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Hyperglycemic Crises in Diabetes Mellitus: Yoshiaki Uda ICU Training

This document discusses hyperglycemic crises in diabetes mellitus, specifically diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS). DKA is characterized by absolute insulin deficiency, ketonemia, and acidosis, while HHS involves relative insulin deficiency and hyperosmolality without significant acidosis. The causes, diagnostic criteria, pathogenesis, and management goals are described for each condition. Treatment involves fluid resuscitation, insulin therapy, electrolyte replacement, and identifying precipitating factors. Complications can include hypoglycemia, hypokalemia, and cerebral edema.

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yoshiuda
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184 views

Hyperglycemic Crises in Diabetes Mellitus: Yoshiaki Uda ICU Training

This document discusses hyperglycemic crises in diabetes mellitus, specifically diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS). DKA is characterized by absolute insulin deficiency, ketonemia, and acidosis, while HHS involves relative insulin deficiency and hyperosmolality without significant acidosis. The causes, diagnostic criteria, pathogenesis, and management goals are described for each condition. Treatment involves fluid resuscitation, insulin therapy, electrolyte replacement, and identifying precipitating factors. Complications can include hypoglycemia, hypokalemia, and cerebral edema.

Uploaded by

yoshiuda
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Hyperglycemic Crises

in Diabetes Mellitus
Yoshiaki Uda
ICU Training
Hyperglycemic Crises in DM
DKA HHS (previously HONK)
Absolute insulin deficiency Relative insulin deficiency
Predominantly T1DM Predominantly T2DM
Younger adults Elderly, debilitated +/- dementia
Higher mortality
Ketonemia, acidosis, hyperglycemia (usually Hyperosmolality, Hyperglycemia (BSL usually
BSL<44) >56), Dehydration
Early presentation (24/24) Late presentation (several days, week)
Hyperglycemia Hyperglycemia
•Polyphagia, polydypsia, polyuria •Polyuria
Ketoacidosis Severe Dehydration
•Abdo pain, n+v, •Diuretic use, reduced access to water,
•Kussmaul breathing, Fruity breath impaired thirst perception
Dehydration Hyperosmilality
Altered conscious state •Altered conscious state (Osm>320)
•Focal neurological signs, seizure, visual
•Risk of thromboembolic complication
GI symptom rare
DKA and HHS Trigger
• Infection
• Insulin omission
• CVA
• Pancreatitis
• MI
• ETOH/drug abuse
• Pregnancy
• Eating disorder (recurrent DKA)
• Substance abuse

• Medication affecting carbohydrate metabolism – corticosteroid, thiazide, beta-


blocker, second generation antipsychotic
• Restricted water intake from illness, immobilization, altered thirst mechanism in the
elderly (HHS)
• Mechanical problems with insulin pump (DKA)
DKA and HHS: Diagnostic Criteria

American
Confounding acid-base disturbances
e.g. Metabolic alkalosis from vomitting/diuretic use
Diabetes
e.g. Lactic acidosis from hypoperfusion association 06
Testing for Ketone
Insulin required to
suppress lipolysis
is 1/10th of that
required to
promote glucose
utilization
Pathogenesis – Spectrum of disease
Kitabchi et al

Extreme
Ketosis and hyperglycemia
acidosis without
ketosis/acidosis
Kitabchi et al

Leukocytosis
Raised lipase, amylase

Beware of pseudohyponatremia/pseudohypo-normoglycemia
that can occur in severe hyperlipidaemia
Corrected serum Na
 Corrected serum Na is used to estimate the magnitude of water loss that has
occurred in the development of hyperglycemia

Corrected serum Na =

 Elevated corrected sodium concentration means dehydration


 Normal corrected sodium concentration means either patients maintained
adequate water intake or the onset of hyperglycemia was very acute
 Measured sodium level should rise as glucose fall

 Measured sodium should be used in calculating plasma osmolality or anion


gap

Lawrence
2001
DKA and HHS management goals

1. Improving circulatory volume and tissue perfusion


2. Decreasing serum glucose and plasma osmolality towards normal levels
3. Clearing the serum and urine ketones at a steady state
4. Correcting electrolyte imbalances
5. Identifying and treating precipitating cause
Fluid therapy
 In DKA and HHS, all of intravascular, interstitial, and intracellular compartments are contracted.

 Estimated typical water deficit


 DKA 100ml/kg (~6 to 7L)
 HHS up to 200ml/kg (up to 10-12L)

 It is recommended to start fluid resus with 0.9% NaCl. (No K) This will
 Restore intravascular volume to restore tissue perfusion
 Decrease counter-regulatory hormones and lower blood glucose
 By improving hyperosmolar state, insulin therapy become more effective
 K+ level can be obtained in the meantime
 Once intravascular volume is restored, some experts switch to half normal saline (hypotonic solution) depending on
corrected serum Na values
Fluid therapy
Kitabchi 2009

DKA

HHS
Insulin therapy
Insulin therapy
Kitabchi 2009
Insulin therapy
Potassium
Kitabchi 2009
?Bicarbonate in DKA
Kitabchi 2009

•Prospective randomized studies so


far has not shown advantage of alkali
therapy in terms of neuro,
cardiovascular function or rate of
recovery of ketoacidosis

•No prospective randomized study


concerning use of bicarbonate in
DKA with pH<6.9 has been reported

•In patients with pH<6.9 bicarbonate


therapy may be indicated because
severe acidosis can lead to impared
myocardial contractility, cerebral
vasodilatation, coma, GI
complications
Transition to SC insulin

Kitabchi 2009
Other important points
Complications from therapy
 Hypoglycemia
 Hypokalaemia
 Hyperchloraemic metabolic acidosis
 Cerebral oedema
Reference
 Kitabchi, AE, Umpierrez, GE, Miles, JM, Fisher, JN. Hyperglycemic crises in adult patients
with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care
2009; 32:1335
 Kitabchi, AE, Nyenwe EA, Hyperglycemic Crisis in Diabetes Mellitis: diabetoc Ketoacidosis
and Hyperglycemic Hyperosmolar State. Endocrinol Metab Clin N Am 23 (2006) 725-751
 Hillman, K, Fluid resuscitation in diabetic emergencies – a reappraisal. Intensive Care Med
1987: 13:4
 Brenner ZR, Management of hyperglycemic emergencies. AACN Clin Issues 2006: 17: 56-65
 Scherer Clinical Communications 2005: Management of Diabetic Ketoacidodsis and
Hyperosmolar Hyperglycemic State
 American Diabetes Association: Hyperglycemic Crises in patients with diabetes mellitus
 Southern Health Protocol: Management of Diabetic Ketoacidosis in Adults Protocol
Thank You!

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