ACUTE COMPLICATION

HYPOGLYCAEMIA
HYPERGLYCAEMIA CRISIS

Djoko wahono Soeatmadji

HYPERGLYCAEMIA CRISIS
Ketoacidosis
and
Hyperosmolar Hyperglycemia

Mortality Rate
Diabetic Ketoacidosis (DKA) : 5 10%; <5% in
experienced centers
Hyperosmolar hyperglycemic state (HHS) : ~
15%
Saiful Anwar Hospital, Malang, 2000 - 2005
(37%)
Worsened at the extremes of age and in the
presence of coma and hypotension

PRECIPITATING FACTORS
Infection (Pneumonia, UTI)
CVA
Alcohol abuse
Myocardial infarction
Trauma
Drugs (steroids, sympathomimetics, thiazides)
Pancreatitis
Discontinuation of or inadequate insulin in
established type 1 diabetes

PATHOGENESIS
net effective action of circulating insulin
concomitant elevation of counterregulatory
hormones (glucagon, catecholamines,
cortisol, and growth hormone)

Insulin Defciency

Lipolysis

Hyperglicemia

Ketogenesis

Osmotic diuresis

Ketoacidosis

Hyperosmolarity

Pure DKA

Pure HHS
Wickoff and Abrahamson. Joslins Diabetes 2005,p.887

DIAGNOSIS
History and physical examination
Laboratory findings
Differential diagnosis

Clinical features of diabetic

ketoacidosis

Polyuria, nocturia; thirst

Rapid weight loss
Muscular weakness
Visual disturbance
Air hunger-acidotic (Kusmaul) respiration
Abdominal pain leg cramps
Nausea, vomiting
Confusion, drowsiness, coma (10%)

Laboratory findings
Plasma glucose, blood urea nitrogen/creatinine,
serum ketones, electrolytes (with calculated
anion gap), osmolality
Urinalysis, urine ketones by dipstick
Initial arterial/venous blood gases
Complete blood count with differential
Electrocardiogram
Bacterial cultures of urine, blood, and throat, etc.
Chest X-ray

DIAGNOSIS OF SEVERE KAD

Hyperglycemia (> 250 mg%)
Ketosis (blood/urine)
Acidemia (pH < 7.3)

(ADA,2003)

Hyperglycemia < 300 mg%

pH > 7.2
BE > -12 mmol/L
Severe symptoms (severe dehydration, shock/
hypotonia, persistent vomiting, drowsiness/coma,
grave concomittant/underlying disease) (Wagner,1999)

Diagnostic criteria for DKA and

HHS
DKA
Mild

Plasma glucose (mg/dl)

Arterial pH
Serum bicarbonate (mEq/l)
Urine ketones
Serum keton
Effective serum osmolality
(mosm/kg)
Anion gap
Alteration in sensoria and
mental

Moderate

HHS
Severe

> 250
7.257.30
1518
(+)
(+)
Variable

> 250
7.007.24
10 to 15
(+)
(+)
Variable

> 250
< 7.00
< 10
(+)
(+)
Variable

600
> 7.30
> 15
Small
Small
>320

> 10
> Alert

> 12
> Alert/drowsy

12
Stupor/coma

>Variable
Stupor/co
ma

Serum osmolality :2[measured Na (mEq/l)]glucose (mg/dl)/18

Anion gap : (Na+) - (Cl + HCO3) (mEq/l).

Causes of coma or impaired

consciousness in diabetic patients
Diabetic ketoacidosis
Hyperosmolar non-ketotic hyperglycemia
Hypoglycemia
Lactic acidosis
Other causes:
Stroke (more common in diabetic patients)
Post-ictal (including hypoglycemia-convulsions
also causes a self-correcting lactic acidosis)
Cerebral trauma (may follow hypoglycemia)
Ethanol intoxication (may induce or exacerbate
hypoglycemia in diabetic patients).
Drug overdose

Differential diagnosis
lactic acidosis
ingestion of drugs such as salicylate,
methanol, ethylene glycol, and
paraldehyde
chronic renal failure

TRATMENT
1. IV fluid (NS) ( initial : 1 l/hour or 1520 ml kg1 BW h-1)
2. Insulin (Continuous IV drip/im)
3. K+
4. Bicarbonate (pH < 7)

PRECIPITATING FACTOR(S)

Management of Adult Patients with DKA

Complete Initial Evaluation

IV fluid

Insulin

Potassium

Biocarbonate

Management of Adult Patients with DKA

Complete Initial Evaluation; Start i.v. Fluid 1.0 L of 0.9%
NaCl per hour initially (15 20 ml/kg/h)

IV fluid

Insulin

Potassium

Biocarbonate

Typical total body deficits of water

and electrolytes in DKA and HHS*
Total water (L)
Water (mg/kg)
Na (mEq/kg)
Cl (mEq/kg)
K (mEq/kg)
PO4 (mmol/kg)
Mg (mEq/kg)
Ca (mEq/kg)

6
100
7 10
35
35
57
12
1-2

9
100 200
5 13
5 15
46
37
12
1-2

Guide to initial treatment of diabetic

ketoacidosis in adults
Fluids and electrolytes
Volumes
1L/h x 2-3, thereafter adjusted according to need
Fluids
Isotonic (normal) saline (150 mmol/L) generally
Hypotonic (half-normal) saline (75 mmol/L) if serum sodium
exceeds 150 mmol/L (no more than 1-2 L-consider 5%
dextrose with increased insulin if marked hypernatraemia)
5% dextrose 1 L-4-6-hourly when blood glucose has fallen to
270 mg/dl (15 mmol/L) (severely dehydrated patients may
require simultaneous saline infusion)
Consider sodium bicarbonate ( 700 mL of 1.26% or 100 mL of
8.4% if large vein cannulated) if pH < 7.0 (with extra
potassium)

I. IV Fluids
Hydration Status ?
Hypovolemic shock

Mild hypotension

0.95% NaCl (1 L/h)

and/or plasma expander

Serum Na
high

Cardioogenic shock

Hemodynamic
monitoring
Evaluate corrected serum Na+
(add 1.6 mEq to sodium value)
Serum Na
normal

Serum Na
low

Serum glucose reaches 250 mg%

Change to D5% with 0.45% NaCl at 150 250 ml/h
with adequate insulin (0.05 0.1 u/kg/h) iv infusion

II. INSULIN
INTRAVENOUS
Insulin Regular
0.15 u/kg/bolus/i

INTRAMUSCULAR
Insulin Regular 0.4
u/kg/bolus/

RI 0.1 u/kg/h/iv
infusion

0.1 u/kg/h/im

If serum glucose does not fall by 50 70 mg%

Double insulin
hourly until glucose
fall by 50 70 mg%

Give 10 u/h/bolus
until glucose fall by
50 70 mg%
STABILIZED
Start Subcutaneous Insulin

III. POTASSIUM

Initial serum
K+< 3.3 mEq/L

Initial serum
K+ 3.3 5.5 mEq/L

Hold insulin and give 40

mEq K+/h (2/3 as KCL
and 1/3 as KPO4 until K+
3.3 mEq/L

Initial serum
K+ 5.0 mEq/L

Do not give K+ and

check K+ every 2 h

Give 20 30 mEq K+ in
each liter of iv fluid (2/3
as KCL and 1/3 as
KPO4) to keep serum
K+ at 4 5 mEq/LmEq

IV. ASSESS NEED FOR BICARBONATE

pH < 6.9

NaHCO3 (100 mmol/L)

Dilute in 400 ml H2O
infuse at 200 ml/h

pH 6.9 - 7

pH > 7

NaHCO3 (50 mmol/L)

Dilute in 200 ml H2O
infuse at 200 ml/h

No
NaHCO3

Repeat HCO3 administration

every 2 h until pH > 7.0
Monitor serum K+

V. MAINTENANCE
Keep the serum
glucose 150 200 mg
% until metabolic
control is achieved

Check electrolyte creatinine and glucose

every 2 4 h. Start NPO, continue IV
insuin for 1 2 h to ensure adequate
plasma insulin and supplement with RI sc
as needed. When the patient can eat
initiate a multidose insulin regiment and
ajust as needed.

Continue to look for precipitating factor(s)

HYPERGLYCAEMIA
HYPEROSMOLAR STATE

Protocol for the management of

adult patients with HHS
Diagnostic criteria:
blood glucose >600 mg/dl
arterial pH >7.3
bicarbonate >15 mEq/l
mild ketonuria or ketonemia
effective serum osmolality >320 mOsm/kg H2O
Na should be corrected for hyperglycemia (for
each 100 mg/dl glucose >100 mg/dl, add 1.6
mEq to sodium value for corrected serum value

Protocol for the management of

adult patients with HHS
Diagnostic Criteria
Blood glucose >600 mg/dl
Arterial pH >7.3
Bicarbonate >15 mEq/l
Mild ketonuria or ketonemia
Effective serum osmolality >320 mOsm/kg H2O
Na+ should be corrected for hyperglycemia (for each 100
mg/dl glucose >100 mg/dl, add 1.6 mEq to sodium value
for corrected serum value

r
u
o
y
r
o
f
u
Thankyo
attention