ACUTE COMPLICATION

HYPOGLYCAEMIA HYPERGLYCAEMIA CRISISDjoko wahono Soeatmadji

Ketoacidosis and Hyperosmolar Hyperglycemia HYPERGLYCAEMIA CRISIS

Mortality Rate Diabetic Ketoacidosis (DKA) : 5 10%;

PRECIPITATING FACTORS Infection (Pneumonia, UTI)CVAAlcohol abuseMyocardial infarctionTrauma Drugs (steroids, sympathomimetics, thiazides)PancreatitisDiscontinuation of or inadequate insulin in established type 1 diabetes

PATHOGENESIS net effective action of circulating insulin concomitant elevation of counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone)

Insulin DefciencyLipolysisHyperglicemia KetogenesisOsmotic diuresisKetoacidosisHyperosmolarityPure DKAPure HHSWickoff and Abrahamson. Joslins Diabetes 2005,p.887

DIAGNOSIS History and physical examinationLaboratory findingsDifferential diagnosis

Clinical features of diabetic ketoacidosisPolyuria, nocturia; thirstRapid weight lossMuscular weaknessVisual disturbanceAir hunger-acidotic (Kusmaul) respirationAbdominal pain leg crampsNausea, vomitingConfusion, drowsiness, coma (10%)

Laboratory findingsPlasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes (with calculated anion gap), osmolalityUrinalysis, urine ketones by dipstickInitial arterial/venous blood gasesComplete blood count with differentialElectrocardiogramBacterial cultures of urine, blood, and throat, etc.Chest X-ray

DIAGNOSIS OF SEVERE KADHyperglycemia (> 250 mg%)Ketosis (blood/urine)Acidemia (pH < 7.3)(ADA,2003) Hyperglycemia < 300 mg% pH > 7.2 BE > -12 mmol/L Severe symptoms (severe dehydration, shock/ hypotonia, persistent vomiting, drowsiness/coma, grave concomittant/underlying disease) (Wagner,1999)

Diagnostic criteria for DKA and HHSSerum osmolality :2[measured Na (mEq/l)]glucose (mg/dl)/18Anion gap : (Na+) - (Cl + HCO3) (mEq/l).

Causes of coma or impaired consciousness in diabetic patientsDiabetic ketoacidosisHyperosmolar non-ketotic hyperglycemiaHypoglycemiaLactic acidosisOther causes:Stroke (more common in diabetic patients) Post-ictal (including hypoglycemia-convulsions also causes a self-correcting lactic acidosis)Cerebral trauma (may follow hypoglycemia)Ethanol intoxication (may induce or exacerbate hypoglycemia in diabetic patients). Drug overdose

Differential diagnosislactic acidosisingestion of drugs such as salicylate, methanol, ethylene glycol, and paraldehydechronic renal failure

TRATMENTIV fluid (NS) ( initial : 1 l/hour or 1520 ml kg-1 BW h-1)Insulin (Continuous IV drip/im)K+Bicarbonate (pH < 7)PRECIPITATING FACTOR(S)

Management of Adult Patients with DKA Complete Initial Evaluation IV fluidInsulinPotassiumBiocarbonate

Management of Adult Patients with DKA Complete Initial Evaluation; Start i.v. Fluid 1.0 L of 0.9% NaCl per hour initially (15 20 ml/kg/h)IV fluidInsulinPotassiumBiocarbonate

Typical total body deficits of waterand electrolytes in DKA and HHS*

Total water (L)Water (mg/kg)Na (mEq/kg)Cl (mEq/kg)K (mEq/kg)PO4 (mmol/kg)Mg (mEq/kg)Ca (mEq/kg)61007 103 53 55 71 21 - 2 9100 2005 135 154 63 71 21 - 2

Guide to initial treatment of diabetic ketoacidosis in adultsFluids and electrolytesVolumes1L/h x 2-3, thereafter adjusted according to needFluidsIsotonic (normal) saline (150 mmol/L) generallyHypotonic (half-normal) saline (75 mmol/L) if serum sodium exceeds 150 mmol/L (no more than 1-2 L-consider 5% dextrose with increased insulin if marked hypernatraemia)5% dextrose 1 L-4-6-hourly when blood glucose has fallen to 270 mg/dl (15 mmol/L) (severely dehydrated patients may require simultaneous saline infusion)Consider sodium bicarbonate ( 700 mL of 1.26% or 100 mL of 8.4% if large vein cannulated) if pH < 7.0 (with extra potassium)

I. IV FluidsHydration Status ?Hypovolemic shockMild hypotensionCardioogenic shock0.95% NaCl (1 L/h) and/or plasma expanderHemodynamic monitoringEvaluate corrected serum Na+Serum Na highSerum Na normalSerum Na lowSerum glucose reaches 250 mg%Change to D5% with 0.45% NaCl at 150 250 ml/h with adequate insulin (0.05 0.1 u/kg/h) iv infusion(add 1.6 mEq to sodium value)

II. INSULIN Insulin Regular 0.15 u/kg/bolus/iRI 0.1 u/kg/h/iv infusionIf serum glucose does not fall by 50 70 mg%Insulin Regular 0.4 u/kg/bolus/0.1 u/kg/h/imDouble insulin hourly until glucose fall by 50 70 mg%Give 10 u/h/bolus until glucose fall by 50 70 mg%STABILIZEDStart Subcutaneous InsulinINTRAVENOUSINTRAMUSCULAR

III. POTASSIUM Hold insulin and give 40 mEq K+/h (2/3 as KCL and 1/3 as KPO4 until K+ 3.3 mEq/LInitial serum K+ 5.0 mEq/LGive 20 30 mEq K+ in each liter of iv fluid (2/3 as KCL and 1/3 as KPO4) to keep serum K+ at 4 5 mEq/LmEqInitial serum K+< 3.3 mEq/LDo not give K+ and check K+ every 2 h Initial serum K+ 3.3 5.5 mEq/L

IV. ASSESS NEED FOR BICARBONATE pH < 6.9NaHCO3 (100 mmol/L) Dilute in 400 ml H2O infuse at 200 ml/hpH 6.9 - 7NaHCO3 (50 mmol/L) Dilute in 200 ml H2O infuse at 200 ml/hpH > 7No NaHCO3Repeat HCO3 administration every 2 h until pH > 7.0 Monitor serum K+

V. MAINTENANCE Keep the serum glucose 150 200 mg% until metabolic control is achievedCheck electrolyte creatinine and glucose every 2 4 h. Start NPO, continue IV insuin for 1 2 h to ensure adequate plasma insulin and supplement with RI sc as needed. When the patient can eat initiate a multidose insulin regiment and ajust as needed. Continue to look for precipitating factor(s)

HYPERGLYCAEMIA HYPEROSMOLAR STATE

Protocol for the management of adult patients with HHS Diagnostic criteria: blood glucose >600 mg/dl arterial pH >7.3 bicarbonate >15 mEq/l mild ketonuria or ketonemia effective serum osmolality >320 mOsm/kg H2ONa should be corrected for hyperglycemia (for each 100 mg/dl glucose >100 mg/dl, add 1.6 mEq to sodium value for corrected serum value

Protocol for the management of adult patients with HHS Diagnostic Criteria Blood glucose >600 mg/dl Arterial pH >7.3 Bicarbonate >15 mEq/l Mild ketonuria or ketonemia Effective serum osmolality >320 mOsm/kg H2ONa+ should be corrected for hyperglycemia (for each 100 mg/dl glucose >100 mg/dl, add 1.6 mEq to sodium value for corrected serum value

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