Diabetic emergencies

1. Diabetic ketoacidosis
2. Hyperglycemic Hyperosmolar state
3. Hypoglycemia
1. Hypoglycemia
• DXT <3.9
• Presence of autonomic or neuroglycopenic symptoms
• Able to reversed by CHO intake
Severity of hypoglyacemia
Risk factors
• Advanced age
• GCS poor/ cognitive impairment
• Poor health knowledge/ hypoglycemia unawareness
• Long duration of insulin therapy / over treatment
Treatment
• Level 1 & 2 hypoglycemia
• 15g of simple CHO eg honey 1
table spoon, 150-200cc fruit
juice, 3 teaspoon sugar
dissolve in water
• Recheck DXT 15min, if still
low, repeat another 15g
• Level 3 hypoglycemia
• 20-50cc D50% over 15min
• 1mg s/c glucagon
Nocturnal hypoglycemia
• May manifest as
• Poor sleep quality, vivid dreams/nightmare
• Morning headache, chronic fatigue
• nocturnal convulsion
• Somogyi vs Dawn effect
• Somogyi = rebound hyperglycemia due to over-treatment (nocturnal
hypoglycemia lead to glucagon release)
• Dawn effect = under-treatment ( physiological hormone GH causes
hyperglycemia)
Diabetic ketoacidosis
• DKA triad • Look for cause !
• Infection
• CBS > 11
• Capillary ketone >3 or urine ketone 2+ • Missed insulin
• Venous pH <7.3 or HCO3- <15 • Non-compliance
• drugs( (steroids)
• Presentation • CVA/ACS/surgery
• Abdominal pain
• Hypotension (clinically dehydrated)
• Vomiting
• Tachypneic (respiratory compnesation)
• Acetonic breath
• Drowsiness
• coma
Investigation DKA
• CBS (if high, take RBS)
• VBG
• Urine/ blood ketone ( UFEME look for precipitating factor)
• RP (electrolyte imbalance)
• FBC (HCT and WBC) wbc >15 not always infection, can be dehydration
• Septic work-up/ CRP/ blood c+s , CXR look for cause
• ECG
Monitoring
• CBD for I/O charting • Severe DKA
• Bicarbonate <5
• Ryles tube if risk of aspiration • Ketone >6
• QID VBG, BUSE, ketone • Ph <7.1
• Continuous cardiac • K+ <3.5 on admission
monitoring • GCS <12
• SAO2 <92% on RA in ABG
• CVP if severely dehydrated or
• SBP <90
in congestive heart failure
• HR >100
( prevent over treat)
• Anion gap >16 (na+k –
(cl+hco3))
Principle of treatment
1. Correct dehydration
2. Correct electrolyte imbalance
3. Insulin therapy
4. Treat precipitating factor
5. Prevent complications
• Aim
• Rate of fall ketone
0.5mmol/L/hr
• Bicarbonate rise 3mmol/L/hr
• Plasma glucose fall 3mmol/L/hr
• Potassium maintain in normal
range
• Not to over correct
hypperglycemia in 12-24hr”,
avoid lowering glucose <14
 1. Correction of dehydration
• DKA = up to 10% body weight fluid deficit • Depending on co-morbids,
• If SBP <90, start 500cc 0.9%NS over 10-15 min hemodynamic status, urinary
• if cannot pick up, repeat another 500cc output
• KIV colloids • May need HDDU admission if
• If SBP >90 elderly, pregnancy, existing
• Step 1 = 1 Litre NS0.9% over 1 hour CCF/ advanced CKD/ ESRf
• Step 2 = 1 Litre NS0.9% over 2 hour
• Step 3 = 1 Litre NS0.9% over 4 hour
• Step 4 = 1 Litre NS0.9% over 6-8 hour ( 4pin/24H)

• IF Na>145, to use half saline

• When DXT <14, change to NSD5/ D5 alone based
on Na and CL level
2. Correct electrolyte imbalance
• Hyperkalemia can be observed initially deu to metabolic acidosis
• Remember to add potassium in solution
• Add 0.5g KCL in each pin initially
• Aim serum K+ 3.5 -5.5
• If no urine output, to withhold K+
3. Insulin therapy
• Start fixed rate IV insulin infusion
(FRIII) 0,1 unit/kg/hour based on
weight
• 50 unit short acting human insulin in
50cc NS0,9%
• Delay insulin if initial potassium <3.5
• May consider continue S/C long
acting insulin while on iV insulin
infusion
• Hourly DXT
• If <14, change to D5 or NSD5
• If persistent ketonemia
• Change to D10%, continue FRIII
• If DXT did not fall by 3 every hour,
consider increase FRIII 1unit/hr
• AIM = DXT 8-12
• Insulin dose should taper down,
Don’t correct hypoglycemia too
fast as may cause cerebral edema
IVI insulin (fixed rate insulin infusion)
DXT IVI insulin rate IV fluid of choice
>20 0.1U/kg/hour and review NS 0.9%
15-20 0.06U/kg/hour NS 0.9%
10-15 0.03-0.05U/kg/hour NSD5 or D5
5-10 0.015-0.03U/kg/hour NSD5 or D5
<5 omit/ NSD5
Note in HTI, fixed dose until out of
DKA
others
• IV HCO3 • Phosphate
• No role due to • No evidence to support routine
• Increase partial pressure of CO2 in CSF phosphate replacement for DKA
fluid, leading to paradoxical increaase in
CSF acidosis
• Delay in fall of lactate and ketone level
• Risk of cerebral edema in young age group
• May consider if pH<6.9 (lacking
evidence)
• 1 amp (50cc) 8,4% NaHCO3 in 200cc D5%
over 1 hour
Resolution
• pH>7.3
• Plasma ketone <0.6

• Overlap IVI insulin to basal bolus

• Overlap s/c insulin with infusion for ½ hour (inject s/c insulin then run
concurrent IVI insulin for 30min, then off IVI sliding and drip)
• How to calculate?
• TDD = Body weight x 0.5,
• if obese or insulin resistance use x0.75
• Give 50% of TDD for basal insulatard, another 50% for TDS short acting actrapid
Be alert of complications of DKA
• Hypoglycemia
• Hypokalemia
• Cerebral oedema (drop in GCS)
• DVT in view of stasis
• Gastroparesis, if unconscious, for continuous NG aspiration
Other ketoacidosis
• Euglycemic ketoacidosis • Treatment
• DXT <11, with ketoacidosis • Withhold SGLT 2-i if any
(usually dxt 11-15) • Treat as per DKA but change fluid
to D5%
• Similar presentation as DKA
• Risks
• Prolonged fasting (ramadan)
• SGLT2-i
Other ketoacidosis
• Starvation ketoacidosis
• Occur in NBM patients
• Management: replacement of CHO with IVD d5% or D10%
Hyperglycemic hyperosmolar state (HHS)
• Can be initial presentation of T2DM, life threatening emergency
• Criteria
Severe dehydration
DXT >30
Serum osmolarity >320
effective serum osmolarity formula: 2Na + glu
• Clinical feature
• No significant ketonemia <3 / acidosis pH >7.3, HCO >15
• Poor GCS (maybe due to cerebral edema – sudden drop in osmolality, electrolyte
disturbance)
• Precipitated by: non adhrence, infection
Mangement
• 1. treat underlying cause
• 2. correct dehydration and
electrolyte imbalance
• 3. correct hyperglycemia
• Sensitive to insulin hence low
dose needed
• Another factor for low dose,
need to correct osmolarity
slowly due to risk of cerebral
edema
• 4. prevent complication
• IV NS0.9% main principle fluid
• IV Half saline if Na >145
• Dont use Hypertonic saline !
Pseudohyponatremia is due to
severe hyperglycemia
• Aim gradual increase of
osmolality 3-8mOsm/kg/hr
• Aim Na correctio not more
than 10mmol/L in 24 hour
Resolution
• Patient alert, eating well
• Serum Osm <320
• Glucose <14
• Once resolved, change IV insulin to Sc basal bolus