Hyperglycemic Emergencies in Adults

Abstract

KEY MESSAGES • Diabetic ketoacidosis and hyperosmolar hyperglycemic state should be suspected in people who have diabetes and are ill. If either diabetic ketoacidosis or hyperosmolar hyperglycemic state is diagnosed, precipitating factors must be sought and treated. • Diabetic ketoacidosis and hyperosmolar hyperglycemic state are medical emergencies that require treatment and monitoring for multiple metabolic abnormalities and vigilance for complications. • A normal or mildly elevated blood glucose level does not rule out diabetic ketoacidosis in certain conditions, such as pregnancy or with SGLT2 inhibitor use. • Diabetic ketoacidosis requires intravenous insulin administration (0.1 units/ kg/h) for resolution. Bicarbonate therapy may be considered only for extreme acidosis (pH ≤7.0). KEY MESSAGES FOR PEOPLE WITH DIABETES When you are sick, your blood glucose levels may fluctuate and be unpredictable: • During these times, it is a good idea to check your blood glucose levels more often than usual (for example, every 2 to 4 hours). • Drink plenty of sugar-free fluids or water. • If you have type 1 diabetes with blood glucose levels remaining over 14 mmol/L before meals, or if you have symptoms of diabetic ketoacidosis (see Table 1), check for ketones by performing a urine ketone test or blood ketone test. Blood ketone testing is preferred over urine testing. • Develop a sick-day plan with your diabetes health-care team. This should include information on: • Which diabetes medications you should continue and which ones you should temporarily stop • Guidelines for insulin adjustment if you are on insulin • Advice on when to contact your health-care provider or go to the emergency room. 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 lifethreatening cerebral edema with DKA in children and adolescents. The specific issues related to treatment of DKA in children and adolescents are addressed in the Type 1 Diabetes in Children and Adolescents chapter, p. S234. Symptoms Signs Hyperglycemia Polyuria, polydipsia, weakness ECFV contraction Acidosis Air hunger, nausea, vomiting and abdominal pain Altered sensorium Kussmaul respiration, acetone-odoured breath Altered sensorium Precipitating condition See list of conditions in Table 2 Can J Diabetes 42 (2018) S109-S114 Contents lists available at ScienceDirect Canadian Journal of Diabetes j o u r n a l h o m e p a g e : w w w. c a n a d i a n j o u r n a l o f d i a b e t e s. c o m

Management of diabetic ketoacidosis in adults: A narrative review

“…Venous pH measurement provides an adequate assessment of the degree of acidosis and response to therapy as well as helps avoid the pain and possible complications that are associated with repeated arterial punctures. [ 34 35 36 37 ] Venous pH is usually 0.015–0.03 lower than arterial pH. [ 34 35 36 ] The accumulation of ketoacids results in high anion gap metabolic acidosis; the anion gap is calculated by the following formula: [Na − (Cl + HCO 3 )].…”

“…[ 40 ] Currently, most of the available literature regarding fluid therapy is based on consensus guidelines and expert opinions. [ 13 37 41 ]…”

“…Patients with hypovolemic shock are continued on 0.9% sodium chloride at a rate of 1–2 L/h until their condition becomes stable, while patients with mild or moderate hypovolemia are given 0.9% sodium chloride at a rate of 500 ml/h for 4 h followed by 250–500 ml/h, depending on the clinical condition. [ 13 37 ] Once patients with severe hypovolemia become stable, the IV fluid management is changed to the same as those with mild or moderate hypovolemia. Once hypovolemia is corrected, the type of IV fluids is determined by the level of corrected serum sodium; if the level is low (<135 mmol/L), 0.9% sodium chloride is continued and if the level is normal or high (≥135 mmol/L), IV fluids should be changed to 0.45% sodium chloride.…”

“…Once hypovolemia is corrected, the type of IV fluids is determined by the level of corrected serum sodium; if the level is low (<135 mmol/L), 0.9% sodium chloride is continued and if the level is normal or high (≥135 mmol/L), IV fluids should be changed to 0.45% sodium chloride. [ 13 37 ] The rate of IV fluids in both groups will be 250–500 ml/h, depending on the patient's clinical status such as weight, vital signs, urine output and the presence of comorbid conditions. Once blood glucose reaches ≤11.1 mmol/L (200 mg/dL), 5% dextrose should be added along with 0.45% sodium chloride at a rate of 150–250 ml/h to maintain blood glucose concentration at 8.3–11.1 mmol/L (150–200 mg/dL).…”

Undetectable measured serum bicarbonate associated with hypertriglyceridemia-induced pancreatitis

“…Given our concern about the undetectable TCO 2 , we administered a sodium bicarbonate infusion at 150-200 mL/hr despite normal pH; this was not in keeping with diabetic ketoacidosis treatment guidelines. 1 The laboratory technician reported the patient's blood sample to be lipemic and her lipid panel showed severe hypertriglyceridemia (36.78 [normal 0-1.70] mmol/L).…”