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DIABETIC

EMERGENCIES
DKA & HHS

Case Based Discussion


Dr. Yogeswari Venugopal,
Endocrinologist,
Diabetic Revision Course HSNZKT

Discussion Outline
DKA & HHS pathogenesis
DKA Case Discussion
Diagnosis of DKA
Criteria for Critical Care
Principles of Management
DKA pathway of care in adults

HHS Case Discussion


Definition and Diagnostic Criteria
Principles of Management
HHS Pathway

Pathogenesis DKA
& HHS

Abbas E. Kitabchi et al. Dia Care

Case Study
Diabetic
Ketoacidosis

Case Study
A 43-year-old gentleman with a long history of type 2
diabetes (> 6 years), dyslipidemia and hypertension
presented to the emergency department with a
6-day history of weakness, fever, nausea, vomiting and a
painful left foot with foul smelling pus discharge from ulcer
on the sole.
He was on gliclazide and metformin since diagnosis. Mixtard
30 units bd was started 1 year ago because of poor
glycaemic control.
Stopped injecting insulin for 1 week ago poor appetite
precipitated hypoglycaemia.

Examination
Temperature 38.9oC
BP 96/60 mmHg, Pulse 136 beats/minute, low volume
Respiration 36 breaths/minute, deep sighing breathing
Drowsy but arousable.
Tongue coated, dry mucosa and decrease skin turgor
Lungs clear; Heart sounds normal.
The abdominal exam - mild epigastric tenderness to deep
palpation; no rebound tenderness or guarding.
Left foot suppurative ulcer with adjacent cellulitis extending
to the knee.
Capillary blood glucose: 28 mmol/L

Laboratory Results
Urinalysis:
Glucose 4+, ketones 3+, nitrite and leucocyte negative
Venous blood gas:
pH of 7.06, pCO2 17 mmHg, bicarbonate 5.6 mmol/L

Blood glucose: 30 mmol/L, serum ketone 4.2mmol/L


Blood lactate: 3.2 mmol/L (0.5 1.0 mmol/L)
Renal profile:
Urea 12 mmol/L, sodium 142 mmol/L, potassium 5.0 mmol/L,
chloride of 112 mmol/L, creatinine 136 mol/L

FBC:
Leucocyte 23 x 109/L with predominant neutrophils, haematocrit
55%

Imaging
Chest X-ray: unremarkable
X-ray left foot:
Diabetic foot with osteomyelitic changes of 1-3
metatarsals.

More tests?

Serum
osmolality

Anion gap

Others

Formula : (2 x serum [Na]) +


[glucose] + [urea]
(all in mmol/L)
Or laboratory measured value

([Na+] + [K+]) ([Cl-] + [HCO3])

Septic workup
Pus for culture and sensitivity
Blood cultures

(2 x [142]) + [30] + [12] =

326
Normal range 275-295 mosmol/kg

29.4

(142 + 5) (112 + 5.6) =


Normal range 8 16 mmol/L

ECG

What is the diagnosis?


This patient

Blood glucose 30 mmol/L


pH 7.06, serum ketone 4.2, urine ketone 3+
Bicarbonate 5.6 mmol/L

Criteria for
diabetic
ketoacidosis

Capillary blood glucose >11 mmol/L


Capillary ketones >3 mmol/L or urine ketones 2+
Venous pH <7.3 and/or bicarbonate <15 mmol/L

Diagnosis

Diabetic ketoacidosis

What are the precipitating factors?


Precipitating
factors
Infection
Missed insulin therapy
Acute coronary
syndrome
CVA
Surgery

This patient
Infection of left foot
Missed insulin therapy

DKA : Principles of Management


Restoration of hydration
Suppression of ketoacidosis
Restoration of biochemical normality
Careful and frequent monitoring to avoid
complications due to therapy
Hypokalemia, cerebral Oedema,
pulmonary oedema

ICU / Critical Care


ICU / critical care and insertion of central line in the following
circumstances:
Elderly
Pregnant ladies
Heart or kidney failure
Other serious comorbidities
Severe DKA

Criteria For Severe Ketoacidosis

Venous bicarbonate <5 mmol/L


Blood ketones >6 mmol/L
Venous pH <7.1
Anion Gap > 16
Glasgow Coma Scale (GCS)<12
Oxygen saturation <92% on air (arterial blood gases
required)
Systolic BP <90 mmHg
Pulse >100 or< 60 beats/minute

What may happen if treatment is delayed?


High mortality rate:
Overall mortality is <1%
Mortality rate >5% in the elderly

Prognosis
Excellent with prompt treatment
High-dependency unit (HDU) care / ICU care

What is the immediate management?


K
Replaceme
st
nt:
1Fluid
hour
FRII:
( Replaceme
A&E)
nt:
Aim 4-

Commence
5mmol/L

0.1 U/kg/hr
0.9% saline
give
until
ketosis
drip
-large

NS in
as
quickly
maintenance
(as
acidosis
bore
cannula.
possible) in
Commence
- IV
drip,
separate
resolves
drop
shock,
assess
fixed
rate
line,
in
ketones rate
at
hydration,
intravenous
maintenance
least
0.5
insulin
of
10-15ml/kg
in
(0.1
IVD
500ml
4
hrly
mmol/L/hr
stinfusion
1 few hrs,
unit/kg/hr). on
depending
maximum
Assess
hydration
status

If BGL drops
>
<50ml/kg
patient: 1st 4
and
urine output
5mmol/hr
but
Investigatio
hours
BGL
ns still > 15

Monitoring
K replacement
mmol/L
then on

dependent
regime
in everyinsulin
500ml
reduce
hydration
Look for status
NS
:-urinerate
infusion
and
precipitatin
g5.5
Frequent
nil
causes
output.
and
4.6-5.4
0.5g
If
BGLtreat
drops
to
assessment
of
accordingly
KCl status inadd
15mmol/L,
fluid
1st
infected
4.1
4.5
1g
dextrose,
foot
ulcer
6
hours
to and
cellulitis
KCl
maintain
BGLfor
7decide
need
3.5-4.0 1.5g

2nd - 6
Aims
: th
hour

Reassess

Ratepatient,
of fall of
monitor
ketones
of atvital
signs
least 0.5
Continue fluid
mmol/L/hr,
or
replacement
Bicarbonate
rise
via infusion
pump
3 mmol/L/hr,
and

Assess
Blood glucose
response to
fall 3 mmol/L/hr
treatment
Maintain
serum
Additional
potassium
in
measures:
fluid
balance
normal range (4chart; urinary
5mmol/L)
catherisation
Avoid
if anuric; nil
by mouth and
hypoglycaemia,
ng tube, ABG,
once BGL
15
ECG
mmol/L,
monitoring if
indicated
concurrent
dextrose 5% or
dextrose 10%
with maintenance

6 - 12
Aims
hours:

Reassess
patient,
monitor
vital
Ensure
clinical
signs
(reduce
and
biochemical
Resolution
of
fluid; K
parameters
balance;
DKA
improving
blood glucose
* Blood
ketones
15
mol/l

Continue
IV fluid
D5/D10
<0.6
mmol/L,
replacement
infusion)
* Venous
pH >7.3
Avoid
Reassess
cardiovascula
hypoglycaemia
(do
not
use
r
status
Assess forat
bicarbonate
as12a
hours; further
complications
of
fluid may
be
surrogate
at this
treatment
e.g.
required;
stage)
for
fluid Check
overload,
fluid overload
cerebral
Review
If oedema
DKA
not resolved
biochemical
review
insulin
Treat
and
metabolic
parameters:
precipitating
infusion
/ IV lines
check for
factors
as
resolution
of
necessary
dka; referral
to diabetes
team

Aims
:
12-24
hours
Ensure clinical

Reassess
and biochemical
patient,
parameters
monitor vital
improve
or are
signs,
review
normalbiochemical
Continue
IV fluid
and metabolic
parameters
& insulin
infusion if
not eating well
If ketonaemia
cleared and patient
is not eating and
drinking, titrate
insulin infusion rate
accordingly
Reassess for
complications of
treatment e.g. fluid
overload, cerebral
oedema
Continue to treat
precipitating factors
Change to
subcutaneous
insulin if patient is
eating and drinking

DKA has resolved : How do you manage the patient now ?

Management after resolution of DKA : patient able to take


orally well

Calculate subcutaneous insulin dose in insulin-nave


patients; Calculating a Basal Bolus (QID) Regimen.
1. Estimate Total Daily Dose (TDD) of Insulin. The TDD can
be calculated by multiplying the patients weight (in kg) by
0.5 to 0.75 units ( for obese or insulin resistant)
2. Estimate TDD from hourly insulin dose which maintains
BGL 7-10mmol/L after DKA resolves - Calculate the
average insulin intravenous infusion rate in the last 12 h
to obtain the mean hourly rate then multiply by 24 to get
the total daily insulin requirement.

Example using weight


An 80-kg person would require approximately 80 x 0.5
units or 40 units in 24 hours.
Give 50% of total dose at bedtime in the form of long
acting insulin and divide remaining dose equally between
pre-breakfast, pre-lunch and pre-evening meal.
E.g. Short-acting insulin 6-8u TDS ( pre meals) & 20
units intermediate / long acting bedtime

Example using insulin requirement


Approximately 2 u / hour x 24 = 48
units / day (TDD)
50 % TDD basal, 50 % TDD prandial
Sc Insulatard 24 IU ON,
sc actrapid 8u TDS adjust according to
diet

Case Study
Hyperglycaemic
Hyperosmolar State

Case study
A 71-year-old obese lady with a 12-year history of T2DM.
Family members found patient confused after a fall at home.
Associated with poor appetite urinary incontinence.
On metformin and gliclazide since diagnosis, with
inadequate diabetic control. Refused insulin therapy.
No self-monitoring of blood sugar levels at home.
Last A1c was 11.2% ~ 1.5 years ago.
Family members observed urinary and fecal incontinence.

Physical examination
BP 84/52 mmHg, Pulse rate 126 beats/minute
Temperature 38.6C, Respiratory rate 24 breaths/minute
Peripheral oxygen saturation 100%
Dextrostix: Hi
Drowsy, dysphasic, unable to swallow
Oral mucosa was dry and skin turgor diminished
Lungs decrease air entry right lower zone with coarse
crepitations, no raised jugular venous pulse
Right sided hemiparesis
Examination of the abdomen -unremarkable.

Investigation results
Serum glucose 59.8 mmol/L
Renal profile
Urea 14.6 mmol/L, sodium 154 mmol/L, potassium 5.4 mmol/L, chloride
110 mmol/l, creatinine 176 mol/L
Arterial blood gases pH 7.32 with bicarbonate 20 mmol/L
Urine FEME
Cloudy, ketone 1+, nitrites and leucocytes present
Full blood count
WBC 19 X 109/L (80% polymorphonuclears), hematocrit and platelet
counts were normal
ECG
Sinus tachycardia, no ischaemic changes
CXR:
Consolidation right lower zone

What else needs to be done?

Serum
osmolality

Others

Formula : (2 x serum [Na]) +


[glucose] + [urea]
(all in mmol/L)
Or laboratory measured value

Septic workup
Urine for culture and sensitivity
Blood culture

(2 x [154]) + [59.8] + [14.6] =

382.4
Normal range 275-295 mosmol/kg

Stroke workup
Including swallowing test and CT
brain

What is the diagnosis?


This patient

Criteria for
Hyperglycaemic
Hyperosmolar State

Diagnosis

Dehydration - tachycardia, bp 84/52, dry mucosa and diminished skin


turgor, confusion
Blood glucose 59.8 mmol/l , serum Osmolality 382
Urine ketones minimal
Bicarbonate 20 mmol/l no acidosis

Hypovolemia dehydration,
Marked hyperglycaemia > 33.3 mmol/l
pH > 7.3, bicarbonate > 15 mmol/l
Urine or blood ketones nil or minimal
Serum osmolality > 320 mOsm/kg

Hyperglycaemic
Hyperosmolar State

What are the precipitating factors?

Precipitating factors
Infection and sepsis
Thrombotic stroke
Intracranial
haemorrhage
Silent myocardial
infarction
Pulmonary infarction

This patient
Stroke

What happens if treatment is delayed or


not properly carried out?
Vascular complications such as myocardial infarction,
stroke or peripheral arterial thrombosis are common.
Seizures, cerebral oedema and osmotic demyelination
Rapid changes in osmolality - precipitant of osmotic
demyelination syndrome.
Mortality higher than DKA

What are the management goals?


Gradually and safely:
1. Normalize the osmolality
2. Replace fluid and electrolyte losses
3. Normalize blood glucose
4. Prevention of complications
Treat the underlying cause: stroke management and
aspiration pneumonia
Care in high dependency ward

What is the immediate management?

K
Replaceme
Serum
nt:
Fluid
FRII: Na:
1st
hour
Replaceme
Commence
NS
(
A&E)
Aim
0.054U/kg/hr,
nt:
st

in
1 hr
5mmol/L
ensure
Commence
regardless
of
give
in
adequate

NS assaline
quickly
0.9%
serum
Na,
high
maintenance
hydration
first
drip
-large
as
possible
in IV
Na,
repeat
BUSE
drip,
separate
bore
cannula.
shock,
assess
after
1stin
hour
line,
Commence
drop
BGL- of
3hydration,
rate
fluid
resus
fixed
rate
maintenance
5mmol/hr
intravenous
of
10-15ml/kg
in
IVD
500ml
stinsulin
drop
in
1 Iffew

repeat
Na
saline
4hrs,
hrly
infusion
(0.05
osmolality
3-8
maximum
still
high
/
unit/kg/hr).
depending
on
mOsm/kg/hr,
st
<50ml/kg
1
4

Assess status
increasing
with
hydration
increase
patient:
hours
( IL/hr)
no
drop
in
and
urine
infusion
Investigatio
osmolality
output.
(0.1u/kg/hr) if
ns
dependent on
despite
Monitoring
this
not
hydration
status
adequate
regime

K
replacement
achieved
and
urine
hourly
urine
hydration
with
in
every
500ml
output
and
output.
Caution
drop
in
BGL,
saline
:-in
If fluid
drop
input
in
elderly.
then
charting

5.5change
nil >8
osmolality
Frequent

Look
for
fluid
to
4.6-5.4
0.45%
0.5g
mOsm/kg/hr
precipitatin
assessment
of
saline
KCl
with
drop in BGL
g
causes
fluid
in 1st

aim
drop
in
4.1
status
4.5
1g
treat
>and
5mmol/hr,
6
hours to 3-8
osmolality
accordingly
KCl
reduce
infusion

2Serum
- 6 Na :
Aims
hour :
nd

th

Resolution
of
Reassess
Ifpatient,
Na increasing
Rate
of fall
monitor
vital
with drop in
osm
signsosmolality
serum
<3mOsm/hr,
Continue fluidhr
3-8mOsm/kg/
check
fluid
replacement
Blood
glucose
via
infusion
balance, if fluid
fallpump
3-5mmol/L/hr
balance
Maintain
Assess serum
adequate,
response switch
to
potassium
in
to 0.45%
saline
treatment
normal
range (4 Additional
5mmol/L)
measures:
Urine
output at
fluid balance
Avoid
least
0.5ml
/kg/hr
chart;
urinary
hypoglycaemia,
catherisation
once
15
nilBGL
by
mouth
If; Na
increasing
mmol/L,
ng tube,
andand
hydration
still
ABG,
ECG
concurrent
inadequate
monitoringwith
if
dextrose
5% or
indicated
increasing
dextrose
10%
DVT
osmolality
with
prophylaxis
maintenance
consider further
NS, maintain BGL
resuscitation with
10-15 mmol/L in
NS
st

Aims :
6 - 12
hours
HHS
24
-72

Reassess
Ensure
clinical
patient,
and biochemical
monitor vital
parameters
signs (reduce
fluid; K
improving
balance;
Hourly
BGL, 2 -4
blood glucose
hrly serum
15 mmol/l
osmolality
D5 infusion)
Reassess
Continue
IV fluid
cardiovascula
replacement
r status at 12
Avoid
hours; further
hypoglycaemia
fluid may be
required;
Assess
for
Check for
complications
of
fluid overload
treatment
Reviewe.g.
fluid biochemical
overload,
and
cerebral metabolic
parameters:
oedema
minitor serum
Treat
osmolality
;referral to
precipitating
diabetes
factors
as
team
necessary

Aims :
12-24
Gradual
hours

hrs
Reassess
decline
in serum
patient,

BGL, not
morevital
monitor
than 5mmol/L/hr
signs, review
biochemical
Continue
IV
and
metabolic
fluid & insulin
parameters
infusion
Osmolality 4
Gradual
hrly
decline in Na,
with decline in
serum osmolality
not more than
8mOsm /kg/kr
Reassess for
complications of
treatment e.g.
fluid overload,
cerebral oedema
Continue to
treat
precipitating
factors

* Patient steadily recovering, beginning to eat


and drink
Biochemistry normalized
Consider sc insulin regime once taking orally
well
Remove CBD, early mobilization if possible,
DVT prophylaxis until discharge / mobilizing
well

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