Presentation on theme: "Hyperglycemic Emergencies DKA/HONC William Harper, MD, FRCPC Endocrinology & Metabolism Assistant Professor of Medicine, McMaster University."— Presentation transcript:
Hyperglycemic Emergencies DKA/HONC William Harper, MD, FRCPC Endocrinology & Metabolism Assistant Professor of Medicine, McMaster University
Case 40 y.o. male, T1DM x 20y Normally on Novolin 30/70 38/20 Presents with decr LOC, confusion 80/60, P120 reg, JVP < SA, dry mucus mem RR 32, fruity odor to breath CBG 39 mM
Case |33|18|95|98% What are the acid-base disturbances? 42 BS
Case |33|18|95|98% What other tests need to be done? 42 BS
DKA A collection of severe and potentially life-threatening metabolic disturbances: Hyperglycemia Osmotic diuresis »Urinary loss of fluids & electrolytes »ECFv contraction »Depletion of total body K + stores (even though may be hyperkalemic 2° to cell shift) Ketone production Metabolic acidosis »Compensatory Respiratory alkalosis (hopefully!) Uncontrolled lipolysis severe TG
DKA: Diagnosis Symptoms & Signs: Polyuria, polydipsia, weight-loss Fatigue N/V, abdominal pain ECFv, Kussmaul’s, Acetone breath, mild impairment in cognition Laboratory: pH 14 mM Raised serum ketones (and urine ketones) BS > 14 mM (occasionally normal or only mild BS)
DKA: Management 1.Monitoring 2.IV Fluid Resuscitation (3-9L deficit) 3.Potassium (“no pee no K”) K + deficit 3-5 mEq/Kg 4.IV insulin 5.Identify & Rx underlying cause Noncompliance, infection, MI, etc.
DKA: Monitoring Consider ICU: pH < 6.9, inadequate respiratory compensation decreased LOC Severe K + disturbance (K mEq/L) Stepdown/Telemetry: all others Ward: Only very mild DKA! pH > 7.2, serum HCO3 > 20, AG < 14 ECFv near normal Not elderly, no hi-risk DKA precipitant (ex. MI)
DKA: Monitoring CBG q1-2h on IV insulin gtt q2h: Serum lytes, creatinine, glucose q4-6h: pH > 7.2, HCO3 > 20, AG < 15 ECFv stable and IV maintenance rates normal K + Calcium profile: Initially, then q12-24h unless abnormal Phospate levels can be high at 1 st but drop with Rx of DKA Flowcharts to record biochemical parameters shown to be useful
DKA: IV Fluids IV NS 0.5-1L/h x 1-2h or longer so no more tachycardia, hypotension, orthostatic changes, low JVP. Then change to 1/2 NS: cc/h over 12h in order to replace ½ estimated deficit Then lower to cc/h until deficit restored and eating/drinking well If hypotension recalcitrant to fluids consider AI (Schmidt PGAS II) and send stat plasma cortisol and ACTH, then give solucortef 100 mg IV q8h.
DKA: Potassium K + defecit: 3-5 mEq/Kg (350 mEq for 70Kg) Normal to high serum K + K+K+ K+K+ H+H+ H+H+ Ketoacidosis Insulin
DKA: Potassium K + deficit 3-5 mEq/kg (350 mEq 70kg) Need K with initial IV fluid & insulin Rx unless: Anuric K > 5.5 mEq/L or hyperkalemic ECG changes Initial [K]Replacement > 5.5 mEq/Lnil (initially) mEq/L10 mEq/h mEq/L20 mEq/h 3-4 mEq/L30 mEq/h < 3 mEq/L40 mEq/h > 20 mEq/h: Cardiac monitor > 60 mEq/L: Central line
DKA: IV Insulin Might delay starting IV insulin for a few hours if K + severely low ( 7.0) Humulin R or Novolin Toronto Bolus U/kg IV Then IV U/kg/h (50 U of regular insulin in 500cc D5W; 1U/10cc) Aim is to demonstrate correction of Anion Gap (AG) and decrease in BS 4.4 mM/L/h Monitoring serial serum ketones NOT useful as most assays measure Acetoacetate only: ßHß (not detected) DKA Rx Acetoacetate (detected)
DKA: IV Insulin Using insulin to treat 2 different and separate metabolic disturbances in DKA: 1.Ketoacidosis 2.Hyperglycemia
DKA: IV Insulin If AG not correcting and/or BS not decreasing then increase IV gtt rate 1.5-2X If BS < 13 but AG still not corrected do NOT decrease insulin IV gtt. Instead start IV glucose gtt: cc/h Once AG corrected than titrate IV insulin to BS When BS < 13 and AG normal: reduce IV insulin gtt to 1-2 U/h and add IV glucose if not already done.
DKA: Switch to S.C. insulin Can consider switch to SC insulin when: AG normalized BS < 15 mM Insulin IV gtt requirements < 2U/h Patient able to eat Overlap insulin IV gtt with 1 st SC insulin by 2-4h to avoid recurrent ketosis T2DM patients with DKA: Don’t necessarily have to be d/c on insulin SC (I often do!) Once acute stress resolved, many do well on OHA
DKA: Other Rx Bicarbonate May exacerbate hypokalemia Only give if pH < 6.9 AND evidence of cardiovascualr instability (arrythmia, CHF, hypotension) 1-2 amps bicarb in 1L D5W IV with mEq of added KCl given over 2h or until pH > 7.1 Phosphate Routine IV not recommended Rx symptomatic hypophosphatemia (rhabdo, unexplained CHF or respiratory failure, severe confusion) 10cc K Phos soln (3.0mEq Pi and 4.4 mEq K/cc) in 1L NS IV over 8-12h
DKA: Other Rx Cerebral Edema Usually only kids Persistent decreased LOC despite standard Rx of DKA CT scan to confirm diagnosis Decadron 10 mg IV Mannitol 25 mg IV
DKA: Management 1.Monitoring ICU: pH 6), decr LOC 2.IV Fluid Resuscitation (3-9L deficit) 3.Potassium (“no pee no K”) 4.IV insulin 5.Identify & Rx underlying cause Noncompliance, infection, MI, etc.
DKA Rx: EBM In patients not in shock, recovery is more rapid with slower rates of IV fluids (500 mL/h x 4h, then 250 mL/h) RCT: Adrogue et al, 1989, JAMA: 262: Low-dose insulin ( U/Kg bolus, then rate of U/Kg/h) has similar rate of recovery and less hypokalemia than high-dose insulin ( U/h) RCT: Kitabchi et al, 1976, Ann Intern Med: 84:633-8 RCT: Heber et al, 1977, Arch Intern Med: 137: No clinical benefit to giving IV HCO3 RCT: Gamba et al, 1991, Rev Invest Clin: 43: No benefit to giving IV phosphate RCT: Fischer et al, 1983, JCEM:57:177-80
HONC Hyperosmolar Non-Ketotic Coma T2DM, elderly (mean age 60-73), F > M Pathogenesis poorly understood Mild ECFv instigating factor Insulin/Glucagon ratio sufficient to limit DKA Diminished thirst or access to water Vicious cycle develops…
HONC: IV Fluids 25% body water lost (deficit 4-12 L) If hypotensive: Start with NS: 1L/h x 1-2h Once ECFv normal change to 1/2NS: IV cc/h initially Correct ½ deficit over 1 st 12h Correct total deficit by 36h Lower fluid rates if elderly or known CHF
HONC: Insulin? Patients can be treated successfully without insulin If IV fluids inadequate BS and serum OSM will not drop despite insulin Majority of studies used insulin Hi-dose Insulin: severe hypokalemia, shock Therefore if going to use insulin, use low doses: Bolus 0.1 U/kg, Rate 1-2 U/h (or 0.1 U/kg/h)
HONC: Management 1.Coma Management ABCs, O 2, narcan, D50W, thiamine, etc. 2.Monitoring 3.IV Fluid Resusciation (10L free water defecit) 4.Insulin? IV fluids will decrease BS by 4 mM/L/h by itself For most patients insulin not absolutely neccesary Insulin IV bolus 5-10 U, 1-2 U/h 5.Potassium (Deficit mEq) Replace as in DKA 6.Identify & Rx underlying precipitant!
HONC: Prognosis Hi-mortality: Earlier series 58% Recent studies 12-17% (but some with mixed DKA) 30% complicating illness: LRTI, GI bleed, ARF, CVA, MI, Pulm embolism DVT prophylaxsis beneficial? Independent mortality predictors: Advanced age High osmolality, elevated ureas After recovery: Discharged on Insulin or OHA (I prefer insulin!) Monitor closely for water intake/dehydration (especially nursing home patients)