Metabolic & Electrolyte emergenciesDr G R Letchuman

Contents:

• Hyperglycaemia• Hypoglycaemia• Hyperkalemia

Hyperglycaemic emergencies

• diabetic ketoacidosis (DKA)• hyperosmolar hyperglycaemia state (HHS)

• Mortality %:< 5 – DKA ( more ketosis)

~ 15 – HHS (more dehydration)Worse if extreme ages, hypotension, hypothermia & coma• ADA in Diabetes Care, vol 27, supp 1, Jan 2004• Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, Wall BM:

Management of hyperglycemic crises in patients with diabetes. Diabetes Care 24:131–153, 2001

• 25 y.o. lady. Accounts clerk. Single • T1DM since age of 14 years old• On basal bolus insulin regime, actrapid 12/8/19

& insulatard 12 u ON but not compliant to treatment

• Admitted to hospital on 20/5/08 c/o nausea, vomitting, blurred vision, fever, abdominal discomfort, polyuria and polydipsia – 2 days

• LMP: Mid may.• PMH: multiple admissions for hyperglycaemia

• Clinically alert. wt~45kg• PR 120/min, BP 106/74 mmHg. 37.5C• CV and Resp system normal.• Abdomen soft, nontender

Diagnosis :

The patient:• Urine ketone 3+• RBS 30.3• VBG pH 7.14, • HCO3 8 mmol/L• Anion Gap 27

Diagnosis :

The patient:• Urine ketone 3+• RBS 30.3• VBG pH 7.14, • HCO3 8 mmol/L

ADA• Urine ketone +• Glucose > 14• pH ≤ 7.3• bicarbonate ≤ 18• Serum ketone +

Diagnosis

• Urine acetone maybe negative because beta hydorxybutyrate is not measured by urine ketone strip)

Blood ketone testing> urine• ADA. Tests of glycaemia. Diabetes Care

2003:26(supp.1)S106-8

• > sensitive than urine ketone

• Assist in decision making for admission and discharge.

• S. Beta-hydroxybutyrate ≥ 3.8mmol/l maybe superior than HCO3 Diabetes Care 31:643-647,2008

• When glucose ≥16.7

Blood ketone mmol/l

Action: Assess clinical status

<0.6 assess. Kiv discharge

0.6-1.5 Recheck in 2-4 hours

>1.5 Immediate treatment

Differential Diagnosis:

• Starvation ketosis• Alcohol ketoacidosis• Lactic acidosis

• BUSE 6.9/ 127/ 4.8/ 92 creat 65.8• Hb 10.6 TW 6.4• UFEME Leucocyte 3+

• Diagnosis: DKA with UTI

sodium

• Na+ = 127

sodium

• Na+ = 127• (+1.6 for every 5.5mmol rise above 5.5) • Corrected Na+ = 127 + (30.3-5.5)/5.5 X 1.6 = 134 mmol/l

• What about serum osmolality?

Coma in HHS/DKA

• Conscious level correlates to serum osmolality. Diabetes Care 3:53-56,1980, Arch Intern Med 157:669-675,1997

• If osmolality < 320, look for other causes.

Management at casualty:

• 1430• i/v NS one pint• i/v s. insulin 10 unit stat• FBC/Renal profile/RBS/Urine FEME/VBG• Admit

Management in ward• 3.50 pm

– Run 2 pints of NS fast over 1 hour– To review one hour post fluid challenge. If still tachycardia, another fluid

challenge– Then 6 pints of drip over 24 hours– I/V s. insulin 10 unit stat. Then sliding scale.– i/v antibiotics (2nd cephalosporin)

• Inform doctor about K+ level• Blood glucose 2 hrly• Use NS if BS >15 and use D5% if BS <15• Strict I/O• KIV KCL• ECG/RBS/FBC/RP/Urine FEME/Urine C&S• Lipids cm

Therapy :

1. Fluid2. Insulin3. Potassium4. Underlying precipitating factor

Therapy :

1. Fluid2. Insulin3. Potassium4. Underlying precipitating factor

MONITORING!

ADA:Fluid therapy :

• 1st hour : 0.9% NaCl 15-20ml/kg (50kg~1L)

• Then : 0.45% NaCl 4-14ml/kg/hr (50kg~500mls/hr) if corrected S. Na+ is normal or high

• Use 0.9% NaCl if corrected S Na+ is low

• Beware in renal or cardiac failures

ADA Standards of Medical Care in Diabetes—2007 Diabetes care in the hospital

• Patients controlled with continuous intravenous insulin typically require hourly blood glucose testing until the blood glucose levels are stable, then every 2 h.

Insulin therapy• Insulin Sliding Scale

– CBS < 4 omit– CBS 4 – 7 1 unit/hr– CBS 7.1- 11 2 unit/hr– CBS 11.1- 15 3 unit/hr– CBS 15.1 – 20 4 unit/hr– CBS 20.1 – 25 5 unit/hr– CBs > 25 6 unit/hr

• Monitor CBS 2-hourly

• CBS trend and insulin infusion rate– HI 1800 6 unit/hr– 8.3 2000 3 unit/hr– 5.4 2200 1 unit/hr– 18.2 12mn 4 unit/hr– 9.2 0200 2 unit/hr– 4.8 0400 1 unit/hr– 3.1 0600 omit– 15.2 0800 4 unit/hr

• Subsequently changed to basal-bolus regime

ADA Standards of Medical Care in Diabetes—2007 Diabetes care in the hospital

• Scheduled prandial insulin doses should be given in relation to meals and should be adjusted according to point-of-care glucose levels. The traditional sliding-scale insulin regimens are ineffective as monotherapy and are not recommended. (C)

ADA: Insulin therapy

Once hypokalemia K+ < 3.3 is ruled out,• Bolus I/V S. insulin 0.1/kg• Then S. insulin infusion 0.1/kg/hr• Glucose reduction - 3-4 mmol/l per hour• If above not achieved, double dose

Potassium

Time taken K+ Action

1430 6.6 Doctor informed at 2100. ECG. Triple regime. Rpt BUSE

1530 4.8

2300 3.3 KCL 1g alternate pint

0930 3.9

22/5 4.2

ADA: Potassium

• Total body depletion• Insulin, correction of acidosis & volume

expansion decreases potassium• Start K+ when serum < 5.3 & adequate

urine output ~50ml/hr.• Generally 1.0 – 1.5 g KCL in 500 mls.• If first K+<3.3, Correct with K+ & fluids.

Delay insulin therapy until K+>3.3 • Check electrolytes every 2 -4 hours

Bicarbonate:

• VBG pH 7.14, • HCO3 8 mmol/L• Treat?

ADA :Bicarbonate • Bicarbonate therapy did not alter recovery

outcomes in adults with moderate DKA (pH 6.9-7.14). Kitabchi, Abbas E.; Umpierrez, Guillermo E.; Fisher, Joseph N.; Murphy, Mary Beth; Stentz, Frankie B.

• < 6.9 prudent to treat but be careful of hypokalemia.

• 100 mmol sodium bicarbonate in 400 ml an isotonic solution with 20 mEq KCl administered at a rate of 200 ml/h for 2 h until the venous pH is >7.0.

Bicarbonate:

• VBG pH 7.14, • HCO3 8 mmol/L• Treat?

• By 16 hours :VBG pH 7.28HCO3 17 mmol/l

Precipitating factor:

• UTI?• Missed dose?• Urine C&S – no growth

Management:

• By 16 hours :B/P stable. P/R 83/minBG: 3.1 VBG pH 7.28 HCO3 17 mmol/l

Plan:Off sliding scaleBasal bolus insulin. S/C S. Insulin 14 tds

Intermediate insulin 12 units ON

Management:

Date Time glucose Insulin21/5 Pre lunch 14 SI 14 tds

Pre dinner 12.1Pre bed 25.0 Interm 12

22/5 Pre BF 3.7Pre lunch 4.7Pre dinner 3.5 omitPre bed 17.3 Long act 8

23/5 Pre BF 7.0

ADA: Glucose < 11mmol/l :

• 5%DW +/- 0.45%NaCl at 150-250ml/hr (~500mls every 2 -3 hrs)

• Insulin 0.05-0.1/kg/hr (2-5 unit per hour)• KCL in drip as previous• Keep glucose 8-11mmol/l• Monitor BUSE & glucose 2-4 hourly until stable

Once patient able to eat…

• Change to basal bolus regime• Dose will depend on previous dose

required Continue insulin infusion for 1-2 hours after s/c insulin. (consider s/c basal early)

Complications:

• hypoglycemia and hypokalemia due to overzealous treatment with insulin

• Cerebral edema is a rare but frequently fatal complication of DKA

• noncardiogenic pulmonary edema

Diagnosis of DKA / HHS:

DKA HHSGlucose mmol/l > 14 > 33pH ≤ 7.3 >7.3bicarbonate ≤ 18 > 15Urine ketone + smallSerum ketone + smallS osmolality mOsm/kg

variable > 320

Anion gap > 12 variableMental state Alert/ drowsy Stupor/coma

Summary

• DKA & HHS – medical emergencies• Diagnosis – role of blood ketone• Fluid • Insulin • Potassium• Precipitating cause

Pitfalls:

• Delay in tracing electrolytes & hence K+ replacement

• Inadequate fluids• Not correcting Na+• Dependence on sliding scale• Non overlap of insulin infusion & S/C insulin• Inadequate intensive MONITORING

Second case

• 77 year old patient with T2DM and Hypertension

• C/O lethargy and weakness for 2 days.• Drowsy, B/P 150/90 P/R 96/min

• Glucometer : 1.1 mmol/l• I/V dextrose 50% 20mls stat• I/V DW 10% infusion

medication

• Metformin 1g tds• Glibenclamide 10mg bd• Nifedipine 10mg tds• Perindopril 8mg daily• Hydrochlothiazide 50mg daily• Aspirin 150mg daily• Lovastatin 20mg daily

What to do now?

• Send home?• Admit?• Find out cause of hypoglycaemia?

• Patient admitted

• 31.8/6.5/137 creat 890• Hb 11.6 wbc 21.7 platelets 236.• pH 6.74 HCo3 2• Ca 2.25 PO4 4.46 Alb 20

What is your diagnosis

• Hypoglycamia precipitated by CRF?• Hypoglycamia precipitated by ARF?• Addisonian Crisis?

• I/V DW 10%• I/V calcium• I/V Sodium Bicarbonate• I/V hydrocortisone 100mg tds

Hyperkalemia

•• Signs & Symptoms: neuromuscular in nature. ECG=Tall T loss of P widening of

QRS sine wave VF/asystole/heart block.•• Rx:: Immediate;• Calcium chloride or gluconate – several amp of 10ml of 10% solution – antagonism of

K+ at cardiac membrane. Effect lasts 40mins• Regular insulin 10 units i/v + 20%Dextrose water (to prevent hypo). Effect lasts 4hr.• Sodium bicarbonate 40mmols by slow i/v push over 5-15 mins. Effect lasts 2 hours.•• Oral K+ exchange resins.

•

Conclusion

• In hypoglycaemia, find ppt cause & monitor hourly initially.

• High index of suspicion for hyperK

What was the pre admission sequence of events?

Summary

• Hyperglycaemia• Hypoglycaemia• Hyperkalemia

• Thank you

Thirty Years of Personal Experience in Hyperglycemic Crises: Diabetic Ketoacidosis

and Hyperglycemic Hyperosmolar State

• Kitabchi, Abbas E.; Umpierrez, Guillermo E.; Fisher, Joseph N.; Murphy, Mary Beth; Stentz, Frankie B.

• The Journal of Clinical Endocrinology & Metabolism Issue:Volume 93(5), May 2008, pp 1541-1552

• Division of Endocrinology, Diabetes, and Metabolism University of Tennessee Health Science Center, Memphis,Tennessee 38163

• Division of Endocrinology (G.E.U.), Emory University School of Medicine, Atlanta, Georgia 30322

Insulin therapy

• High-Dose (263 +/- 45 U) vs. Low-Dose (46 +/- 5 U)

Insulin in Adult DKA. Resolution of acidosis, hyperglycaemia similar but high dose group had higher hypoglycemia & hypokalaemia.

Route of insulin :

• I/V vs I/M vs S/C• i/v faster at 2 hours but by 8 hours it is

similar

• Not necessary to add albumin to the insulin infusate, as done in previous protocols.

• Use of Phosphate Therapy in DKA – no difference in outcome

• concluded that bicarbonate therapy did not alter recovery outcomes in adults with moderate DKA (pH 6.9-7.14)

• Concluded that the use of sc rapid-acting insulin analogs every 1 or 2 h represents a safe and effective alternative to the use of iv regular insulin in uncomplicated DKA.

Future studies:1) Efficacy of bicarbonate in DKA for a pH <6.9; 2) Need for a initial bolus insulin dose in DKA; 3) Mechanisms for the absence of ketosis in HHS; 4) Reasons for elevated proinflammatorycytokines and cardiovascular risk factors; 5) Cost benefit of using sc regular insulin vs.

analogs for DKA.

• Division of Endocrinology, Diabetes, and Metabolism University of Tennessee Health Science Center, Memphis,Tennessee 38163

• Division of Endocrinology (G.E.U.), Emory University School of Medicine, Atlanta, Georgia 30322

Management in ward

8.55pm K+ = 6.6 Cardiac monitorTriple regimeRpt BUSE 1 hour

1030pm K+ 4.8KCL 1g alternate pintsUse NS if CBS >15 and use D5% if CBS <15

Management in ward

21/5 9.30am K+ 3.3

0.5 g KCL per pint

management• Fluid Therapy

• Potassium supplement– Add 1g KCL in alternate pint of drip

insulin

• Potassium trend while on insulin infusion– 4.8 ( prior to insulin infusion ) -> 6.6 -> 3.3 ->

3.9

• Treat precipitating cause– IV Augmentin for UTI– Ensure compliance even during sick days

Diagnosis

Most imp: • 1. Increased Anion gap usually > 20 ( N =

< 14 mEq/l). • 2. HCO3 < 10 • Urine acetone maybe negative because

beta hydorxybutyrate is not measured by urine ketone strip)

Serum osmolality

• Osmolality = 2(Na+ + K+) + glucose + urea

• This patient = 2(134 + 3.3) + 30.3 + 6.9 = 311.8

Management in ward

21/5 s/c lantus 10 units sweating early morning