DIABETIC

EMERGENCIES
DKA & HHS
Case Based Discussion

Dr. Yogeswari Venugopal,

Endocrinologist,
Diabetic Revision Course HSNZKT
 Discussion Outline

• DKA & HHS pathogenesis

• DKA Case Discussion
Diagnosis of DKA
Criteria for Critical Care
Principles of Management
DKA pathway of care in adults
• HHS Case Discussion
Definition and Diagnostic Criteria
Principles of Management
HHS Pathway
Pathogenesis DKA & HHS

Abbas E. Kitabchi et al. Dia Care 2006;29

 Case Study
Diabetic Ketoacidosis
 Case Study
A 43-year-old gentleman with a long history of type 2
diabetes (> 6 years), dyslipidemia and hypertension
presented to the emergency department with a
6-day history of weakness, fever, nausea, vomiting and a
painful left foot with foul smelling pus discharge from ulcer
on the sole.

He was on gliclazide and metformin since diagnosis. Mixtard

30 units bd was started 1 year ago because of poor
glycaemic control.

Stopped injecting insulin for 1 week ago – poor appetite

precipitated hypoglycaemia.
Examination
Temperature 38.9oC
BP 96/60 mmHg, Pulse 136 beats/minute, low volume
Respiration 36 breaths/minute, deep sighing breathing

Drowsy but arousable.

Tongue coated, dry mucosa and decrease skin turgor

Lungs clear; Heart sounds normal.

The abdominal exam - mild epigastric tenderness to deep
palpation; no rebound tenderness or guarding.
Left foot suppurative ulcer with adjacent cellulitis extending
to the knee.

Capillary blood glucose: 28 mmol/L

Laboratory Results
Urinalysis:
• Glucose 4+, ketones 3+, nitrite and leucocyte negative
Venous blood gas:
• pH of 7.06, pCO2 17 mmHg, bicarbonate 5.6 mmol/L
Blood glucose: 30 mmol/L, serum ketone 4.2mmol/L
Blood lactate: 3.2 mmol/L (0.5 – 1.0 mmol/L)
Renal profile:
• Urea 12 mmol/L, sodium 142 mmol/L, potassium 5.0 mmol/L,
chloride of 112 mmol/L, creatinine 136 μmol/L
FBC:
• Leucocyte 23 x 109/L with predominant neutrophils, haematocrit
55%
Imaging
Chest X-ray: unremarkable

X-ray left foot:

• Diabetic foot with osteomyelitic changes of 1-3
metatarsals.
More tests?

Serum
Anion gap Others
osmolality
Formula : (2 x serum
Septic workup
[Na]) + [glucose] + [urea]
([Na+] + [K+]) − ([Cl-] + [HCO3−]) Pus – for culture and sensitivity
(all in mmol/L)
Blood cultures
Or laboratory measured value

(2 x [142]) + [30] + [12] =

326 (142 + 5) – (112 + 5.6) = 29.4 ECG
Normal range 8 – 16 mmol/L
Normal range 275-295 mosmol/kg
What is the diagnosis?

• Blood glucose 30 mmol/L

This patient • pH 7.06, serum ketone 4.2, urine ketone 3+
• Bicarbonate 5.6 mmol/L

Criteria for • Capillary blood glucose >11 mmol/L

diabetic • Capillary ketones >3 mmol/L or urine ketones ≥2+
• Venous pH <7.3 and/or bicarbonate <15 mmol/L
ketoacidosis

Diagnosis • Diabetic ketoacidosis

 What are the precipitating factors?

Precipitating
This patient
factors

• Infection • Infection of left foot

• Missed insulin therapy • Missed insulin therapy
• Acute coronary
syndrome
• CVA
• Surgery
DKA : Principles of Management
• Restoration of hydration
• Suppression of ketoacidosis
• Restoration of biochemical normality
• Careful and frequent monitoring to avoid
complications due to therapy – Hypokalemia,
cerebral Oedema, pulmonary oedema
 ICU / Critical Care
• ICU / critical care and insertion of central line in the following
circumstances:

• Elderly

• Pregnant ladies

• Heart or kidney failure

• Other serious comorbidities

• Severe DKA
 Criteria For Severe Ketoacidosis
• Venous bicarbonate <5 mmol/L
• Blood ketones >6 mmol/L
• Venous pH <7.1
• Anion Gap > 16
• Glasgow Coma Scale (GCS)<12
• Oxygen saturation <92% on air (arterial blood gases
required)
• Systolic BP <90 mmHg
• Pulse >100 or< 60 beats/minute
What may happen if treatment is delayed?

• High mortality rate:

• Overall mortality is <1%
• Mortality rate >5% in the elderly

Prognosis
• Excellent with prompt treatment
• High-dependency unit (HDU) care / ICU care
 What is the immediate management?

1st hour ( A&E) 2nd - 6th hour 6 - 12 hours 12-24 hours

Aims• Reassess
:
K Replacement:
Fluid Aims• Reassess
:
monitor
patient,
vital
• Reassess patient, patient,
FRII:
• Commence 0.9% Aimsmonitor
: vital monitor vital
• Ensuresigns,
clinical and
Replacement:
saline drip -large signs signs (reduce
biochemical
review
parameters
fluid; K balance; biochemical and
bore 4-5mmol/L
• Aim cannula. • Rate• of
Continue
fall offluid blood glucose ≤ metabolic
improve or are normal
•give
• 0.1 replacement via
inU/kg/hr
Commence - until
maintenance ketonesinfusion
of at least
pump0.5 • Ensure clinical
15 mol/l – and • Continueparameters
IV fluid &
•ketosis
NS
fixedasrate
quickly
( acidosis as Resolution of DKA
drip, separate
intravenous IV ) mmol/L/hr,
• Assessorresponse D5/D10 infusion)
biochemical insulin infusion if not
possible
resolves in shock,
– drop in * Blood ketones <0.6
line, maintenance
insulin infusion • Bicarbonate rise 3
to treatment • Reassess
parameters improving eating well
assess
ketones hydration,
at least cardiovascular
IVD (0.1500ml 4 hrly0.5
unit/kg/hr). • Additional
mmol/L/hr, and mmol/L,
• Continue • If ketonaemia cleared
rate
mmol/L/hrof 10-15ml/kg status IV fluid
at 12
in
• Assess patient:
depending
1st few hrs,
on • Bloodmeasures:
glucose fluid
fall 3 * Venous
replacementpHfurther
hours; >7.3 (do and patient is not eating
• Investigations balance chart; and drinking, titrate
hydration status and mmol/L/hr
urinary not usefluid
• Avoid bicarbonate
may be as
maximum
• IfMonitoring
•urine BGL <50ml/kg
drops > required; Check insulin infusion rate
st output • Maintain serum if
catherisation hypoglycaemia
a surrogate atoverload
this accordingly
15mmol/hr
4 hours but BGL
regime for fluid
anuric;
potassium in nil by
normal • Assess for • Reassess for
• Look for
still > 15 mmol/L in mouth and ng stage) • Review
• Kprecipitating
replacement range (4-5mmol/L) complications
biochemical of and complications of
•thendependent
reduce on
insulin tube, ABG, ECG
causes
every and treat
500ml NS :- • Avoidmonitoring if treatment e.g. fluid
metabolic treatment e.g. fluid
hydration
accordingly
infusion status
rate – and If DKA not resolved overload, cerebral
≥ 5.5 – nil hypoglycaemia,
indicated once parameters:
overload, cerebral
urine output.
infected foot check for infusion / oedema
4.6-5.4
ulcer – 0.5g KCl
and BGL ≤ 15 mmol/L, review
oedema insulin
Frequent
If4.1
BGL drops resolution of dka; • Continue to treat
– 4.5
cellulitis – 1gtoKCl concurrent dextrose IV•lines
Treatreferral
precipitating
to precipitating factors
assessment
≤15mmol/L, of
addfluid
3.5-4.0 – 1.5g st KCL 5% or dextrose 10% diabetes team
factors as necessary • Change to
status
dextrose, in 1maintain
6 hours
<3.5 – rapid with maintenance NS, subcutaneous insulin if
to
BGL decide need for
7-10mmol/L
correction/ senior maintain BGL 7- patient is eating and
resuscitation fluid drinking normally
consult 10mmol/L
 DKA has resolved :
How do you manage
the patient now ?
 Management after resolution of DKA :
patient able to take orally well

Calculate subcutaneous insulin dose in insulin-naïve

patients; Calculating a Basal Bolus (QID) Regimen.

1. Estimate Total Daily Dose (TDD) of Insulin. The TDD can

be calculated by multiplying the patient’s weight (in kg) by
0.5 to 0.75 units ( for obese or insulin resistant)

2. Estimate TDD from hourly insulin dose which maintains

BGL 7-10mmol/L after DKA resolves - Calculate the
average insulin intravenous infusion rate in the last 12 h
to obtain the mean hourly rate then multiply by 24 to get
the total daily insulin requirement.
 Example using weight

An 80-kg person would require approximately 80 x 0.5

units or 40 units in 24 hours.

Give 50% of total dose at bedtime in the form of long

acting insulin and divide remaining dose equally between
pre-breakfast, pre-lunch and pre-evening meal.

E.g. Short-acting insulin 6-8u TDS ( pre meals) & 20

units intermediate / long acting bedtime
Example using insulin requirement

Approximately 2 u / hour x 24 = 48 units / day

(TDD)

50 % TDD basal, 50 % TDD prandial

Sc Insulatard 24 IU ON,
sc actrapid 8u TDS – adjust according to
diet
 Case Study
Hyperglycaemic
Hyperosmolar State
 Case study
A 71-year-old obese lady with a 12-year history of T2DM.

Family members found patient confused after a fall at home.

Associated with poor appetite urinary incontinence.

On metformin and gliclazide – since diagnosis, with

inadequate diabetic control. Refused insulin therapy.

No self-monitoring of blood sugar levels at home.

Last A1c was 11.2% ~ 1.5 years ago.

Family members observed urinary and fecal incontinence.
 Physical examination
BP 84/52 mmHg, Pulse rate 126 beats/minute
Temperature 38.6°C, Respiratory rate 24 breaths/minute
Peripheral oxygen saturation 100%
Dextrostix: Hi

Drowsy, dysphasic, unable to swallow

Oral mucosa was dry and skin turgor diminished
Lungs decrease air entry right lower zone with coarse
crepitations, no raised jugular venous pulse
Right sided hemiparesis
Examination of the abdomen -unremarkable.
 Investigation results
Serum glucose 59.8 mmol/L
Renal profile
• Urea 14.6 mmol/L, sodium 154 mmol/L, potassium 5.4 mmol/L, chloride
110 mmol/l, creatinine 176 μmol/L
Arterial blood gases pH 7.32 with bicarbonate 20 mmol/L
Urine FEME
• Cloudy, ketone 1+, nitrites and leucocytes present
Full blood count
• WBC 19 X 109/L (80% polymorphonuclears), hematocrit and platelet
counts were normal
ECG
• Sinus tachycardia, no ischaemic changes
CXR:
• Consolidation right lower zone
What else needs to be done?

Serum
Others
osmolality
Formula : (2 x serum
[Na]) + [glucose] + [urea] Septic workup
(all in mmol/L) Urine for culture and sensitivity
Or laboratory measured value Blood culture

(2 x [154]) + [59.8] + [14.6] = Stroke workup

Including swallowing test and CT
382.4 brain
Normal range 275-295 mosmol/kg
 What is the diagnosis?

• Dehydration - tachycardia, bp 84/52, dry mucosa and diminished skin

turgor, confusion
This patient • Blood glucose 59.8 mmol/l , serum Osmolality 382
• Urine ketones minimal
• Bicarbonate 20 mmol/l – no acidosis

Criteria for •
•
Hypovolemia – dehydration,
Marked hyperglycaemia > 33.3 mmol/l
Hyperglycaemic •
•
pH > 7.3, bicarbonate > 15 mmol/l
Urine or blood ketones nil or minimal
Hyperosmolar State • Serum osmolality > 320 mOsm/kg

• Hyperglycaemic
Diagnosis Hyperosmolar State
 What are the precipitating factors?

Precipitating factors This patient

• Infection and sepsis • Stroke

• Thrombotic stroke
• Intracranial
haemorrhage
• Silent myocardial
infarction
• Pulmonary infarction
What happens if treatment is delayed or
not properly carried out?

• Vascular complications such as myocardial infarction,

stroke or peripheral arterial thrombosis are common.
• Seizures, cerebral oedema and osmotic demyelination
• Rapid changes in osmolality - precipitant of osmotic
demyelination syndrome.
• Mortality higher than DKA
 What are the management goals?
Gradually and safely:
1. Normalize the osmolality
2. Replace fluid and electrolyte losses
3. Normalize blood glucose
4. Prevention of complications

Treat the underlying cause: stroke management and

aspiration pneumonia

Care in high dependency ward

 What is the immediate management?

1st hour ( A&E) 2nd - 6th hour 6 - 12 hours 12-24 hours

FRII: Na:
Serum
Fluid Aims•:Reassess patient,
K Replacement: • Reassess patient,
Serum Na : Aims :
• Reassess patient,
• Commence 0.9% monitor vital monitor vital monitor vital
Replacement:
saline drip -large
Aims :
signs signs (reduce signs, review
• Commence
0.05 U/kg/hr, • Gradual decline in
••stAim
bore 4-5mmol/L
cannula.
NS in
Resolution
• Continue fluid of HHS – 24 -72 hrs
fluid; K balance;
• Ensure clinical and
biochemical and
serum BGL, not more
1ensure
• NS
give Commence
adequateof
hrinregardless - as
maintenance
• If replacement
Na increasing via with blood glucose ≤ metabolic
•serum
hydrationas quickly
first • Rate of fall serum biochemical
15 mmol/l – D5 than 5mmol/L/hr
parameters
Na, high dropinfusion
in osmpump<
drip, fixed
possible
rate
separate
in IVNa, st
shock, osmolality 3- infusion)
parameters improving • Osmolality
• Continue IV fluid4 hrly
&
intravenous
repeat BUSE after 1 • Assess response
3mOsm/hr, check fluid
line, maintenance 8mOsm/kg/ hr
assess
•
hour
IVD
rate(0.05
* Patient steadily recovering, beginning to eat and insulin
insulin
drop hydration,
ininfusion
BGLresus
ofunit/kg/hr).
500ml fluidsaline
of 10-15ml/kg
3-
4
to treatment
balance, if fluid
• Blood
drinkinfusion
glucose fall 3-
• Additional
• Reassess
Hourly BGL, 2 -4 hrly
cardiovascular
5mmol/hr balance adequate, serumstatus
osmolality
• Gradual decline in
hrly
•
• Assess
in
• If
drop • Biochemistry normalized
depending
1strepeat
few patient:
hrs,
in osmolality
• Investigations
hydration Na
status
on
still
and
5mmol/L/hr fluid
measures:
switch to 0.45%
balance
• Continue
Na, with decline in
chart; saline
at 12
hours; IV fluid
further
maximum <50ml/kg • Maintain serum replacement
fluid may be
1
3-8
high
•
urine • Consider sc insulin regime once taking orally wellserum
mOsm/kg/hr,
/ increasing
Monitoring
output.
st 4 hours
increase
withregime ( IL/hr)
–infusion
no drop hourlyin Urine
urinary
potassium in normal
catherisation
output at; least
nil
osmolality not
required; Check
• Avoid
more than 8mOsm
for fluid overload
urine
•osmolality
K • Remove CBD, early mobilization if possible, DVT /kg/kr
(0.1u/kg/hr)output
replacement
fluid
•adequate input
dependent
if this
and
despite
on in
range
0.5ml
(4-5mmol/L)
by mouth
/kg/hr
tube,
• Avoid ABG,
and ng
ECG
hypoglycaemia
• Review
• Assess
• Reassess for for
not achieved hydration monitoring if biochemical and
every charting
hydration
with
•
≥urineLook
prophylaxis until discharge / mobilizing well
500ml
drop
for
5.5 –output.
nil in
saline
status
BGL, and:- hypoglycaemia,
• If indicated
BGL
once
Na increasing and
≤ 15prophylaxis
mmol/L,
complications
metabolic of
complications of
parameters:
If precipitating
drop
then in osmolality
change fluid • DVT
hydration still treatment e.g. fluid treatment e.g. fluid
4.6-5.4
Caution –and
in0.5g KCl to
elderly. concurrent dextrose minitor serum
overload, cerebral overload, cerebral
>8
0.45%mOsm/kg/hr
causes saline treat inadequate with osmolality
4.1 – 4.5
Frequent
accordingly – 1g KCl 5% or dextrose 10% oedema oedema
with
• aim drop
drop ininBGL > increasing osmolality • ;referral to
3.5-4.0
assessment – 1.5gofKCLfluid with maintenance NS, • Treat precipitating
diabetes team • Continue to treat
5mmol/hr, 3-8
osmolality reduce consider further
<3.5
status – rapid st
in 1 6 hours maintain BGL 10-15 factors as necessary precipitating factors
infusion
mOsm/kg/hr resuscitationst with NS
correction/
to decide need seniorfor mmol/L in 1 24 hrs
consult
resuscitation fluid