Hyperglycemic Emergencies in Adults

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Jeannette Goguen MD, MEd, FRCPC Jeremy Gilbert MD, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  • Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) should be suspected in ill patients with diabetes. If either DKA or HHS is diagnosed, precipitating factors must be sought and treated.
  • DKA and HHS are medical emergencies that require treatment and monitoring for multiple metabolic abnormalities and vigilance for complications.
  • A normal blood glucose does not rule out DKA in pregnancy.
  • Ketoacidosis requires insulin administration (0.1 U/kg/h) for resolution; bicarbonate therapy should be considered only for extreme acidosis (pH ≤7.0).

Note: Although the diagnosis and treatment of diabetic ketoacidosis (DKA) in adults and in children share general principles, there are significant differences in their application, largely related to the increased risk of life-threatening cerebral edema with DKA in children and adolescents.

Highlights of Revisions

  • Recommendations have been expanded to provide more information about the principles of treatment for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
  • A new recommendation suggests point-of-care capillary beta-hydroxybutyrate may be measured in the hospital in patients with type 1 diabetes with capillary glucose >14.0 mmol/L in order to screen for DKA. Also, a beta-hydroxybutyrate >1.5 mmol/L warrants further testing for DKA.

Recommendations

  1. 1.In adult patients with DKA, a protocol should be followed that incorporates the following principles of treatment: 1) fluid resuscitation, 2) avoidance of hypokalemia, 3) insulin administration, 4) avoidance of rapidly falling serum osmolality, and 5) search for precipitating cause [Grade D, Consensus].
  2. 2.In adult patients with HHS, a protocol should be followed that incorporates the following principles of treatment: 1) fluid resuscitation, 2) avoidance of hypokalemia, 3) avoidance of rapidly falling serum osmolality, 4) search for precipitating cause, and 5) possibly insulin to further reduce hyperglycemia [Grade D, Consensus].
  3. 3.Point-of-care capillary beta-hydroxybutyrate may be measured in the hospital in patients with type 1 diabetes with capillary glucose >14.0 mmol/L to screen for DKA, and a beta-hydroxybutyrate >1.5 mmol/L warrants further testing for DKA [Grade B, Level 2 (1–6)].
  4. 4.In individuals with DKA, IV 0.9% sodium chloride should be administered initially at 500 mL/h for 4 hours, then 250 mL/h for 4 hours [Grade B, Level 2 (7) ] with consideration of a higher initial rate (1–2 L/h) in the presence of shock [Grade D, Consensus]. For persons with a HHS, IV fluid administration should be individualized based on the patient's needs [Grade D, Consensus].
  5. 5.In individuals with DKA, an infusion of short-acting IV insulin of 0.10 U/kg/h should be used ([Grade B, Level 2 (8,9)]. The insulin infusion rate should be maintained until the resolution of ketosis [Grade B, Level 2 (10)] as measured by the normalization of the plasma anion gap [Grade D, Consensus]. Once the plasma glucose concentration reaches 14.0 mmol/L, IV dextrose should be started to avoid hypoglycemia [Grade D, Consensus].

Abbreviations:
DKA, diabetic ketoacidosis; HHS, hyperosmolar hyperglycemic state; IV, intravenous.

References

  1. Charles RA, Bee YM, Eng PH, Goh SY. Point-of-care blood ketone testing: screening for diabetic ketoacidosis at the emergency department. Singapore Med J 2007;48:986-9.
  2. Naunheim R, Jang TJ, Banet G, et al. Point-of-care test identifies diabetic ketoacidosis at triage. Acad Emerg Med 2006;13:683-5.
  3. Sefedini E, Prasek M, Metelko Z, et al. Use of capillary beta-hydroxybutyrate for the diagnosis of diabetic ketoacidosis at emergency room: Our one-year experience. Diabetol Croat 2008;37:73-8.
  4. MacKay L, Lyall MJ, Delaney S, et al. Are blood ketones a better predictor than urine ketones of acid base balance in diabetic ketoacidosis? Pract Diabetes Int 2010;27:396-9.>
  5. Bektas F, Eray O, Sari R, Akbas H. Point of care blood ketone testing of diabetic patients in the emergency department. Endocr Res 2004;30:395-402.
  6. Harris S, Ng R, Syed H, Hillson R. Near patient blood ketone measurements and their utility in predicting diabetic ketoacidosis. Diabet Med 2004;22: 221-4.
  7. Adrogue HJ, Barrero J, Eknoyan G. Salutary effects of modest fluid replacement in the treatment of adults with diabetic ketoacidosis. JAMA 1989;262: 2108-13.
  8. Heber D, Molitch ME, Sperling MA. Low-dose continuous insulin therapy for diabetic ketoacidosis: prospective comparison with “conventional” insulin therapy. Arch Intern Med 1977;137:1377-80.
  9. Butkiewicz EK, Leibson CL, O’Brien PC, et al. Insulin therapy for diabetic ketoacidosis: bolus insulin injection versus continuous insulin infusion. Diabetes Care 1995;18:1187-90.
  10. Umpierrez GE, Cuervo R, Karabell A, et al. Treatment of diabetic ketoacidosis with subcutaneous insulin aspart. Diabetes Care 2004;27:1873-88.

 

Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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