Guidelines for the Management of patients with DKA and HHS in the ED

DIAGNOSIS INITIAL EVALUATION

Diabetic Ketoacidosis (DKA) Hyperosmolar Hyperglycaemic State (HHS) Resuscitation within the ABCDE system assumed, ask for help
BGL > 15mmol/L BGL Often high > 28) Airway patent or controlled, breathing maintained and IV access with two lines, monitored
pH <7.15 pH >7.3 Commence IV Fluids
HCO3 < 15mmol/L HCO3 >15 Lab - VBG (seek result if not bedside), finger prick BSL
Serum/urine ketones elevated Ketones can be present but low - FBC / UEC / Osmolality / Lipase / Mg / PO4 / BHCG** / BC / Coags / ketone
Euglycaemic DKA can occur in: Osmolality >320 mosmol/L Urine - U/A / MCS / Ketone / BHCG
- pregnancy Undiagnosed or known type II DM ECG, Chest Xray
- pre-hospital insulin Hypernatraemia in 50% cases Admit ICU/Endocrine, involve early
- reduced oral intake ALOC spectrum confusion to coma
CRITERIA FOR ICU/HDU MANAGEMENT OF DKA / HHS TRENDS
1. Haemodynamic Instability Vital signs - Temp, PR, BP, SatO2 ongoing
2. Inability to protect airway Glucose - (VBG, ABG, fingerprick) q1H
3. Obtundation Lab electrolytes/ - q2H (X3), then q4H until normalisation of levels
4. Presence of abdominal distension or succussion splash Glucose
(Acute gastric dilatation) Ketones - q4H until clearance( blood levels give more immediate result
5. Insulin infusion (varies in different institutions) Unstable patients - Arterial BP, CVP when available
FLUIDS INSULIN POTASSIUM OTHER THERAPIES
1. Fluid overload in elderly / cardiac / renal patients 1. Give fluids, resuscitate Note: Consider:
Consider CVP 2. Delay in pts with severe K+ (<3.3) 1. Initially, no additional K+ HCO3 replacement, generally NO.
2. Difficult iv access consider external jugular vein, 3. No Bolus 2. Exclude Hyperkalaemia Consider if pH < 6.9 (in setting of high K+ or arrhythmias
intraosseous or central access initially 4. Check pump hourly 3. Ensure Urine output >30ml/hr or HCO3 5), consult widely
3. Fluid deficits = 5-10L are common in DKA and HHS adults 5. HHS pts may be very sensitive to exogenous insulin 4. Generally KCL is given (consider other preparation to May be beneficial if resuscitated with NS and
4. Monitor haemodynamics, hydration, and urine output 6. Patients with SC insulin pump avoid excess Chloride) hyperchloraemic acidosis
5. Balanced fluids such as Plasmalyte less risk of safer to disconnect pump, start iv insulin
hyperchloraemic acidosis, suggest use these for mild DKA, interrogate pump/flow issue, may Heparin for HHS cases
discuss with endocrinologist POTASSIUM Note that large vessel arterial thrombosis and
Volume of Fluids and rate, resuscitation phase 7. Monitor hourly BGL, fluid status embolisation are common events
2L in 1st Hour (adult) 8. Give usual basal long acting insulin dose SC REPLACEMENT Low dose heparin provided no clinical evidence of
THEN concurrent with infusion thrombosis
500-1000mls/h over next 2-4h 9. Consider use of Regular SC Rapid acting insulin + Nil
regimens for mild to moderate DKA, DW your K >5
Hypo/HyperNa
Change to: endocrine team Stabilize circulation with Plasmalyte
+
K 45 20 mmol/L in replacement Then consult senior ED, endochrine, ICU
When circulation is stable INFUSION: (corrected Na+ = [(Glucose 10) 3] + measured Na+)
Note: 50 units ACTRAPID in 50 mls 0.9% Saline via Syringe fluid (Lab flame techniques)
- Suggest ongoing use fluids use Plasmalyte + 30-40 mmol/L in
K 34 replacement fluid or via
- 0.45% Saline reduces risk of hyperchloraemic acidosis and NB: Flush 10ml of solution through tubing before Phosphate / Magnesium replacement
non- AG acidosis, if NS used in resuscitation connecting to patient separate infusion pump PO4<0.32 - K2PO4 20mmol over 6 hours
- Aim to correct remaining fluid deficit gradually over next 24- + 40-60 mmol/L in Mg<0.6 MgSO4 2g over 4h
K <3 replacement fluid or via
48h
A. Start Insulin infusion at 5 ml/h separate infusion pump, Empirical/directed Antibiotics with sepsis
Match with urine output (U/O) + 100-200 ml/h
B. Titrate only if no or excessive response initially central access if >10 See Sepsis guidelines (link)
C. In ED setting usually do not reduce rate, consult
ADD 5%-10% Dextrose when BGL <15 mmol/H
endochrine
- Titrate to maintain BGL around 10-15 during insulin infusion D. Taper Insulin & commence SC bolus insulin when
- Increased sugar requirements in late pregnancy( 2 times) hyperglycaemia and ketoacidosis clears.
In HHS pts, endpoint of treatment is based on
Continue dextrose/Insulin until Ketones*/ AG clearance & pt normalisation of osmolality and
tolerating fluids PO
normal mental LOC
*serum ketones earlier and more reliable detection then urine
PRECIPITATING EVENTS MAIN CAUSES OF DEATH
DKA HHS DKA HHS (5-20% Mortality)
Infection (Temp and WCC not helpful) New onset diabetes Aspiration (gastroperesis) Aspiration
New onset diabetes AMI Hyper/hypokalaemia Pre-existing pathology
Poor compliance Acute abdomen Cerebral oedema (extremely rare in adults, 0.3-1% in Cerebral oedema
Acute abdomen (pancreatitis)Alcohol/Drugs Any serious /significant physiological/metabolic event children).
Silent MI / CVA (older pts)
Steroids
Trauma

FurtherReferencesandResources:DiabeticketoacidosisBMJBestPractice

DevelopedbytheECIbasedonManagementofAdultPatientswithDiabeticKetoacidosis(DKA)&HyperosmolarNonketoticComa(HONK)bySaysana,K.ISLHD,December2012
Updated June 2016