1. Endocrine Emergencies & Management
Diabetic Ketoacidosis (DKA) & Hyperglycemic Hyperosmolar Syndrome (HHS)
Endocrine Emergencies
& Management

2. Learning Goals Understand the physiology of DKA and HHS.
Apply the revised Insulin infusion nomogram to patients experiencing DKA and HHS.

3. DKA Triad: Medical Emergency
Diabetic Ketoacidosis (DKA) can occur in both type 1 & 2 diabetes mellitus.
It presents with three common characteristics:
Hyperglycemia
Hyperketonemia
Metabolic Acidosis

4. Hyperglycemia Without insulin… Glucose does not move into the cell
Glucose accumulates in the bloodstream (leading to serum hyperosmolality)
Cells begin to starve; lipolysis occurs to compensate
PLEASE SEE COMMENT

5. Electrolyte imbalances
Hyperosmolality
As glucose concentration increases in the bloodstream, the kidneys attempt to excrete the glucose (along with water, potassium, phosphate, and magnesium)
Leads to:
Polyuria
Polydipsia
Dehydration
Electrolyte imbalances

6. Lipolysis Cells go into survival mode and breakdown fat for glucose
Adipose tissue (fat stores) are broken down
Produces byproduct of ketones which accumulates in bloodstream (hyperketonemia)

7. Hyperketonemia Cells use insulin to break down ketones
Without sufficient insulin, ketones accumulate in bloodstream along with the glucose (exacerbating serum hyperosmolality)
Excessive ketones changes the pH of blood to become more acidic (metabolic acidosis)

8. Metabolic Acidosis Blood pH < 7.3 Anion gap of 10-12 mEq/L
Body tries to compensate:
Hyperventilating (Kussmaul respirations) to decrease CO2 levels in blood and correct pH
Excrete ketones through renal system
Mental status changes, lethargy, and hypotension (LATE SIGNS! TREAT AGRESSIVELY!)

9. Classifying the Severity
Mild
Moderate
Severe
Plasma Glucose
>250
Arterial pH
7.25 – 7.30
<7.24
<7.0
Serum Bicarb
15 – 18
10 - <15
<10
Urine Ketone
Positive
Serum Ketone
Anion Gap
>10
>12
Mental Status
Alert
Alert/Drowsy
Stuperous

10. Hyperglycemic Hyperosmolar Syndrome (HHS)
Complication of type 2 diabetes
When glucose cannot move into the cell, it accumulates in the bloodstream (leading to hyperglycemia and hyperosmolality)
Since insulin is still produced in type 2 diabetes, it is sufficient to prevent lipolysis (which causes ketone byproducts)
HHS does not cause ketoacidosis
PLEASE SEE COMMENT

11. Differences in DKA & HHS
Correct acidosis
Lower blood glucose
Rehydrate
Correct electrolytes
Resolve cause
Criteria for resolved DKA:
pH > 7.3
Bicarbonate ≥ 15 mEq/L
Blood glucose < 200 mg/dL
Anion gap < 12
Patient is able to eat
HHS:
Lower blood glucose
Rehydrate
Correct electrolytes
Resolve cause
Criteria for resolved HHS:
BG 200 – 300 mg/dL
Patient is able to eat

12. Critical Note… Goal of DKA is to reverse the metabolic acidosis and
normalize serum glucose
Remember:
Hyperglycemia is not causing the acidosis—the ketones are!
It takes twice as long for insulin to treat ketones than it does for glucose.
Requires meticulous care and frequent monitoring for hours until acidosis is reversed.

13. Treatment Rehydrate Correct electrolyte deficits & acidosis
Restore glucose metabolism
Provide glucose when necessary
Prevent complications

14. Focus on restoring the volume
Rehydration
Focus on restoring the volume
1 liter of 0.9% NaCl bolus followed with maintenance fluids
Na+ levels during fluid resuscitation
Serum Na+ ≥ 135 mEq/L then 0.45% NaCl is used
Serum sodium ≤135 mEq/L then 0.9% NaCl is used
Give IV fluids until anion gap is closed or volume deficit is corrected.

15. Correcting Electrolyte Deficits & Acidosis
Correcting labs are crucial to your patient’s outcome
Chem 10, Magnesium & Phosphate are routinely ordered every 2 hours
ABG/VBG will show you if your acidosis is correcting

16. Do NOT start an insulin drip if potassium is < 3.3 mEq/L
Electrolytes
Magnesium
Phosphate
Potassium
≥ 1.8 mg/dL
≥ 1.5 mg/dL
≥ 5.1 mEq/L
The new order set has specific directions to replace each of these electrolytes.
However the physician may chose to write their own orders.
Do NOT start an insulin drip
if potassium is < 3.3 mEq/L

17. Respiratory Alkalosis
ABG / VBG
Test
Normal Ranges pH
7.35 – 7.45
pCO2
35 – 45 mmHg
pO2
80 – 100 mmHg
O2 Sat
95 – 100%
HCO3-
22 – 26 mmHg pH
CO2
HCO3-
Respiratory Acidosis
< 7.35
> 45 mmHg
Normal
Metabolic Acidosis
< 22 mEq/L
Respiratory Alkalosis
> 7.45
< 35 mmHg
Metabolic Alkalosis
> 26 mEq/L

18. Anion Gap Goal is to decrease anion gap to <12 in DKA patients
Calculated measurement of ions
in the blood:
Sodium – (Chloride + Bicarbonate)
Anion gap is high when you have DKA,
because of the ketoacids (anions).
Goal is to decrease anion gap
to <12 in DKA patients

19. The lungs can blow off the CO2 (acids).
Using Bicarbonate
HCO3 + H  H2CO3  H2O + CO2
The lungs can blow off the CO2 (acids).
New Order Set:
For pH less than 6.9, dilute 100 mEq Sodium Bicarbonate in 400 mL of D5W. Infuse over 2 hours.
For pH , dilute 50 mEq Sodium Bicarbonate in 200 mL of D5W. Infuse over 1 hour.

20. Glucose Target is: 150 – 200 mg/dL while in DKA
200 – 300 mg/dL while in HHS
Reduce glucose levels by mg/dL every hour until goal is reached
Glucometer reading “HI” (>500): Get a serum glucose STAT
Blood glucose levels hourly while on insulin drip

21. Insulin Drip Regular Insulin IV drip
Loading dose (if critically ill) = 0.1 units/kg
Start infusion rate = 0.1 unit/kg/hour
Nomogram titration is based upon finger stick blood glucose/sugar (FSBS).
Pump is programmed in units/kg/hour
PLEASE SEE COMMENT

22. DKA Nomogram

23. HHS Nomogram

24. Insulin Management
Do NOT stop insulin infusion unless you have hypoglycemia (< 70 mg/dL) or DKA is resolved
Criteria for resolved DKA:
Venous pH > 7.3
Bicarbonate ≥ 15 mEq/L
Blood glucose < 200 mg/dL
Anion gap < 12
Patient is able to eat

25. Converting Insulin IV to SubQ
Call physician to initiate subcutaneous insulin
AND
Wait to discontinue your insulin IV drip until
2 hours after subcutaneous insulin is initiated

26. Glucose Administration
Use dextrose-based IV fluids once target glucose has been reached
When blood glucose reaches 200 mg/dL, change IV fluids to D51/2 NS per MD order
Remember…Glucose levels correct faster than ketonemia. Need to correct the ketones that are causing the acidosis!

27. Preventing Complications
Hypoglycemia
Hourly monitoring of blood glucose level during insulin infusion
Hypokalemia
Caused by inadequate potassium replacement or inappropriate bicarbonate administration
Cerebral Edema (Rare, but severe complication)
Avoid excessive hydration and rapid decrease in plasma osmolarity
Maintain a slow, gradual decrease in serum glucose