:

Most patients will have major fluid deficits

IV Fluids: Expand intravascular volume, restore renal perfusion, & reduce insulin resistance by decreasing counter-regulatory hormones

Bicarbonate use in DKA

** DKA ONLY, to correct acidosis

+ Only indicated if pH < 6.9

+ Dose:

Sodium Bicarbonate 50-100 mmol (50-100 mEq) as on isotonic solution

- Example: 100 mmol (mEq) in 400 ml sterile water over 2 hrs

- Example: 50-150 mmol (mEq) in 1000 ml D5W over 1-1.5 hrs

- Repeat every 2 hrs until pH > 7

Goal glucose reduction for DKA & HHS

~ 50-75 mg/dl/hr

- Avoid overly rapid correction

Transition to maintenance insulin regimen for DKA & HHS when:

• Glucose < 250 mg/dL

• pH > 7.3 (DKA)

• Serum bicarbonate > 18 mEq/L (DKA)

• Serum Osmolality < 310 mOsm/kg (HHS)

• Mental status changes improved (if applicable)

EDKA Insulin Considerations

+ Start insulin at a rate of 0.05 - 0.1 units/kg/h for management of ketosis PLUS

+ Co-administer IV dextrose 5% infusion

If Potassium < ______ mEq/L, Hold Insulin & give ________

3.3

KCl 20 - 30 mEq/hr until K > 3.3

Goal K

4-5 mEq/L

• Check every 2 hrs

What do we do if Potassium 3.3 - 5.2

Start Insulin

+ Give KCl 20 - 30 mEq/L of IVF