Diabetic Emergencies

Hypoglycaemia

Treatment

Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycaemic State (HHS)

General Measures

Medicine Treatment

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Diabetic emergencies includes hypoglycaemia, diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar syndrome (HHS).

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ICD-10 Code: E10.0-1/E10.6/E11.0-1/E11.6/E12.0-1/E12.0-1/E12.6/E13.0-1/E13.6/E14.0-1/E14.6

HYPOGLYCAEMIA

Diagnosis: Clinical

Symptoms:

• Anxiety
• Palpitations
• Headaches
• Sweating
• Hunger
• Behavioural changes

Signs:

• Sweating
• Tachycardia
• Bizarre neurological signs
• Coma
• Tremor
• Confusion
• Seizures

Biochemical

Act on finger prick blood glucose. Confirm with laboratory measurements if uncertain.

TREATMENT

Start immediately.

• Dextrose 50%, rapid IV injection, 50 mL.

Assess clinical status and finger prick glucose level over the next 5–10 minutes.

LoE:III²¹

Establish a large bore intravenous line and keep open with:

• Dextrose 10%, IV.

If no clinical response, give a second injection of:

• Dextrose 50%, IV, 50 mL.

To prevent recurrent hypoglycaemia, continue infusion with:

• Dextrose 10%, IV infusion, at a rate of ± 1 L 6 hourly.

Once blood glucose is normal or elevated, and the patient is awake, check blood glucose hourly for several hours, and check serum potassium for hypokalaemia.

If the patient has not regained consciousness after 30 minutes with normal or elevated blood glucose, look for other causes of coma.

Once the patient is awake, give a snack if possible, and admit for observation and education etc., to prevent further hypoglycaemic episodes.

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If hypoglycaemia was caused by a sulphonylurea, the patient will require hospitalisation and a prolonged intravenous glucose infusion.
Observe patient for at least 12 hours after glucose infusion has stopped.

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Recurrent hypoglycaemia

In cases of recurrent hypoglycaemia consider:

• inappropriate management, e.g. too much insulin or too high dose of sulphonylurea,
• poor meal adherence
• poor adherence,
• alcohol abuse,
• physical exercise,
• factitious administration of insulin,
• the “honeymoon” period of type 1 diabetes,
• the advent of renal failure,
• hypoglycaemic unawareness, or
• pancreatic diabetes/malabsorption.

Other causes of hypoglycaemia should also be considered e.g. associated Addison’s disease or hypopituitarism.

Recurrent hypoglycaemia may be the cause of hypoglycaemic unawareness, which may occur in patients with type 1 diabetes. The loss of warning symptoms can lead to severe hypoglycaemia. In some cases this situation can be restored to normal with avoidance of any hypoglycaemia for at least 2–4 weeks.

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ICD-10 Code: E10.0-1/E11.0-1/E12.0-1/E13.0-1/E14.0-1

DIABETIC KETOACIDOSIS (DKA) AND HYPEROSMOLAR HYPERGLYCAEMIC STATE (HHS)

Diabetic comas – recognition and clinical profiles

DKA often occurs in younger patients and develops over hours to days. There may be vomiting, abdominal pain and acidotic breathing.

• blood glucose usually < 40 mmol/L
• blood ketones are positive
• serum osmolality < 350 mOsm/L.

Hyperosmolar hyperglycaemic state (HHS) is a syndrome characterised by impaired consciousness, sometimes accompanied by seizures, extreme dehydration and severe hyperglycaemia, that is not accompanied by severe ketoacidosis (pH usually >7.2). It usually occurs in the elderly type 2 diabetic patients and develops over days to weeks.

• Blood glucose usually > 40 mmol/L.
• Blood ketones usually negative to moderately elevated.
• Urine ketones may be positive.
• Serum osmolality is > 320 mOsm/L.

Anion gap = Na – (CI + HCO3) (Normal = ± 12 : DKA > 20)

Calculated serum osmolarity = 2 (Na + K) + glucose + urea.

GENERAL MEASURES

All patients:

• Set up an intravenous line.
• Protect airway and insert a nasogastric tube, if unconscious.
• Monitor urine output.
• Monitor plasma glucose, ketones, urine and electrolytes and venous blood gas.
• Look for precipitating causes, e.g. infection and MI.

MEDICINE TREATMENT

Fluids
Average deficit 6 L, may be as much as 12 L.
If renal or cardiac disease is present, monitor with central venous pressure.
In the absence of renal or cardiac compromise:

• Sodium chloride 0.9%, IV, 15–20 mL/kg in the first hour.
  • Patients <20 years of age: initial volume of 10–20 mL/kg in the 1st hour.
  • Subsequent infusion rate varies from 5–15 mL/kg/hour depending on the clinical condition.
  • Correction of estimated deficits should take place over 24 hours.
  • The volume infused in the first 4 hours should not exceed 50 mL/kg.
  • Fluid therapy thereafter is calculated to replace the estimated deficit in 48 hours, ± 5 mL/kg/hour.
  • Reduction in serum osmolality should not exceed 3 mOsm/kg/hour.

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Correct plasma sodium value for blood glucose.
[Rough guide: divide glucose by 3 and add to sodium value.]

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If plasma Na+ > 140 mmol/L:

• Sodium chloride 0.45%, IV.

If plasma Na+ ≤ 140 mmol/L:

• Sodium chloride 0.9%, IV.

If plasma glucose < 15 mmol/L, but ketones still present:

• Dextrose 5% or dextrose 10% in sodium chloride 0.9%, IV.

LoE:III²²

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Note
Adjust fluid volumes according to clinical criteria.
Cerebral oedema may occur with over-aggressive fluid replacement or rapid sodium change.

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Potassium

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Potassium will fall on insulin treatment and patients with DKA have potassium depletion even if initial potassium is normal or high.
It is therefore essential to monitor and replace potassium.

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Total body deficit 300–1 000 mmol.
(1 ampoule = 20 mmol = 10 mL)

• Potassium chloride, IV, added to 1 L of fluid.
  • potassium < 3.5 mmol/L:      add 40 mmol (2 ampoules)
  • potassium 3.5–5.5 mmol/L:  add 20 mmol (1 ampoule)
  • potassium > 5.5 mmol/L:      do not add any potassium
• Maximum potassium dose: 40 mmol/hour.
• Monitor potassium hourly initially, then 2 hourly when stabilised.

LoE:III

If serum potassium results are not readily available:

• Potassium chloride, IV, 20 mmol (1 ampoule) added to 1 L of fluid as soon as the patient has established adequate urinary output.

Bicarbonate
There is no proven role for the use of intravenous sodium bicarbonate and it could potentially cause harm.

Insulin therapy
Patients should be preferentially managed with continuous intravenous infusions or hourly intramuscular injections (see below) in a high care ward, with appropriate monitoring.

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Note
Ketonaemia takes longer to clear than hyperglycaemia and combined insulin and glucose (and K+) are needed to ensure clearance of ketonaemia.
Avoid focusing on glucose control alone!
Continue insulin until acidosis and ketosis have resolved.

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Continuous intravenous infusion:

• Insulin, short-acting, IV infusion, 50 units in 200 mL sodium chloride 0.9%.
  • 4 mL solution = 1 unit insulin.
  • Initial infusion: 0.1 unit/kg/hour.
  • Usually 5–7 units/hour: 20–28 mL/hour.
  • If plasma glucose does not fall by 3 mmol/L in the 1st hour, double the insulin infusion (hourly) until a steady reduction of plasma glucose is achieved, i.e. at least 3–4 mmol/L per hour.
  • If plasma glucose < 14 mmol/L, reduce insulin infusion rate to 1-2 units/hour and adjust subsequently according to hourly bedside capillary glucose level measured with glucose test strips.

Hourly intramuscular bolus injections:

Where intravenous infusion cannot be safely administered:

• Insulin, short acting
  • Dilute 100 units with sodium chloride 0.9% to 10 mL i.e. 10 units/mL.
  • Loading dose: 0.5 units/kg body weight.
  • Administer half the dose as an intravenous bolus injection and the other half IM. Do not administer with an insulin syringe and needle.
  • Subsequent hourly doses: ± 5–10 units IM every hour (i.e. 0.1 units/kg/hour) and titrated against the bedside capillary glucose level.

Progress management

Continue insulin therapy until the acidosis has resolved and:

• the patient is able to eat, and
• subcutaneous insulin therapy is instituted either at previous doses or, for newly diagnosed diabetes at 0.5–1 unit/kg total daily dose divided into at least 2 doses with mixed short and long acting insulin (biphasic insulin 2/3 in the morning and 1/3 at night).

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Infusion must overlap with subcutaneous regimen for 1–2 hour to avoid reversion to keto-acidosis.

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Heparin

For all patients:

• Low molecular weight heparin, e.g.:
  • Enoxaparin, SC, 40 mg daily.

LoE:I²³

OR

• Unfractionated heparin, SC, 5 000 units 12 hourly.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2024 Edition