Diabetic Hyperglycaemic Emergencies

Introduction
Identification
Severity assessment
Management based on severity
Relevant history, examination
Investigations
Referral criteria
Discharge
Treatment Algorithm

Introduction/ Description

• DKA: Diabetic ketoacidosis is a serious hyperglycaemic complication of diabetes that occurs when the body produces high levels of blood ketones in response to its inability to produce enough insulin.
• HHS: Hyperosmolar hyperglycaemic state is a complication of predominantly type 2 diabetes in which high blood glucose causes severe dehydration and increases in osmolality (usually > 320 mosmol/kg).
• Simple hyperglycaemia: A less serious complication of diabetes that occurs when blood glucose is raised without any production of ketones or increases in osmolality

Identification/recognition/diagnosis of problem

Early symptoms of DKA include polydipsia and polyuria. Malaise, generalised weakness and fatigability, often associated with nausea, vomiting, diffuse abdominal pain, decreased appetite and anorexia are often present on admission.  Altered consciousness points to severe disease.  Causes include:

• Non-compliance of medication (non-adherence or medication error)
• Sepsis (ENT, respiratory, meningitis, PID, appendicitis, skin, feet)
• New diabetic/ first diagnosis
• Acute coronary syndrome
• Stroke
• Pancreatitis

Differential Diagnosis

• Alcoholic ketoacidosis
• Appendicitis, acute
• Hyperosmolar coma
• Hypophosphatemia
• Hypothermia
• Lactic acidosis
• Metabolic acidosis
• Acute coronary syndrome
• Pancreatitis, acute
• Pneumonia, immunocompromised
• Shock, septic
• Toxicity, salicylate
• Urinary tract infection

Severity assessment (Triage)

Management based on severity

Immediate action

Stabilise using ABCs, perform blood glucose 2 hourly, apply oxygen if hypoxic and establish IV access.

Non-drug treatment: Fluid Management

• Choice of fluid:
  • Saline 0.9% as initial fluid
  • If Glucose ≥ 15mmol/l continue Saline 0.9% 1L 6 hourly
  • If Glucose < 15 mmol/l change to 5% Dextrose containing fluid (e.g. Rehydration Solution) 1L 6 hourly
  • In HHS change to Saline 0.45% only if osmolality and glucose not declining using standard regiment above (should always be done in consultation with the medical team)
• Adjust rate of fluid administration in elderly patients and patients with poor cardiac function or renal compromise.

Drug treatment

• Insulin Administration: start once SBP > 90mmHg
  • Rate minder available: 50 Units Actrapid in 200 ml N/S at rate of 24 ml/hr (6 Units/hr)
  • No rate minder then: 10 Units SC stat, then 6 Units Actrapid SC hourly
  • Hourly glucose checks once insulin started
  • Keep at constant rate as above and change fluid depending on glucose until DKA resolved
• Potassium administration: Repeat K⁺ every 6 hours and adjust replacement as needed

• Bicarbonate Administration
  • No evidence that it improves morbidity/ mortality.  Worsens the ketosis and delays clearance of blood ketones. If to be given first ensure patient is fluid resuscitated and then consider:
    • If pH < 6.9 then 100 mmol 4 % NaHCO₃ in 400 mL Saline 0.9% with 20 mmol KCL over 2 hours
    • If pH < 7 then 50 mmol 4 % NaHCO₃ in 200 mL Saline 0.9% with 10 mmol KCl over 2 hours
• Antibiotic Administration
  • If source of sepsis found then antibiotics administered according to presumed organisms
  • If pH < 7 OR patient not responding to treatment then Blood Culture and administer broad spectrum antibiotics
• DVT Prophylaxis
  • If patient drowsy/ decreased LOC then give DVT prophylaxis

• Resolution of DKA/ HHS: Glucose < 11; Bicarbonate ≥ 18; pH> 7.3; normalisation of the serum anion gap (less than 12 mEq/L; anion gap = Na⁺ - (Cl^- + HCO₃^-)); patient has resumed eating and drinking with normal level of consciousness
• Patient will still require a further period of observation prior to discharge to ensure glucose levels stabilise
• Start usual medications as soon as possible following resolution
• In newly diagnosed diabetics start on a sliding scale or appropriate regime and adjust as needed. Provide the first sc dose at least an hour prior to cessation of the infusion in association with a meal.

Relevant history, Examination

• Examine for precipitants (e.g. infection; arrhythmias; anaemia)
• Measure and Record Vital Signs
• Point of care haemoglobin and glucose

Investigations

• Venous blood gas and U-dipstick
• FBC, renal function
• ECG
• CXR
• Osmolality (if unable to measure an approximation of osmolarity can be calculated where osmolarity = 2 x Na + glucose + urea

Referral criteria

• Confirmed DKA/HHS: admit to ICU or high dependency are under medical team
• Simple hyperglycaemia: admit medicine

Discharge

• If discharging patient, write a comprehensive referral letter back to the clinic, and consider an MOPD appointment for specialist input.

 Treatment algorithm for diabetic hyperglycaemic emergencies