HYPERGLYCEMIA

EMERGENCIES IN DIABETES
 DIABETIC KETOACIDOSIS
AND
HYPERGLYCEMIC HYPEROSMOLAR STATE
 DKA Statistics

• Type 1 Diabetes
• Occasionally in Type 2
– Infection, Trauma, Cardiac
– Newly diagnosed Type 2 DM
• More common in young people & women
• Mortality primarily due to precipitating illness
• Prognosis worse with
– Old Age, Coma, Hypotension
DKA Mortality
 DKA
(DIABETIC KETOACIDOSIS)
• Occurs when muscle cells become so starved for energy that
body takes emergency measures & breaks down fat  toxic
acids as ketones
• Most common type 1 DM insufficient insulin to adjust 
raise of blood sugar
• Cause by extreme stress or illness
• Infection  body produce adrenalin  works against insulin
• Forget to take insulin
Pathophysiology of diabetic ketoacidosis (DKA) and
hyperglycemic hyperosmolar state (HHS)
laktic acid ↑
 Signs & symptoms of DKA

• Lost more than 5% body weight

• Deep, rapid breathing >30x/mnts
• Sweet, fruity smell on breath
• Loss of appetite
• Nausea • Fatigue
• Vomiting • Weakness
• Fever • Confusion
• Stomach pain • Drowsiness
What should you do?
 Fluid Replacement
• Mainstay of initial therapy
• Expand the intravascular volume & improve renal
blood flow
• Avg fluid loss for DKA: 3-6 Liters (8-10 in HHS)
• Isotonic saline
– Rapidly infuse volume without acute lowering of plasma
osmolarity
– Switch to ½ NS in subacute phase if Na normal or high
• 15-20 ml/kg initially then decrease to 5-10ml/kg/hr
• Fluids alone initially decrease BG by 35-70
 Insulin Therapy
• Role of Insulin
– Lower serum glucose (mainly by decreasing liver
production)
– Reduce ketogenesis in liver by reducing lipolysis and
glucagon secretion
– Increase ketone utilization
• Insulin IV bolus and continuous drip is standard of
care
– Some studies have looked at frequent, rapid-acting insulin,
but not enough data to support use except in mild DKA
cases
 Insulin Therapy
• Check Potassium first!
– If K <3.3, delay insulin until begin K repletion
– May drive insulin into the cells and lead to life-
threatening hypokalemia
• Continuous infusion, start at 0.1 U/Kg/hr
• Goal is to decrease glucose by 50-70 mg/dl
per hour; will require further titration of drip
 Insulin Therapy
• Addition of dextrose to IVF
– Avoid hypoglycemia
– Continue insulin drip while awaiting resolution of
ketoacidosis
– Continue nutrition while patient NPO
• Once BG < 200 (<300 in HHS) start dextrose
(usually D5 ½ NS)
 Resolution of DKA
• Goals
– Resolve ketoacidosis
• Normal AG
• Ketones may remain (+) because of slower resolution of
acetone
– Neurologically alert/intact : Plasma Osm <315
– Taking PO nutrition
– Resume regular diet
– Add long-acting insulin, based on prior dosing or
24 hr insulin requirements on drip
– Stop insulin infusion 1-2 hrs after SQ insulin dose
 HHS Statistics
• <1% of all diabetes-related admissions
• More common in elderly & Type 2 diabetics
• A high level of blood glucose
• Trigger factors: high-dose steroid, diuretics, infection,
illness, stress or drinking excessive alcohol
• Symptoms : Excessive thirst, Increased urination, Weakness,
Leg cramps, Confusion, Rapid pulse, Convulsions, Coma
• Mortality
– Variable 10-50%
– Most often due to the precipitating illness
What should you do?
 Resolution of HHS

• Goals
– Neurologically alert/intact : Plasma Osm <315
– Taking PO nutrition
– Resume regular diet
– Add long-acting insulin, based on prior dosing or
24 hr insulin requirements on drip
– Stop insulin infusion 1-2 hrs after SQ insulin dose
 To Be Concern …!!!
• Anion Gap
• Osmolarity (Sodium corrected)
• Choice of Fluid Replacement
• Heart Function
• Renal Function
• Nutrition (Oral, PPN,TPN)
• Insulin Addition
 Anion Gap
• It is calculated by subtracting the serum
concentrations of chloride and bicarbonate (anions)
from the concentrations of sodium and potassium
(cations):

([Na+] + [K+]) − ([Cl−] + [HCO3−])

• A high anion gap indicates that there is loss of HCO3− without

a concurrent increase in Cl−
• A high anion gap indicates acidosis. e.g. In
uncontrolled diabetes, there is an increase in
ketoacids (i.e. an increase in unmeasured anions)
• In patients with a normal anion gap the drop
in HCO3− is compensated for almost
completely by an increase in Cl− Gastrointestinal loss of
HCO3− (i.e., diarrhea); Renal loss of HCO3− (i.e. proximal renal tubular
acidosis(RTA)

• A low anion gap is frequently caused by

hypoalbuminemia.
 Osmolarity
• Effective osmolarity(mOsm/L)
= 2(Na+ +K+ [mEq/L]) + Glucose (mg/dL)
18
• True Na+
= Na (mEq/L) + 1.6mEq/L [Serum glucose (mg/dL)-100mg/dL]
100mg/dL
• If individuals with impaired cardiac function develop
DKA, hemodynamic assessments must be made in
order to administer adequate quantities of fluid
while avoiding overhydration
• In Renal Failure setting clearly requires intensive
monitoring, as volume overload and hyperkalemia
may complicate the condition.

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EMERGENCIES IN DIABETES

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