A review of the investigation and management of diabetic ketoacidosis in newly diagnosed type I diabetes. Patient details have been changed and anonymised to protect the identity of the individual.
2. Presentation
YA – admitted 12/11/2016
19 years old, male, single, employed in military in janitorial
Polyuria of 2 weeks duration
Frequent urination up to once per hour
Accompanied by intense thirst and dry mouth
Drinking water every hour to compensate for urination
Consumed some powder last month to increase muscle mass
Weight loss of 3kg in 2 weeks, weight 56kg now
Polydipsia, general weakness and abdominal pain
Used to running a time of 11:30min and now 13:40min
Diffuse abdominal pain began 2 days prior to admission
Gradually worsened until admission, then improved in hospital
No change in urine appearance or odour, no gross haematuria
No fever, no nausea, no vomiting, no diarrhoea
Background: G6PD, non-modified diet; NKDA
3. What could it
be?
Type 1 DM
Monogenic DM (previously MODY) (5% of paediatric cases)
Diabetes is diagnosed within 6 months of birth
A strong family history of diabetes is present, without type 2 features
(eg, obesity or higher-risk ethnicity)
Mild fasting hyperglycemia is observed, especially in young, non-obese
children
Diabetes is present, but islet cell autoantibodies, obesity, and insulin
resistance are absent
Secondary hyperglycaemia
Endocrine tumour
Drugs: thiazides, phenytoin, glucocorticoids
Pancreatitis
When in doubt, treat the patient with insulin and close monitoring of
glucose levels. It is not unusual for adolescents or young adults,
particularly Hispanic or African-American patients, to present with
DKA and subsequently be found to have type 2 DM
4. What should
be the initial
management?
Acute hyperglycaemia is harmful
>240mg/dL osmotic diuresis ensues, with loss of glucose, electrolytes,
and water
no absolute level of blood glucose elevation mandates admission to
the hospital or administration of insulin in the ED
In general, lowering glucose in the ED does not correct underlying
cause and has no long-term effect on the patient’s glucose levels.
Volume repletion, insulin therapy, and specific metabolic corrections
are the keys to treatment in DKA and acute hyperglycaemia
WBC, blood and urine cultures to rule out infection.
Urine ketones are not reliable for diagnosing or monitoring DKA, but
may show if hyperglycemic individual may have a degree of
ketonemia.. beta-hydroxybutyrate level—is a more reliable indicator
of DKA, with plasma bicarbonate or arterial pH
5. How much
insulin?
The insulin coverage, with a sliding scale for insulin administration
Not alone, because it is reactive rather than proactive.
The initial daily insulin dose is calculated by patient weight. Usually one half is
administered before breakfast, one fourth before dinner, and one fourth at
bedtime.Then adjust the amounts, types, and timing according to the plasma
glucose levels so that preprandial plasma glucose is 80-150 mg/dL (4.44-8.33
mmol/L)
Moderate hyperglycemia without ketonuria or acidosis
single daily subcutaneous injection of 0.3-0.5 U/kg of intermediate insulin
Hyperglycemia and ketonuria without acidosis or dehydration
0.5-0.7 U/kg of intermediate insulin and SC 0.1 U/kg regular q4-6hr
In HHS, begin a continuous insulin infusion of 0.1 U/kg/h
Monitor blood glucose every hour at bedside; if glucose levels are stable for 3
hours, decrease the frequency of testing to every 2 hours
Set target blood glucose level at 250-300 mg/dL; adjust downwards after the
patient is stabilized and increase or decrease by 0.5U/h per ∆50mg/dL range
Continue intermediate-acting (ie, NPH or Lente) insulin at 50-70% of the daily
dose divided into 2 or, occasionally, 3-4 daily doses. Administer supplemental
regular insulin on a sliding scale
Blood glucose should be monitored before meals and at bedtime
6. Immediate
Management
Attended clinic at the military base and referred to ER
In ER, blood glucose was found to be >600mg/dL on fingerstick
test and insulin was administered
Actrapid 10IU SC and Actrapid 7IU IV and 1000mL 0.9% NaCl given
Metoclopramide 10mg IV
KCl administration initiated
No blood gas disturbance, acidaemia or ketoacidosis
Glycosuria ++++ Ketonuria ++++
Glucose confirmed in serum 722mg/dL
ECG Sinus rhythm and regular
Chest X Ray clear and symmetric bilaterally
7. Diagnosis
Type 1 Diabetes mellitus is characterised by the inability of beta
islet cells to produce insulin due to autoimmune destruction
Classic symptoms are Polydipsia, Polyuria, Polyphagia, and
Unexplained weight loss
Onset of symptoms may be sudden and may present with DKA
American DiabeticAssociationCriteria
A fasting plasma glucose (FPG) level ≥126 mg/dL (7.0 mmol/L), or
A 2-hour plasma glucose level ≥200 mg/dL (11.1 mmol/L) during a
75-g oral glucose tolerance test (OGTT), or
A random plasma glucose ≥200 mg/dL (11.1 mmol/L) in a patient
with classic symptoms of hyperglycemia or hyperglycemic crisis
HbA1c assay for diagnosing type 1 diabetes only when the
condition is suspected but the classic symptoms are absent.
8. Why did he
present with
this episode
now?
There is a combined effect of lymphocytic infiltration and
destruction of insulin-secreting beta cells of the islets of
Langerhans in the pancreas
Cell mass declines, insulin secretion decreases until insulin amount
is too small to maintain normal blood glucose levels
After 80-90% of the beta cells are destroyed, hyperglycemia
develops
Autoimmunity in genetically susceptible may be triggered by viral
infection and production of antigenically similar molecules (eg,
enterovirus,mumps, rubella, and coxsackievirus B4)
85% have islet cell antibodies and those directed against glutamic
acid decarboxylase (GAD)
Correlated with Grave’s, Hashimoto’s, and Addison’s
Approximately 95% of patients with type 1 DM have either HLA-
DR3 or HLA-DR4 polymorphisms
9. What are the
next steps?
Patients need exogenous insulin to reverse this catabolic
condition, prevent ketosis, decrease hyperglucagonemia, and
normalize lipid and protein metabolism.
Prevent hypoglycaemia due to management errors
Prevent or delay microvascular and macrovascular complications
by maintaining good glycaemic control
Sensory and autonomic neuropathy
Angiopathy
Nephropathy
Infection
Double diabetes
10. In hospital
Management
Hyperglycaemia due toType I DM (new diagnosis)
Insulin therapy continued
Apidra 8U SC once daily (fast)
Lantus 16U SC once daily (long)
Investigations
Urine output 1000mL overnight
HbA1c - 11.0% 13/11
CRP andWBC - normal
LFTs - ALP 153
Us and Es - normal
Mg 1.80
Glucose 291mg/dL on 13/11
Gluc 283 per urine
11. What should
happen for
discharge and
follow-up?
Consider patient age for glycemic goals, with different targets for preprandial,
bedtime/overnight, and HbA1c levels in patients aged 0-6, 6-12, and 13-19
Benefits of tight glycemic control include continued reductions in the rate of
microvascular complications and significant differences in cardiovascular
events and overall mortality
Self-monitoring
Optimal control requires frequent blood glucose measurement, which allows
rational adjustments in insulin doses.
Record blood glucose levels at home and adjust accordingly (CGMs)
Insulin therapy
lifelong insulin therapy
Usually 2 or more injections of insulin daily
basal insulin and a preprandial (premeal) insulin.The basal insulin is either long-
acting (glargine or detemir) or intermediate-acting (NPH). The preprandial insulin
is either rapid-acting (lispro, aspart, insulin inhaled, or glulisine) or short-acting
(regular).
Diet and activity
comprehensive diet plan, with a professional dietitian
A daily caloric intake prescription
Recommendations for amounts of dietary carbohydrate, fat, and protein
Instructions on how to divide calories between meals and snacks
Patients should be encouraged to exercise regularly.
12. Discharge
Management
Endocrinological consultation
DM diagnosis information and management education
Discharge with endocrinological and GP follow-up
Use every opportunity to educate the patient and the parents or
caregiver about the disease process, management, goals, and long-
term complications
signs and symptoms of hypoglycemia and how to manage it
the course of diabetes: they have a chronic condition that requires
lifestyle modification and they are likely to have chronic complications if
they do not take control of their disease
Reassure patients about the prognosis with proper management
Pay attention to older adolescents who may become detached from
health care
A dietitian should provide specific diet control education
A nurse should educate the patient about self–insulin injection and
performing fingerstick tests