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Diabetic ketoacidosis and hyperosmolar hyperglycaemic state. What is DKA?. High blood glucose, ketones, acidosis and dehydration. Absolute or relative insulin deficiency Increase in counter-regulatory hormones Breakdown of fat and muscle Biochemical triad hyperglycaemia ketoacids - PowerPoint PPT Presentation
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Slides current until 2008
Diabetic ketoacidosis andhyperosmolar hyperglycaemic state
DKA and HHSCurriculum Module III-6
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What is DKA?
• Absolute or relative insulin deficiency• Increase in counter-regulatory
hormones• Breakdown of fat and muscle• Biochemical triad
– hyperglycaemia– ketoacids– metabolic acidosis
High blood glucose, ketones, acidosis and dehydration
DKA and HHSCurriculum Module III-6
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Incidence of DKA
• Varies
• Death mainly from cerebral oedema
• Most common at onset in type 1 diabetes
• Recurrent episodes
• Can occur in type 2 diabetes
Kitabchi et al 2001, Joslin 2005
DKA and HHSCurriculum Module III-6
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DKA – cause or trigger
Incidence
New-onset diabetes 5-40%
Acute illness 10-20%
Insulin omission/non-adherence 33%
Infection 20-38%
Heart attack, stroke, pancreatitis <10%
Booth 2001, Joslin 2005
DKA and HHSCurriculum Module III-6
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Insulin deficiency
Glucose uptake Lipolysis
Hyperglycaemia Gluconeogenesis
Glycerol Free fatty acids
Ketogenesis
Ketonemia
KetonuriaOsmotic diuresis
Urinary water losses
Electrolyte depletion
Dehydration
Acidosis
Diabetic ketoacidosis
Adapted from Davidson 2001
Glucosuria
DKA and HHSCurriculum Module III-6
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Ketones
• Used as fuel when calories are restricted
• Physiological ketosis when fasting or with prolonged exercise
• Insulin deficiency lypolysis and ketone production acidosis– beta-hydroxybutyrate– acetoacetate– acetone
DKA and HHSCurriculum Module III-6
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Ketones
• Beta-hydroxybutyrate predominant – not detected by test strips or acetone tablets
• Ketoacidosis may be present without detectable urinary ketones
• Blood ketone testing may enable early identification of DKA
DKA and HHSCurriculum Module III-6
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Earlier clinical symptoms and signs of DKA
• Polyuria
• Polydipsia
• Polyphagia
• Tiredness
• Muscle cramps
• Flushed facial appearance
DKA and HHSCurriculum Module III-6
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Later clinical symptoms and signs of DKA
• Weight loss• Nausea and vomiting• Abdominal pain• Dehydration • Acidotic breath• Hypotension • Shock• Altered consciousness • Coma
DKA and HHSCurriculum Module III-6
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DKA – investigations
Immediate for diagnosis• Capillary blood glucose, urinary
glucose and ketones
Urgent for assessment and treatment• Blood glucose• Blood gases• Electrolytes, urea, creatinine• WBC
Consider• Cardiac monitor• Blood culture, urine culture• Chest X-ray
DKA and HHSCurriculum Module III-6
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DKA – laboratory findings
Blood glucose >14mmol/L (252mg/dL)
Ketones Urine: moderate to large
Blood: >3mmol/L
Osmolality Increased – high blood glucose and urea/creatinine, dehydration
Electrolytes Low/normal Na+ and Cl-
Low/normal/high K+ (often misleading)
Low HCO3 (normal 23-31)
Anion gap >10 mild
>12 moderate to severe
Blood gases pH <7.30, HCO3 <15 (mild)
pH <7.00, HCO3 <10 (severe)
DKA and HHSCurriculum Module III-6
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DKA – treatment
Rehydration 1. Correct shock with bolus saline
2. Rehydration rate depends on clinical status, age and kidney function
Normal saline (0.9%) for resuscitation and rehydration initially
Glucose/saline solution when glucose around 14 mmol/L (252mg/dL)
Rehydrate steadily over 48 hours
3. Consider NG tube
Potassium Essential after resuscitation and when urine output confirmed
Kitabchi et al 1976
DKA and HHSCurriculum Module III-6
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DKA – treatment
Insulin Infusion: 0.1 units/kg/hour after resuscitation, saline established and BG falling
Rate should be increased by 10-20% if glucose not fallen by 2-3 mmol/L (45-54mg/dL) over first hour
Monitoring BG, BP, urine output and hourly neurological status
Blood gases and electrolytes 2-hourly initially
DKA and HHSCurriculum Module III-6
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DKA – complications
• Hypoglycaemia +/- hypokalaemia
• Acidosis not improving – consider continuing dehydration or infection
• Aspiration pneumonia
• Headache +/- falling level of awareness – consider cerebral oedema and urgent treatment with Mannitol
Joslin 2005
DKA and HHSCurriculum Module III-6
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DKA – recovery
• Rapid improvement
• Continue IV insulin while ketosis present
• Oral intake when possible
• Rapid-acting insulin 30-60 minutes before discontinuing IV insulin
• Usual insulin regimen
• Consider drinks and food containing potassium
DKA and HHSCurriculum Module III-6
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What is HHS?
• Ketosis may be present
• Coma not always present
• Primarily in older people with/without history of type 2 diabetes
• Always associated with severe dehydration and hyperosmolar state
• Develops over weeks Kitabchi et al 2001
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HHS – incidence and features
• 0.5% of primary diabetes hospital admissions
• ~15% mortality rate
• Can occur in type 1 diabetes and younger people
Kitabchi et al 2001
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HHS – key features
• Marked hyperglycaemia
• Hyperosmolarity
• Absence of severe ketosis
• Altered mental awareness
Joslin 2005
DKA and HHSCurriculum Module III-6
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HHS – causes or triggers
Booth 2001
Incidence
Infection 40-60%
New-onset diabetes 33%
Acute illness 10-15%
Medicines, steroids <10%
Insulin omission 5-15%
DKA and HHSCurriculum Module III-6
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Signs and symptoms of HHS
• Initially polyuria and polydipsia
• Altered mental status
• Profound dehydration
• Precipitating factors
DKA and HHSCurriculum Module III-6
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HHS – biochemical findings
Jones 2001
Blood glucose >33 mmol/L (600 mg/dl)
Ketones Urine: negative – small
Blood: <0.6 mmol/L
Osmolality >320 mOsm/kg - (raised Na, BG, urea)
Electrolytes Raised Na, BG, urea creatinine
Anion gap <12
Blood gases pH >7.30
normal or raised HCO3
DKA and HHSCurriculum Module III-6
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Treatment
Rehydration Caution!
Normal saline 1 l per hour initially
Consider ½ strength normal saline
Potassium Only if hypokalaemic and renal function adequate – give before insulin
Insulin May be needed as slow infusion0.1 unit/kg/hour to be increased with care if BG is slow to fall
Monitoring BG, BP, neurological function hourly until stableElectrolytes 2-hourlyCardiac or CVP monitoring
DKA and HHSCurriculum Module III-6
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HHS – complications
Complication Prevention
Hypoglycaemia Prevent by adding glucose infusion when glucose <14 mmol/L (250 mg/dL)
Hypokalaemia Early potassium replacement and monitoring
Fluid overload Careful clinical monitoring and central line as needed
Vomiting/aspiration NG tube and may be nursed on side
Cerebral oedema Avoid fast blood glucose falls (should be <4 mmol/L (72 mg/dL) per hour; aggressive Mannitol treatment if any early signs of cerebral oedema
Meltzer 2004
DKA and HHSCurriculum Module III-6
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DKA and HHS – prevention is key
• Identify and treat underlying cause
• Can be prevented by – better public awareness– improved access to medical
care – improved education in treating
hyperglycaemia during illness – emergency communication
with healthcare provider
Slides current until 2008
Managing diabetes during illness
DKA and HHSCurriculum Module III-6
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Diabetes and illnesses
• People with adequate glycaemic control not at increased risk of infection
• Poor metabolic control increases risk
- decreases immunity
- leads to persistent glycosuria and dehydration
DKA and HHSCurriculum Module III-6
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Impact of illness
• Infective illness– increased stress hormones
gluconeogenesis + insulin insensitivity hyperglycaemia + ketones
• Nausea, vomiting, diarrhoea– poor gastric emptying + rapid intestinal
transit + poor food absorption hypoglycaemia
• Milder illnesses– little or no effect
DKA and HHSCurriculum Module III-6
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Mismanagement of illness
• Mismanagement of illness a common cause of increasing hyperglycaemia and ketoacidosis
• Omission of insulin because food not taken or vomiting
• Inadequate hydration during hyperglycaemia, polyuria and fever
• Poor glucose intake during gastroenteritis causing hypoglycaemia
• Inadequate education and written guidelines for management
DKA and HHSCurriculum Module III-6
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Illnesses and hyperglycaemiaGeneral management
• Identify and treat cause of illness
• Treat symptoms such as fever with paracetamol
• Adequate fluids – frequent diet drinks
• More frequent blood glucose tests
• Check urine for ketones
• Blood ketone tests if available
Laffel et al 2005
DKA and HHSCurriculum Module III-6
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Insulin management
• Never stop insulin (fever and stress increase insulin needs)
• Continue intermediate- or long-acting insulin
• Shorter-acting insulin (soluble or rapid acting) should be adjusted according to blood glucose values
• People with type 2 diabetes may need short-term insulin treatment if illness severe
Hanas 2004
DKA and HHSCurriculum Module III-6
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Algorithm for guidance
Breakfast Lunch Supper Bedtime
Usual dose (example) Soluble 10 Soluble 8 Soluble 12 NPH 24
If blood glucose is... Units of insulin reduced (-) or added (+) to usual dose
<4 (72) - 5 units - 4 units - 6 units continue
4.1-6.0 (73-108) - 2 units - 2 units - 2 units
6.1-10.0 (109-180) Usual dose Usual dose Usual dose
10.1-12.0 (181-216) + 2 units + 2 units + 2 units
12.1-14.0 (217-252) + 4 units + 4 units + 4 units
14.1- 18.0 (253-324) + 8 units + 6 units + 10 units
>18.1 (325) + 10 units + 8 units + 12 units
DKA and HHSCurriculum Module III-6
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Insulin correction doses
• Blood glucose >15mmol/L (270 mg/dL), ketones present
• Usual insulin
PLUS
• Short- or rapid-acting insulin 10-20% of total daily dose every 2-4 hours (short-acting insulin) or every 1-2 hours (rapid-acting insulin)
• Glucose tests every 1-2 hours
Eg: blood glucose 20 mmol (360 mg/dL)
normal doses insulin
• Rapid acting =10 + 8 + 12
• NPH = 22
• Total = 52 units/day
Give 20% ~10 units of rapid acting
Give additional doses every 1 to 4 hours until blood glucose <12mmol/L (216mg/dL) and ketones reduced (urine or blood <1.0mmol/L)
DKA and HHSCurriculum Module III-6
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Sick days and pump therapy
• Rapid-acting insulin; no long-acting
• If pump problem, no insulin after 3 hours
• Become sick very quickly
• Need to carry or able to access a new infusion set and insulin pen at all times
• Need to be able to test ketones
DKA and HHSCurriculum Module III-6
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Insulin pump therapy
basal (25% to 100%)
• Know effect of a unit of insulin on blood glucose
• Correction dose for ketones up to double usual correction
• Test in 1 hour and 1–2 hourly thereafter
• If no change suspect site problem
• Use pen
• Re-site cannula
DKA and HHSCurriculum Module III-6
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Food tolerance
Insulin must be given but may be reduced
Eg: blood glucose 10-12 mmol/L (180-216 mg/dL)
• About 150 ml sweetened fluids each hour to hydrate and avoid hypoglycaemia
• If feverish, additional 150 ml low-calorie fluid each hour may be needed for re-hydration
DKA and HHSCurriculum Module III-6
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If unable to tolerate food
Eg: blood glucose >15 mmol/L (270 mg/dL)
(additional insulin needed as above)
• Give 150 ml to 300 ml of low-calorie fluid each hour for hydration and to help blood glucose to fall
• Monitor blood glucose every 1-2 hours
Food tolerance
DKA and HHSCurriculum Module III-6
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Provide a list of drinks easily available
in your community that are suitable for
an ill person with diabetes who is
nauseated and unable to eat food.
DKA and HHSCurriculum Module III-6
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When to seek professional help
Advise to call the physician or nurse if...
• Uncertain of diagnosis
• Persistent vomiting or diarrhoea (3 episodes or more within 6 hours)
• Unwell for 2 days and not getting better
• Blood glucose remains above 15 mmol/L (270 mg/dL) despite extra fluid and insulin
• Moderate to large ketones persist, despite extra fluid and insulin
DKA and HHSCurriculum Module III-6
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Hospital transfer
Transfer to hospital if...
• Abdominal pain worsening
• Breathing difficulty or hyperventilation
• Co-existing serious diseases
• Person looking increasingly unwell/exhausted
• Care-givers exhausted or uncertain of diagnosis
DKA and HHSCurriculum Module III-6
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Type 2 diabetes
• Mr M: 20 years, type 2 diabetes
– maximal sulphonylureas and metformin
– twice a day intermediate acting insulin
• Presented with 12 hours diarrhoea,
nausea, no appetite
• What do you do?
Stop tablets, remain on insulin, or stop insulin and remain on tablets?
DKA and HHSCurriculum Module III-6
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Type 2 diabetes
• Metformin can aggravate gut problems
• Often easier to cease medication and continue insulin
• Easier to control glucose levels with insulin; may need reduced dose
• Re-introduce oral medication when food intake normal and symptoms subside
DKA and HHSCurriculum Module III-6
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Type 2 diabetes
Metformin
• Cease 24 hours before
surgery
• Restart!
DKA and HHSCurriculum Module III-6
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Develop clear plans for sick days
• Make written guideline available and review plans with all people with diabetes regularly
• Determine when healthcare provider should be contacted or alerted
• Establish blood glucose goals for sick days
Adapted from: Diab Care 2004; 27 Suppl 1
DKA and HHSCurriculum Module III-6
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Develop clear plans for sick days
• Define how to use supplemental short-acting insulin
• Explain how to use a fluid diet when unable to eat
• Explain what equipment is required
DKA and HHSCurriculum Module III-6
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Education tips
• Under-treated sick days are a common cause of diabetic ketoacidosis and hospitalization
• At each annual complication assessment, ask your patient to solve a sick-day scenario
• Access a 24-hour hotline
DKA and HHSCurriculum Module III-6
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Summary – diabetes and illness
• Never stop insulin
• Do more blood glucose tests– high blood glucose levels means
more insulin
• In case of loss of appetite, eat foods that are easy to digest and drink more sugar-free fluids
• In case of vomiting, drink frequent small volumes of carb-containing fluids
DKA and HHSCurriculum Module III-6
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Summary – diabetes and illness
• Call for help in case of
– persistent or severe vomiting
– exhaustion or confusion
– rapid breathing
– worsening abdominal pain
– uncertainty
DKA and HHSCurriculum Module III-6
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Review question
1. Which of the following is the most important ketone body in DKA?
a. Acetone
b. Acetoacetate
c. Beta-hydroxybutyrate
d. None of the above
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Review question
2. Which feature is more indicative of HHS than DKA?
a. Extreme hyperglycaemia
b. Extreme insulin deficiency
c. Large anion gap
d. Acetone breath
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Review question
3. Which of the following strategies should always be a part of the treatment plan for a person with DKA?
a. Insulin therapy and magnesium replacement
b. Possible insulin therapy and re-hydration
c. Insulin therapy and re-hydration
d. Possible insulin therapy and sodium bicarbonate replacement
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Review question
4. Which of the following strategies should always be a part of the treatment plan for a person with HHS?
a. Insulin therapy and magnesium replacement
b. Insulin therapy and re-hydration
c. Possible insulin therapy and sodium bicarbonate replacement
d. Possible insulin therapy and re-hydration
DKA and HHSCurriculum Module III-6
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Review question
5. Which electrolyte is critical to monitor during DKA as correction of the metabolic acidosis can possibly result in cardiac arrythmias and muscle weakness?
a. Sodium
b. Potassium
c. Acetoacetate
d. Beta-hydroxybutyrate
DKA and HHSCurriculum Module III-6
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Answers
1. c
2. a
3. c
4. d
5. b
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References – DKA and HHS
1. Booth GL. Short-Term Clinical Consequences of diabetes. In H. Gerstein & RB Haynes (EDs.), Hamilton: BC Decker. Evidence-Based Diabetes Care 2001; 75-90.
2. Jones H, Cleave B, Fredericks C, Hamilton C, Opsteen C. Building Competency in Diabetes education: the essentials. Canadian Diabetes Association, Canada, 2001.
3. Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care 2001; 24(1): 131-53.
4. Kitabchi AE, Ayyagari V, Guerra SMO. The efficacy of low dose versus conventional therapy of insulin for treament of DKA. Ann Int Med 1976; 84: 633-8.
5. American Diabetes Association. Hyperglycemic crisis in patients with diabetes. Diabetes Care 2001; 26(S1): S109-17.
6. Meltzer S, Yale JF, Belton AB, Clement M. Eds. Practical Diabetes Management; Clinical support for primary care physicians 5th ed. Canadian Diabetes Association, Canada, 2004.
7. Davidson MB. Hyperglycemia. In: Franz MJ, ed. A Core Curriculum for Diabetes Education: Diabetes and Complications. 4th ed. Chicago: American Association of Diabetes Educators 2001; 23.
8. Joslin’s Diabetes Mellitus. Eds Kahn CR,Weir GC et al. Publ Lippincott Williams & Wilkins, Philadelphia, 2005; 53.
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References – managing illness
1. Hyperglycemic crises in diabetes. ADA position statement. Diab Care 2004; 27 (Suppl 1).
2. Hanas R. Type 1 diabetes in children, adolescents and young adults. 2nd edition 2004. Publ Class Publishing, London
3. Laffel L, Pasquarello C, Lawlor M. Treatment of the child and adolescent with diabetes. Chap 35 in Joslin’s Textbook Diabetes. Publ Lippincott Williams & Wilkins, Philadelphia, 2005.