Diabetic Hyperglycaemic Emergencies

Question 1

How is DKA characterised?

Answer 1

• Hyperglycaemia (blood glucose >11 mmol/L or known DMT2)
• Ketonaemia
• Acidosis (bicarb < 15 mmol/L and/or venous pH <7.3)

Common signs and symptoms:

• dehydration due to:
• polydipsia
• polyuria
• weight loss
• excessive tiredness
• nausea
• vomiting
• abdominal pain
• Kussmaul respiration
• reduced consciousness

Question 2

How is HHS characterised?

Answer 2

• Hypovolaemia
• Marked hyperglycaemia (blood glucose > 30 mmol/L without significant hyperketonaemia or acidosis)
• Hyperosmolality

Common signs and symptoms:

• dehydration due to:
• polydipsia
• polyuria
• weakness
• weight loss
• tachycardia
• dry mucous membranes
• poor skin turgor
• hypotension
• acute cognitive impairment
• shock (in severe cases)

Question 3

What is the immediate management (0-60 minutes) of DKA?

Answer 3

Action 1:
- Start 0.9% NaCl solution (use large bore cannula)

Action 2:

• Start FRIII (0.1 unit/kg/hr based on estimate of weight)
• If patient normally takes long acting insulin, continue at normal dose

Action 3:
- Assess resp rate, temp., BP, O2 sats, GCS, full clinical examination

Action 4:

• Capillary and blood glucose
• Venous BG
• U&E and FBC
• Blood cultures
• ECG
• CXR
• MSU

Action 5:

• Hourly capillary blood glucose
• Hourly capillary ketones
• Venous bicarb and potassium at 60 minutes, 2 hrs, 2 hrly thereafter
• 4 hrly plasma electrolytes
• Continuous cardiac monitoring if required
• Continuous pulse oximetry if required

Action 6:
Consider and precipitating causes and treat appropriately

Question 4

What is the immediate management (1-6 hrs) of DKA?

Answer 4

Action 1:

• Reassess patient
• Monitor vital signs

Action 2:

• Continue fluid replacement via infusion pump:
  0. 9% NaCl 1L with Potassium Chloride over next 2 hrs, then 2 hrs, then 4 hrs
• Add 10% glucose 125ml/hr if blood glucose falls below 14 mmol/L

Action 3:

• Assess response to treatment
• Review insulin infusion rate

Question 5

What is the management (6-12 hrs) of DKA?

Answer 5

Action 1:
Re-assess patient and monitor vital signs
Continue IV fluid via infusion pump at reduced rate:
0.9% NaCl 1L with KCl over 4 hrs, then 6 hrs
Add 10% dextrose 125mls/hr if the glucose falls below 14 mmol/L

Check for fluid overload

Action 2:
Review biochemical and metabolic parameters

Question 6

What is the management (12-24 hrs) of DKA?

Answer 6

Action 1:
Re-assess patient, monitor vital signs

Action 2:
Review biochemical and metabolic parameters
- At 12 hrs check venous pH, bicarb, potassium, ketones and glucose
- Resolution is defined as ketones <0.6 mmol/L, venous pH > 7.3

Question 7

What are the treatment goals of HHS?

https://abcd.care/sites/abcd.care/files/resources/JBDS_IP_HHS_Adults.pdf

Answer 7

• Normalise the osmolality
• Replace fluid and electrolyte losses
• Normalise blood glucose

Other goals: 
- Arterial or venous thrombosis 
- Other potential complications: 
Cerebral oedema/ central pontine myelinolysis 
- Foot ulceration