lions and tigers and bears: diabetic ketoacidosis, pump ...€¦ · lions and tigers and bears:...
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Lions and Tigers and Bears:
Diabetic Ketoacidosis, Pump
Mangement and Other
Challenges in Pregnancy
Karin A. Fox, M.D., M.Ed.
Division of Maternal-Fetal Medicine,
Department of Obstetrics and Gynecology
Critical Care Conference
Feb 27, 2017
OBJECTIVES
Describe etiologies of and differences among the 3 major
diabetic emergencies: Diabetic Ketoacidosis (DKA),
Hyperosmolar Hyperglycemic State (HHS) and
Hypoglycemia
Formulate a basic treatment plan for each of the above
Understand the basics of pump management
Counsel patients and healthcare trainees about diagnosis
and management of the above metabolic emergencies.
I have no conflicts of interest to declare
We will discuss briefly insulin management, including
various forms of insulin
HOUSEKEEPING
SIZE AND SCOPE OF THE ISSUE
National Diabetes Statistics Report, National Center for Chronic Disease Prevention and Promotion, Division of Diabetes Translation, CDC, 2012
SIZE AND SCOPE OF THE ISSUE
Menke A,Casagrande S, Geiss L, Cowie C. Prevalence and Trends in Diabetes Among Adults in the United States 1988-201. JAMA. 2015;314(10):1021-1029.
~50% of adults in USA are diabetic or prediabetic Prevalence of diabetes: 12-14% Up to 25% of adults with diabetes are undiagnosed Prevalence increased among all ethnic groups
Center for Disease Control. Overweight and Obesity: Adult Obesity Facts. http://www.cdc.gov/obesity/data/adult.html
SIZE AND SCOPE OF THE ISSUE
NORMAL PHYSIOLOGIC STATE
TYPE 1 DIABETES (T1DM)
Elevated blood glucose
TYPE 2 DIABETES (T2DM)
Elevated blood glucose
Insulin receptor
DIABETIC KETOACIDOSIS (DKA)
A state of absolute or relative insulin deficiency
aggravated by hyperglycemia, dehydration, and
acidosis-producing derangements in intermediary
metabolism (intracellular starvation)
Ketone body formation
Can occur in both Type I Diabetes and Type II
Diabetes
In type II diabetics with insulin
deficiency/dependence
The presenting symptom for ~ 25% of Type I
Diabetics.
KETONES
Prolonged starvation:
Ketone bodies = 70% energy requirements of the
brain.
Normal conditions:
Kidneys excrete about 20 mg of ketone bodies/day.
Blood levels ~1 mg ketone bodies/100 mL of blood.
O O
OH
Acetoacetic acid
OH
OH O
3-b-Hydroxybutyrate
CH3
O
CH3
Acetone
1:10 in
DKA
H+ K+
HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS)
An acute metabolic complication of diabetes
mellitus characterized by impaired mental
status and elevated plasma osmolality in a
patient with hyperglycemia.
Occurs predominately in Type II Diabetics
A few reports of cases in type I diabetics.
The presenting symptom for 30-40% of Type II
diabetics.
Mild DKA Moderate DKA Severe DKA HHS
Plasma glucose (mg/dL) > 250 > 250 > 250 > 600
Arterial pH 7.25-7.30 7.00-7.24 < 7.00 > 7.30
Sodium Bicarbonate
(mEq/L)
15 – 18 10 - <15 < 10 > 15
Urine Ketones Positive Positive Positive Small
Serum Ketones Positive Positive Positive Small
Serum Osmolality
(mOsm/kg)
Variable Variable Variable > 320
Anion Gap > 10 > 12 > 12 variable
Mental Status Alert Alert/Drowsy Stupor/Coma Stupor/Coma
METABOLIC FINDINGS IN DKA/HHS
CAUSES OF DKA
Stressful precipitating event that results in increased catecholamines, cortisol, glucagon.
Infection (pneumonia, UTI)
Alcohol, drugs
Stroke
Myocardial Infarction
Pancreatitis
Trauma
Medications (steroids, thiazide diuretics)
Non-compliance with insulin
New Diagnosis of Diabetes
Pregnancy
PHYSIOLOGIC CHANGES IN PREGNANCY
Increased catecholamines, cortisol, glucagon, Human Placental Lactogen, growth hormone Hyperglycemia
Nausea and Vomiting of Pregnancy
Physiologic Alkalosis of Pregnancy (decreased buffering capacity)
PHYSIOLOGIC CHANGES IN PREGNANCY
SYMPTOMS OF DKA/HHS
Polyuria
Polydypsia
Blurry vision
Nausea/Vomiting
Abdominal Pain
Fatigue
Confusion
Obtundation/Coma
PHYSICAL EXAM FINDINGS
Hypotension
Tachycardia
Kussmaul breathing (deep, labored
breaths)
Fruity odor to breath (acetone)
Dry mucus membranes
Confusion
Abdominal tenderness
OUTCOMES - DKA
Fetal loss rates with single episode of
DKA approx 10-25%
Rare maternal mortality if recognized and
treated, actual incidence unknown
Prompt recognition and treatment key
TREATMENT
MATERNAL- Complete H&P
- Monitor VS and SaO2
- Seek source of infection/stressor
- Evaluate compliance
- Serum glucose, B-OH butyrate,
electrolytes
FETAL- Leftward tilt
- Confirm Viability
- Fetal Heart Monitor if > 24
weeks
FLUID STATUS- Start 0.9% NS 1,000ml/hr
x 2h
- After 2h, switch to 0.45%
NS at 250ml/hr
- When BG< 250mg/dL,
switch to D5/0.45%NS at
250ml/hr
- Total: 6-10 L/24h
- Foley catheter
- Maintain UOP > 50ml/hr
INSULIN- IV bolus 10-15 units
(REGULAR insulin)
- Start IV insulin infusion 0.1
unit/kg/hr
- Double rate if BG does not
decrease by 50mg/dL in 1st
hr
- Decrease to 0.05
units/kg/hr when BG <
200mg/dL
-Target: 100-150 mg/dL
POTASSIUM
- Serum K < 3.3,
hold insulin
infusion
- K >5.3, repeat
q1-2h until < 5.3
- If K 3.3-5.3, add
20-30 mEq K to
each L IVF
-Goal: 4-5 mEq/L
TREATMENT (Continued)
BICARBONATE- Avoid NaCHO3 if maternal pH >7.0
- If pH < 7.0, give 1 amp NaCHO3
- Repeat every 1-2h until pH >7.0
Once patient is stable and tolerating oral intake,
resume subcutaneously dosed insulin
Adapted from: de Veciana M. Diabetes ketoacidosis in pregnancy. Semin Perinatol. 2013Aug;37(4):267-73..
HYPOGLYCEMIA
Of patients with diabetes who die as a
direct result of diabetic complications,
what percentage die from hypoglycemia?
10%
HYPOGLYCEMIA- SYMPTOMS
Shakiness
Weakness
Sudor
Confusion/irritability
Obtundation/Coma
HYPOGLYCEMIA- TREATMENT
GLUCOSE
If able to eat/drinkgive 4 oz juice
(preferred) or soda, continue until BG > 70
If unable Glucagon 1mg IM OR D50 ½
to 1 amp IV
Recheck BG frequently (q15-30min)
Continue to monitor if active insulin on
board, at risk for further hypoglycemia
INSULIN
Basal: Long or intermediate acting(covers gluconeogenesis/periods of fasting)
Bolus: Short or Intermediate acting (covers mealtime glucose boluses from food)
40% TDD
60% TDD
Adjust by 10-20% up or down as needed, may adjust every 2-3 days
INSULIN
Example:Newly dx’d 60 kg patient at 12 weeks:
Same pt dx’d at 20 weeks:
At 32 weeks:
42 units
48 units
54 units
INSULIN DOSING
TDD: Total Daily Dose the total number of units used in 24h
Fixed Dose Regimen: Long acting dose (fixed)Fixed dose of rapid acting insulin with meals Consistent carbs, dose based on time
Carb-counting Regimen: Long acting dose (fixed)Flexible dose of rapid acting insulinFixed ratio of insulin to grams of carbs eatenICR (insulin-to-carb ratio)Correction factor (mg/dL drop with 1 unit)TargetMuch more flexible, but requires counting
Pump regimen: Similar concepts to carb-counting, but uses acontinuous infusion of rapid acting insulin
INSULIN DOSING – CARB COUNTING
Premeal Target BG: 90-110
Insulin to Carb Ratio: Estimated by the “Rule of 500”Divide 500 by TDD
Correction Factor: How much 1 unit will drop BG in mg/dLEstimated by “Rule of 1500”Divide 1500 by TDD
If the premeal BG is 172, and the patient plans to eat 60g carbs at her meal, how much insulin should she give herself?
500/42 = 11.9 1:12
1500/42 = 35.7 36
7 units
INSULIN DOSING – PUMP
Programmable: TargetBasal rate (may set multiple, based on time of day)Insulin-to-carb ratio (ICR) (may be different for each meal)Correction Factor
Patient then has to: Change insertion site q3d while pregnantTroubleshoot tubing/pump and refill reservoirType in premeal BG pump wizard calculates and doses!
*Check BG 8-10x daily (fasting, premeal, postmeal and prn)
Modern pumps communicate with continuous glucose monitors, can alarm when BG low/high, suspend
TAKE-HOME MESSAGES
- Not all diabetes is alike
- Every patient has a unique sensitivity to insulinMUST titrate
- In DKA Treat the underlying cause and mother to aid fetus
- Insulin helps glucose get into the cells, where it can be metabolized
- No matter what the insulin regimen, aim for ~50/50 or 40/60 split of long-acting (basal) to rapid-acting (bolus)
- Extremes of glucose levels are dangerous aim for steady state- watch for signs/symptoms and treat early!
QUESTIONS/COMMENTS