2. Following are the Metabolic
Emergencies in a diabetic person
Diabetic ketoacidosis (DKA)
Hyperglycemic Hyperosmolar state (HHS)
Diabetic Hypoglycemia
3. Introduction
• Uncontrolled blood sugar often contributes to the incidence of
metabolic emergencies of diabetes.
• Individuals who experience blood sugar levels that are too high or
low may develop conditions that could lead to a coma.
• Hypoglycemia results from excessively low blood sugar levels
caused by either insufficient food consumption or the presence of
too much insulin.
4. Introduction (contd….)
• DKA and HHS are life threatening emergencies results from excessively
high blood sugar levels.
• It carries significant risk of death and/or morbidity especially with
delayed treatment.
• The prognosis of DKA is worse in the extremes of age, with a mortality
rates of 5-10%.
• With the new advances of therapy, DKA mortality decreases to < 1%.
• Before discovery and use of Insulin (1922) the mortality was 100%.
5. Introduction (contd….)
• HHS and DKA are not mutually exclusive but rather two conditions that
both result from some degree of insulin deficiency.
• They can and often do occur simultaneously. In fact, one third of patients
admitted for hyperglycemia exhibit characteristics of both HHS and DKA.
6. Precipitating events
Inadequate insulin administration
Infection(Pneumonia / UTI / Gastroenteritis / Sepsis)
Infarction(cerebral, coronary, mesenteric, peripheral)
Drugs (cocaine, that affect carbohydrate metabolism, such as
corticosteroids, thiazides, sympathomimetic agents, and
pentamidine)
Pregnancy.
Harrison’s Principles of Internal Medicine 19th edition
8. DKA vs HHS
Common
More common inType 1
Precipitated by infection
Ketoacidosis
Short prodromal symptoms
Mortality 2-10%
Any Age :Common in young
Uncommon
More inType 2
More severe illness , infection, MI
Not ketoacidotic
Longer prodromal symptoms
Mortality 15-20%
Age 57-70
DKA HHS
9. Symptoms and signs of DKA
Symptoms
Excessive thirst
Frequent urination
Nausea and vomiting
Abdominal pain
Weakness or fatigue
Shortness of breath
Confusion
Signs
Kussmaul breathing ( Deep respirations )
Dry mucous membranes
Decreased skin turgor
Characteristic acetone (ketotic) Fruity breath
odor
Tachycardia
Hypotension
Fever,cough,chills if associated with intercurrent
infection
10. Diagnostic criteria : ADA
DKA
Hyperglycemia: >250 mg/dL
(>13.9 mmol/L)
Urine or serum ketones + or
more
Metabolic acidosis: pH < 7.3
serum bicarbonate < 15 mmol/l.
HHS
>600 mg/dL (> 33 mmol/L)
Absence of severe ketonaemia or
ketonuria. ( ketones +/- )
Arterial pH > 7.3,
serum bicarbonate > 15 mmol/L
Serum total osmolality>330 mOsm/L
11. Symptoms and signs of HHS
• Usually present with dehydrated state and stupor or coma.
• Loss of appetite and polyuria (several weeks)
• Profound dehydration
• Hypotension
• Tachycardia
• Absence of nausea, vomiting, abdominal pain
12. DIAGNOSIS Initial Evaluation
• Identify precipitating event leading to elevated glucose (pregnancy,
infection, omission of insulin, myocardial infarction, central nervous system
event)
• Assess hemodynamic status
• Examine for presence of infection
• Assess volume status and degree of dehydration
• Assess presence of ketonemia and acid-base disturbance
14th edition of Joslin's Diabetes Mellitus
13. DIAGNOSIS LAB INVESTIGATIONS
• Complete blood count
• Serum ketones/ Urine ketones and sugar
• Calculate serum osmolality and anion gap
• Urinalysis and urine culture
• Consider blood culture
• Consider chest radiograph
14th edition of Joslin's Diabetes Mellitus
14. Laboratory values in DKA and HHS
DKA HHS
Glucose,mg/dl 250-600 600-1200
Sodium meq/L 125-135 135-145
Potassium Normal to↑ Normal
Osmolality mosm/ml 300-320 330-380 (>350)
Plasma ketones ++++ +/-
Serum bicarbonate <15meq/L Normal to slightly ↓
Arterial pH 6.8-7.3 >7.3
Arterial pCO2 20-30 Normal
Anion gap ↑ Normal to slightly↑
Harrison’s Principles of Internal medicine 19th edition
15. 14th edition of Joslin's Diabetes Mellitus
Differential Diagnosis of Ketosis and Anion Gap Acidosis
FEATURES DIABETIC
KETOACIDOSIS
ALCOHOL
KETOACIDOSIS
STARVATION
KETOACIDOSIS
URAEMIC
ACIDOSIS
LACTIC
ACIDOSIS
PH
PLASMA
GLUCOSE
ANION GAP
SERUM
KETONES
SERUM
OSMOLALITY
17. Treatment Goals
• Restoration of volume deficits
• Resolution of hyperglycaemia and ketosis/acidosis
• Correction of electrolyte abnormalities (potassium level should be >3.3
mEq/L before initiation of insulin therapy; use of insulin in a patient
with hypokalaemia may lead to respiratory paralysis, cardiac
arrhythmias, and death)
• Treatment of the precipitating events and prevention of complications.
18. Suggested fluid replacement in
DKA/HHS
• 1st hour : 1 L
• 2nd hour : 1 L
• 3rd hour : 500 ml - 1 L
• 4th hour: 500 ml - 1 L
• 5th hour : 500 ml - 1 L
• Total 1st - 5th hour 3.5 - 5 L
• 6th - 12th hour : 250 - 500 ml/hr
19. Suggested Fluid Replacement in
DKA/HHS
• Administer NS as indicated to maintain
hemodynamic status than follow general
guidelines:
– NS for first 4 hours
– consider 1/2 NS thereafter after checking serum sodium ,if
its low continue with NS.
– Change to D5 & 1/2 NS when BG < 200 mg/dl for DKA
BG < 250- 300 mg/dl for HHS
20. Insulin management
Regular insulin 10 U i.v. stat (for adults) or 0.15 U/kg i.v. stat.
Start regular insulin infusion 0.1 U/kg per hour or 5 U per hour.
Increase insulin by 1 U per hour every 1–2 hr if less than 10% decrease in glucose or no improvement in acid-
base status.
Decrease insulin by 1–2 U per hour (0.05–0.1 U/kg per hour) when glucose ≤250 mg/dL and/or progressive
improvement in clinical status with decrease in glucose of >75 mg/dL per hour.
Do not decrease insulin infusion to <1 U per hour.
14th edition of Joslin's Diabetes Mellitus
21. Insulin management contd…
Maintain glucose between 140 and 180 mg/dL.
If blood sugar decreases to <80 mg/dL, stop insulin infusion for no more than 1 hr and
restart infusion.
If glucose drops consistently to <100 mg/dL, change i.v. fluids to D10 to maintain blood
glucose between 140 and 180 mg/dL.
Once patient is able to eat, consider change to s.c. insulin:
Overlap short-acting insulin s.c. and continue i.v. infusion for 1–2 hr.
For patients with previous insulin dose: return to prior dose of insulin.
For patients with newly diagnosed diabetes: full-dose s.c. insulin based on 0.6 U/kg per
day.
14th edition of Joslin's Diabetes Mellitus
23. Monitoring of RX
• Blood glucose hourly
• Electrolytes every 4 hours
• Blood gas analysis after fluid management
• Ok to check venous pH if you can’t get arterial
sample ( 0.03 unit less than arterial ).
• Urine ketone bodies 8th hourly
24. Bicarbonate
• Clinical trials do not support the routine use of bicarbonate replacement
• However, In the presence of severe acidosis (arterial pH <7.0), the ADA
advises bicarbonate [50 mmol/L (meq/L) of sodium bicarbonate in 200 mL
of sterile water with 10 meq/L KCl per hour for 2 h until the pH is >7.0].
Harrison’s PrinciplesOf Internal Medicine 19th Edition & ADA
26. Introduction
• Hypoglycemia is defined as blood sugar below 55 milligrams per
deciliter (mg/dL) or 3 millimoles per liter (mmol/L).
• An estimated 6-10% of people withType1DM die as a result of
hypoglycemia each year.
• Occurs less frequently inType2DM (People who are on insulin ).
Whipple traid:
Symptoms consistent with hypoglycemia
Low plasma glucose concentration
Relief of those symptoms after the plasma glucose level is raised
27. Causes
Common causes of diabetic hypoglycemia include:
• Taking too much insulin or diabetes medication
• Not eating enough.
• Postponing or skipping a meal or snack
• Increasing exercise or physical activity without eating more or adjusting
your medications
• Drinking binge alcohol.
30. Clinical features
SEVERE HYPOGLYCEMIA (<20 mg/dL )
• Associated with severe impairment of neurologic function
• Completely disoriented behavior
• LOC
• Coma
• Seizures
31. MANAGEMENT OF HYPOGLYCEMIA
Patient able to eat then provide 30 gm
(2 tablespoon) or oral glucose or milk
Follow up with some complex
carbohydrate
1) 1 cup of fruit juice
2) 1 slice bread
3) 1 cup of milk
4) 2-3 biscuits(un sweetened)
Hospitalized/emergency room patient with hypoglycemia(BG<60mg)
Patient not able to eat
Administer 20 ml of 50% dextrose bolus
intravenously and then 5 or 10 % dextrose
fluids at 100 mL/ hr until stabilized
If available injection glucagon 1.0 mg
(1 mL)stat can also be administered
instead
Monitor blood glucose q30 min till .100 mg
Once blood glucose>100mg evaluate cause and decide if further monitoring and
observation required
32. Treatment
MILD HYPOGLYCEMIA
• Oral carbohydrates (at least 15gm)
• Sources include
• Three glucose tablets (5g each)
• 2 ½ cups of fruit juice
• 1 cup of milk
• If patient is unable to take orally give IV dextrose
33. MODERATETO SEVERE HYPOGLYCEMIA
• Dextrose - 50mL of 50% dextrose IV bolus after blood
draw followed by 10% dextrose
• Glucagon – 1mg IM or SC can be given
• Effective in treating hypoglycemia only if sufficient liver
glycogen present( absent in alcohol induced
hypoglycemia)
• Patient is urged to eat as soon as possible
34. Prevention
• Patient education
• Knowing signs and symptoms of hypoglycemia
• Take meals on a regular schedule
• Carry a source of carbohydrate
• Self monitoring of blood glucose
• Take regular insulin at least 30 min before eating
35. References
• Harrison’s Principles Of Internal Medicine 19thEdition.
• Joslin’s Diabetes Mellitus 14th Edition.
• ADA Articles.
• Practical Management of Diabetes - CMCVellore
