Presentation on theme: "Hyperglycemic Emergencies DKA/HONC"— Presentation transcript:
1 Hyperglycemic Emergencies DKA/HONC William Harper, MD, FRCPCEndocrinology & MetabolismAssistant Professor of Medicine, McMaster University
2 Case 40 y.o. male, T1DM x 20y Normally on Novolin 30/70 38/20 Presents with decr LOC, confusion80/60, P120 reg, JVP < SA, dry mucus memRR 32, fruity odor to breathCBG 39 mM
3 Case7.29|33|18|95|98%What are the acid-base disturbances?42 BS
4 Case7.29|33|18|95|98%What other tests need to be done?42 BS
5 DKAA collection of severe and potentially life-threatening metabolic disturbances:Hyperglycemia Osmotic diuresisUrinary loss of fluids & electrolytesECFv contractionDepletion of total body K+ stores(even though may be hyperkalemic 2° to cell shift)Ketone production Metabolic acidosisCompensatory Respiratory alkalosis (hopefully!)Uncontrolled lipolysis severe TG
10 DKA: Diagnosis Symptoms & Signs: Laboratory: Polyuria, polydipsia, weight-lossFatigueN/V, abdominal pain ECFv, Kussmaul’s, Acetone breath, mild impairment in cognitionLaboratory:pH < 7.3, serum HCO3 < 15 mEq/L, AG > 14 mMRaised serum ketones (and urine ketones)BS > 14 mM (occasionally normal or only mild BS)
11 DKA: Management Monitoring IV Fluid Resuscitation (3-9L deficit) Potassium (“no pee no K”)K+ deficit 3-5 mEq/KgIV insulinIdentify & Rx underlying causeNoncompliance, infection, MI, etc.
12 DKA: Monitoring Consider ICU: Stepdown/Telemetry: all others Ward: pH < 6.9, inadequate respiratory compensationdecreased LOCSevere K+ disturbance (K+ < 3.0 or > 6.0 mEq/L)Stepdown/Telemetry: all othersWard:Only very mild DKA!pH > 7.2, serum HCO3 > 20, AG < 14ECFv near normalNot elderly, no hi-risk DKA precipitant (ex. MI)
13 DKA: Monitoring CBG q1-2h on IV insulin gtt q2h: Serum lytes, creatinine, glucoseq4-6h:pH > 7.2, HCO3 > 20, AG < 15ECFv stable and IV maintenance ratesnormal K+Calcium profile:Initially, then q12-24h unless abnormalPhospate levels can be high at 1st but drop with Rx of DKAFlowcharts to record biochemical parameters shown to be useful
15 DKA: IV FluidsIV 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 deficitThen lower to cc/h until deficit restored and eating/drinking wellIf hypotension recalcitrant to fluids consider AI (Schmidt PGAS II) and send stat plasma cortisol and ACTH, then give solucortef 100 mg IV q8h.
17 K+ DKA: Potassium Insulin K+ defecit: 3-5 mEq/Kg (350 mEq for 70Kg) Normal to high serum K+KetoacidosisH+H+K+K+Insulin
18 DKA: Potassium K+ deficit 3-5 mEq/kg (350 mEq 70kg) Need K with initial IV fluid & insulin Rx unless:AnuricK > 5.5 mEq/L or hyperkalemic ECG changesInitial [K]Replacement> 5.5 mEq/Lnil (initially)mEq/L10 mEq/h4-5.2 mEq/L20 mEq/h3-4 mEq/L30 mEq/h< 3 mEq/L40 mEq/h> 20 mEq/h:Cardiac monitor> 60 mEq/L:Central line
19 DKA: IV InsulinMight delay starting IV insulin for a few hours if K+ severely low (< 3.0 mEq/L) and metabolic acidosis not severe (pH > 7.0)Humulin R or Novolin TorontoBolus U/kg IVThen 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/hMonitoring serial serum ketones NOT useful as most assays measure Acetoacetate only:ßHß (not detected) DKA Rx Acetoacetate (detected)
20 DKA: IV InsulinUsing insulin to treat 2 different and separate metabolic disturbances in DKA:KetoacidosisHyperglycemia
21 DKA: IV InsulinIf AG not correcting and/or BS not decreasing then increase IV gtt rate 1.5-2XIf BS < 13 but AG still not corrected do NOT decrease insulin IV gtt.Instead start IV glucose gtt:cc/hOnce AG corrected than titrate IV insulin to BSWhen BS < 13 and AG normal: reduce IV insulin gtt to 1-2 U/h and add IV glucose if not already done.
22 DKA: Switch to S.C. insulin Can consider switch to SC insulin when:AG normalizedBS < 15 mMInsulin IV gtt requirements < 2U/hPatient able to eatOverlap insulin IV gtt with 1st SC insulin by 2-4h to avoid recurrent ketosisT2DM 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
23 DKA: Other Rx Bicarbonate Phosphate 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 > 7.1PhosphateRoutine IV not recommendedRx 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
24 DKA: Other Rx Cerebral Edema Usually only kids Persistent decreased LOC despite standard Rx of DKACT scan to confirm diagnosisDecadron 10 mg IVMannitol 25 mg IV
25 DKA: Management Monitoring IV Fluid Resuscitation (3-9L deficit) ICU: pH < 6.9, severe K (< 3, > 6), decr LOCIV Fluid Resuscitation (3-9L deficit)Potassium (“no pee no K”)IV insulinIdentify & Rx underlying causeNoncompliance, infection, MI, etc.
27 DKA Rx: EBMIn 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: 84:633-8RCT: Heber et al, 1977, Arch Intern Med: 137:No clinical benefit to giving IV HCO3RCT: Gamba et al, 1991, Rev Invest Clin: 43:234-48No benefit to giving IV phosphateRCT: Fischer et al, 1983, JCEM:57:177-80
28 HONC Hyperosmolar Non-Ketotic Coma T2DM, elderly (mean age 60-73), F > MPathogenesis poorly understoodMild ECFv instigating factorInsulin/Glucagon ratio sufficient to limit DKADiminished thirst or access to waterVicious cycle develops…
34 HONC: IV Fluids 25% body water lost (deficit 4-12 L) If hypotensive: Start with NS: 1L/h x 1-2hOnce ECFv normal change to 1/2NS:IV cc/h initiallyCorrect ½ deficit over 1st 12hCorrect total deficit by 36hLower fluid rates if elderly or known CHF
35 HONC: Insulin? Patients can be treated successfully without insulin If IV fluids inadequate BS and serum OSM will not drop despite insulinMajority of studies used insulinHi-dose Insulin: severe hypokalemia, shockTherefore if going to use insulin, use low doses:Bolus 0.1 U/kg, Rate 1-2 U/h (or 0.1 U/kg/h)
36 HONC: Management Coma Management Monitoring ABCs, O2, narcan, D50W, thiamine, etc.MonitoringIV Fluid Resusciation (10L free water defecit)Insulin?IV fluids will decrease BS by 4 mM/L/h by itselfFor most patients insulin not absolutely neccesaryInsulin IV bolus 5-10 U, 1-2 U/hPotassium (Deficit mEq)Replace as in DKAIdentify & Rx underlying precipitant!
37 HONC: Prognosis Hi-mortality: 30% complicating illness: Earlier series 58%Recent studies 12-17% (but some with mixed DKA)30% complicating illness:LRTI, GI bleed, ARF, CVA, MI, Pulm embolismDVT prophylaxsis beneficial?Independent mortality predictors:Advanced ageHigh osmolality, elevated ureasAfter recovery:Discharged on Insulin or OHA (I prefer insulin!)Monitor closely for water intake/dehydration (especially nursing home patients)