Transcript 8:30 AM - 9:00 PM Management of Diabetic Emergencies

Diabetic Emergencies
Michael J. Fowler MD
Division of Diabetes and Endocrinology
Vanderbilt University
The patients never stop making water and
the flow is incessant . . . Life is short,
unpleasant and painful, thirst
unquenchable, drinking excessive . . . If
for a while they abstain from drinking,
their mouths become parched and their
bodies dry; the viscera seem scorched
up; the patients are affected by nausea,
restlessness and a burning thirst, and
within a short time, they expire.
Aretaeus of Cappadocia
2nd Century A.D.
Case #1
• 21 year old male with history of poorly
controlled type one diabetes presents to
the ED with symptoms of nausea, vomiting
and abdominal pain. He states the
symptoms began developing last night.
Because he hadn’t been eating anything,
he skipped using insulin at supper.
Case #1 (cont’d)
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Physical exam:
Oral mucosa is slightly dry
Tachycardic with regular heart rate in the 130’s
Deep, regular respirations
Acetone odor
Mild diffuse abdominal tenderness, no R/G/R
hyperactive bowel sounds
• No foot or hand lesions
• Insulin injection sites and blood glucose test
sites are without evidence of infection
Labs
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Na- 130 (low)
K – 5.4 (High)
Cl – 102 (low)
CO2 – 10 (low)
Anion Gap – 18 (high)
Glucose – 597
Ketones - positive > 1:8
• Diagnosis, Doctor?
Anion Gap Metabolic Acidoses
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Methanol
Uremia
DKA
Paraldehyde
Isopropyl alcohol
Lactic acidosis
Ethylene glycol
Salicylates
Diabetic
Ketoacidosis/Hyperosmolar
Crisis
Laboratory Findings
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Anion gap metabolic acidosis
Hyperkalemia
Hyperglycemia
Positive Ketones > 1:2 dilution
pH less than 7.35
Hyperchloremic nonketotic metabolic
acidosis
Why???
Other Causes
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Drugs
Pregnancy
Infarction
Secondary Gain
Incorrect insulin dosing or administration
Unrefrigerated insulin
Diabetic Ketoacidosis
Potassium Flux
The Basic Problem
Ketosis
Insulin
Glucagon
Hyperglycemia
Dehydration
Fat Cells
The Liver: Epicenter
Treatment
• Fluids
• Insulin
• Potassium
Common Mistakes
• Panic over dehydration leads to an IV
flood
• Inadequate or delayed Potassium
• Ignore Co-diagnoses
• Failure to reassess
• Not starting long-acting insulin
immediately
• Use of bicarbonate
Ketoacidosis
Hyperosmolar
Crisis
Unusual DKA
• Euglycemic DKA
• Alkalemic DKA
• “Nonketotic” DKA
Whom to Watch Most Closely
Case Study #2
32 yo Male with type 1 DM is admitted with
acute bacterial meningitis and seizure episode.
The patient was visiting relatives from out of
state. He is currently obtunded and intubated
and no family are present for questioning. His
glucose upon arrival to the MICU is 262. His
serum bicarb is 23 and serum ketones are
absent.
On exam you notice he is wearing an insulin
pump
What do you do?
A. Recommend cranking the insulin pump up to
10 units an hour and head back to the call
room for a nap
B. Remove the device and order a regular insulin
sliding scale
C. Recommend removal of the device, begin an IV
insulin drip with frequent glucose monitoring,
start IVF with 5% Dextrose, and obtain an
endocrine consult
Case Study #3
Your team is called to the bedside of a
morbidly obese 51 year old female with DM
with altered mental status. She responds
sluggishly to painful stimuli and the nurse
reports her FSBG to be 22, respirations 16,
HR 90, and blood pressure 144/61. Her IV
infiltrated several hours ago and she currently
has no IV access.
You Manage the Patient’s
Hypoglycemia by:
A. Drawing a stat blood sample and waiting
to confirm the fingerstick with a serum
glucose value before giving treatment
B. Inserting a central line and administering
an amp of D50
C. Give Glucagon
D. Leaving her alone to “sleep it off”
Causes of Hypoglycemia
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Reduced intake
malnutrition
malabsorption
adrenal insufficiency
Renal/hepatic failure
meal/insulin
mismatch
• Drug interactions
with oral
hypoglycemics
• alcohol
If a patient has an episode of significant
hypoglycemia- FIND OUT WHY
Ketones
Clinical Signs
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Dehydration
Ketotic odor
Kussmaul breathing
Antecedent polyuria and polydipsia
Abdominal pain and Nausea
Critical Calculations
Fluids
• 500-2000 isotonic fluid bolus
• 250cc/hr thereafter
• For practical purposes LR is preferable to
NS
• Potassium should be added to the fluids
as potassium gluconate
Insulin
• IV insulin is used most commonly
• Starting dose of 0.1u/kg/hour is a reasonable
starting dose
• Insulin resistance (due to illness or type 2 DM or
both) may require higher doses of insulin
• Dose is titrated based on clinical response
• Basal insulin is started in the Emergency Room
• Decline in glucose is rapid to a glucose of
200mg/dL
Potassium
• Anion Gap is a useful marker of recovery
• Start potassium supplementation as soon
as normal renal function is verified
Nonketotic Hyperosmolar Crisis
Hyperglycemia
Dehydration
Caveats
• Chronic Renal Insufficiency
• Overt Renal failure
• Pancreoprivic Diabetes Mellitus
Lactic Acidosis
Type 2 Diabetes
Clinical Diabetes
Cori Cycle
Lactate
Definition
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AG Metabolic acidosis with pH < 7.35
Lactic acid level is greater than 5mmol/L
Type A – Inadequate Oxygen availability
Type B – Nonhypoxic etiology
Causes
• Typically does not occur in the setting of
good health
Metformin
• Incidence of Lactic Acidosis is .03/1000
patient years; typically 50% fatal
• Enhances glucose uptake in peripheral
tissues
• Increases lactic acid production
• Inhibits pyruvate conversion to acetyl CoA
Metformin (continued)
• Lactic acidosis is most likely to occur in
drug overdose, renal insufficiency or
dehydration/renal hypoperfusion
• Hold drug for hypoxemia, dehydration,
sepsis or use of IV contrast media
Treatment of Lactic Acidosis
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Prompt recognition
Stop metformin
Bicarb is controversial
Ensure adequate hydration without
inducing fluid overload (renal or cardiac
failure)
• Dialysis
Hypoglycemia
DCCT
• Lower Risk of Complications with better
glycemic control
• Better glycemic control comes with a
higher risk of hypoglycemia
Glargine at HS + Oral Agents
or MDI therepy
Short-Acting
Secretagogue
Glargine
Sensitizer
Insulin Effect
Insulin Effect
Glargine
B
L
S
HS
B
B
L
S
HS
B
Twice-daily Split-mixed
Regimens
Insulin Effect
Regular
NPH
B
L
S
HS
B