Hyperglycemic Emergencies Diabetic Ketoacidosis and Hyperosmolar - PowerPoint PPT Presentation

Hyperglycemic Emergencies Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State Jordanna Kapeluto and Evelyn Wong PGY-5 Endocrinology June 10/June 28, 2015

J Kapeluto 2015 Learning Objectives • Definition and Physiology of Diabetic Hyperglycemia Syndromes • Causes of Diabetic Hyperglycemia Syndromes • Management of DKA/HSS • Special Considerations in DKA 1

J Kapeluto 2015 Abbreviations in this session Abbr Term Abbr Term DKA Diabetic ketoacidosis Na Sodium HHS Hyperglycemic K Potassium hyperosmolar state AG Anion gap T1DM Type 1 diabetes mellitus AGMA Anion gap metabolic T2DM Type 2 diabetes mellitus acidosis SGLT2 Sodium glucose BUN Blood urea nitrogen transporter 2 Osm Osmolality ECG Electrocardiogram NS Normal saline AXR Abdominal x-ray LBW Lean body weight IVF Intravenous fluids HF-PEF Heart failure with HF-REF Heart failure with reduced preserved ejection fraction ejection fraction u/o Urine output ABG Arterial blood gas 2

J Kapeluto 2015 Epidemiology DKA HHS Population Type 1 (2/3) Type 2 Type 2 (1/3) Incidence 4.6 – 8.0 per 1000 < 1 per 1000 person-years person-years Morbidity 5000 – 10 000 500 – 1000 hospitalizations hospitalizations Mortality 4 – 10% 10 – 50% Recurrent DKA:  all- Underlying illness cause mortality 30% Fishbein et al. Diabetes in America. 1995. 3 Chiasson et al. CMAJ. 2003.

J Kapeluto 2015 Clinical Presentation DKA DKA HHS • ฀ skin turgor • • (Polyuria) Polyuria • • Dry axillae • (Polydipsia) Polydipsia Chronic • Dry oral mucosa • • (Weight loss) Weight loss • ฀ JVP • Volume depletion Severity • Tachycardia • Vomiting • Hypotension • Volume depletion • Neurologic Acute – Lethargy • Ketone breath – Coma • Abdominal pain • Kussmaul – Hemianopsia • breathing Hyperventilation – Hemiparesis – Seizures Kitabchi A et al. Diab Care. 2009 4

J Kapeluto 2015 Physiology of Hyperglycemia Chiasson et al. CMAJ. 2003. 5

J Kapeluto 2015 Diagnosis – Diabetic Ketoacidosis + + Hyperglycemia* Ketones Acidosis • • • > 13.9 mmol/L Acetoacetic acid AGMA • • • [Euglycemic DKA] Beta- pH < 7.35 • hydroxybutyric acid AG >12 • • +/- ฀ lactate Acetone • Resp alkalosis 6

J Kapeluto 2015 Diagnosis – Diabetic Ketoacidosis DKA Mimickers Ketones AGMA • • Starvation (HCO3 >18) Lactic acidosis • • Alcohol Toxicities • Acute/chronic renal failure Kitabchi A et al. Diab Care. 2009 6

J Kapeluto 2015 Management – Issues Volume Acidosis Ketosis Hyperglycemia Underlying Potassium Sodium Cause 7

J Kapeluto 2015 Management Volume 8

J Kapeluto 2015 Step 1 – Volume • Hyperglycemia ⬆ osmotic diuresis ⬆ volume depletion • Average fluid deficit: 3-6L • Replacement: • Hemodynamic stability • Start with NS (0.9% NaCl) • 500-1000 cc/hr (15-20cc/kg/hr) x 1 hour • Full replacement over 24 hours • Reassess using JVP/volume status q1h initially and Na • (Dextrose) Kitabchi A et al. Diab Care. 2009 9

J Kapeluto 2015 Step 1 – Volume • Cerebral edema? • More common in patients <20 years (0.3-1%) • Can occur in adults • Mortality 20-40% • DKA >>> HHS • Pathophysiology unknown • Often present prior to therapy • First 12-24 hours • Monitor: headache  lethargy, decreased arousal  seizures, incontinence, pupillary changes, bradycardia, and respiratory arrest Kitabchi A et al. Diab Care. 2009 10

J Kapeluto 2015 Step 1 – Volume • Prevention of (worsening) cerebral edema • • DKA HHS • • Cautious fluid replacement Same as DKA • • 15-20 cc/kg LBW/hr Add dextrose in IVF to maintain serum glucose 13.9-16.7 mmol/L • Maximum <50cc/kg in first 2-3 • hours Maintain serum glucose until hyperosmolality improving and • Dextrose in IVF once serum mental status/clinically stable glucose reaches 11.1 mmol/L • Pulmonary edema – Non-cardiogenic: due to reduction colloid osmotic pressure – Cardiogenic: caution with IVF in oligo/anuric CKD and HF-PEF/HF-REF Kitabchi A et al. Diab Care. 2009 11

J Kapeluto 2015 Monitoring Volume Time 0 6 12 18 24 pH Ketones Kitabchi A et al. Diab Care. 2009 12

J Kapeluto 2015 Management Volume Potassium Volume 13

J Kapeluto 2015 Step 2 - Potassium • Insulin deficiency + acidosis ⬆ extra cellular shift K + urinary losses • Total K deficit 3-5 mEq/kg • Renal function – u/o 50 cc/hr K < 3.3 K 3.4-4.9 K > 5.0-5.2 • • • Do not start insulin IVF 10-40 mmol/L Monitor K until K > 3.3 • IVF 40 mmol/L • Monitor q2h initially then q4h, choose venous or ABG • PO or central IV if K decreasing with IVF • Caution with K replacement in CKD – rarely hypoK Kitabchi A et al. Diab Care. 2009 14

J Kapeluto 2015 Monitoring Potassium Volume Time 0 6 12 18 24 pH Ketones 15

J Kapeluto 2015 Management Volume Potassium Insulin Volume 16

J Kapeluto 2015 Step 3 – Insulin • Insulin deficiency ฀ hyperglycemia + ketosis • Insulin therapy – treating the acidosis NOT hyperglycemia • Bolus vs. No bolus – No benefit to bolus – Theoretical large intracellular shift in potassium • Insulin R IV 0.1-0.15 units/kg LBW/hr to start – Average 70 kg person = 7 units/hr Kitabchi A et al. Diab Care. 2009 17

J Kapeluto 2015 Step 3 – Insulin • Monitoring insulin therapy in DKA • CBG measurements q1h + venous with other electrolytes • IVF lowers sugars ฀ can have rapid decrease in glucose within first hours of treatment – increased renal perfusion and glycosuria – dilutional effect • Do not stop insulin if glucose low – start dextrose (D5 + IVF) and reduce rate of insulin or give insulin 0.1 units/kg SC q2h – DKA: CBG 11.1 mmol/L – HHS: CBG 16.7 mmol/L Kitabchi A et al. Diab Care. 2009 18

J Kapeluto 2015 Step 3 – Insulin • Monitoring acidosis in DKA • Calculate the anion gap with each measurement of electrolytes AG = Na – (Cl + HCO 3 ) • Bicarbonate – IV bicarbonate = controversial – pH <6.9 100 mmol sodium bicarbonate (two amps) in 400 cc sterile water + 20 mEq KCI at 200 cc/hr for 2 h – Stop when pH >7.0 – Monitor K Kitabchi A et al. Diab Care. 2009 19

J Kapeluto 2015 Monitoring AG orHCO3 Glucose Potassium Volume Time 0 6 12 18 24 pH Ketones 20

J Kapeluto 2015 Management Volume Potassium Sodium Volume Insulin 21

J Kapeluto 2015 Step 4 – Sodium • Hyperglycemia + fluid shifts ฀ sodium disturbances – Hypernatremia = indicates severe volume depletion – Hyponatremia = most common – Pseudohyponatremia = lab artifact/dilutional effect from hyperglycemia • Total Na also depleted 7-10 mEq/kg Correction calculation: +3 mmol/L Na for every 10 mmmol/L of glucose above 10 • Monitor q2h initially then q4h • Adjust IVF from NS to 1/2 NS if overcorrecting hypoNa Kitabchi A et al. Diab Care. 2009 22

J Kapeluto 2015 Monitoring AG orHCO3 Sodium Glucose Potassium Volume Time 0 6 12 18 24 pH Ketones 23

J Kapeluto 2015 Management Volume Sodium Potassium Precipitant Volume Insulin 24

J Kapeluto 2015 Step 5 – Causes of DKA Insulin deficiency 25

J Kapeluto 2015 Step 5 – Causes of DKA • New T1DM Insulin deficiency • Adherence 25

J Kapeluto 2015 Step 5 – Causes of DKA • New T1DM • (C-peptide levels) Insulin deficiency • Adherence 25

J Kapeluto 2015 Step 5 – Causes of DKA • (C-peptide levels) Iatrogenic 25

J Kapeluto 2015 Step 5 – Causes of DKA • (C-peptide levels) • Medications Iatrogenic • Glucocorticoids 25

J Kapeluto 2015 Step 5 – Causes of DKA • (C-peptide levels) • Medications Iatrogenic • Glucocorticoids • Thiazide diuretics • Sympathomimetics • Lithium • Cocaine • Atypical antipsychotics • Fluoroquinolones • Prednisone • Dexamethasone • Hydrocortisone 25

J Kapeluto 2015 Step 5 – Causes of DKA • (C-peptide levels) • Urine toxin screen • Medications Iatrogenic • Glucocorticoids • Thiazide diuretics • Sympathomimetics • Lithium • Cocaine • Atypical antipsychotics • Fluoroquinolones • Prednisone • Dexamethasone • Hydrocortisone 25

J Kapeluto 2015 Step 5 – Causes of DKA • (C-peptide levels) • Urine toxin screen • Bacterial > viral > Infection fungal 25

J Kapeluto 2015 Step 5 – Causes of DKA • (C-peptide levels) • Urine toxin screen • Bacterial > viral > Infection fungal ICU Setting (n=40) Type: 1. Urinary 2. Gastrointestinal Pathogens: 1. E. coli 2. Staph aureus 3. Klebsiella pneumoniae Azoulay E et al. Clin Infect Dis. 2001 25

J Kapeluto 2015 Step 5 – Causes of DKA • (C-peptide levels) • Urine toxin screen • Blood cultures • Urine cultures • Bacterial > viral > Infection • Respiratory cultures fungal • Wound/Bone biopsy ICU Setting (n=40) Type: 1. Urinary 2. Gastrointestinal Pathogens: 1. E. coli 2. Staph aureus 3. Klebsiella pneumoniae Azoulay E et al. Clin Infect Dis. 2001 25