Hyperglycaemic emergencies

Hyperglycaemic emergencies

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS) are diabetes emergencies with overlapping features. With insulin deficiency, hyperglycaemia causes urinary losses of water and electrolytes (sodium, potassium, chloride) and the resultant extracellular fluid volume (ECFV) depletion. (J.Goguen, 2013)

Causes

• Diabetes mellitus
• Insulin omission
• Infection
• Myocardial infarction
• Abdominal crisis
• Trauma
• Possibly, treatment with insulin infusion pumps, thyrotoxicosis, cocaine, atypical antipsychotics.
• Possibly, interferon. 

Signs and Symptoms

• Ketonuria
• Inability to swallow or keep fluids down
• Vomiting
• Persistent diarrhoea
• Persistently raised glucose (>28 mmol/L) despite increasing insulin.
• Ketoacidosis is clinically obvious (dehydration, abdominal pain, intractable vomiting, rapid or
  laboured respirations) 

Investigations

• Elevated plasma and/or urinary ketones

      • Metabolic acidosis (raised H+/low serum bicarbonate)

The presence of the following features should alert you to the possibility of DKA:

      • ketonuria

      • Rapid and deep sighing respirations, smell of ketones

      • Vomiting/abdominal pain

      • Drowsiness/reduced conscious level

      • Intra and extra-vascular volume depletion with reduced skin turgor, tachycardia and hypotension (late features)

• FBS

• Blood test to test ketones level in blood serum.

Treatment

• In the early stages, where patient is fully conscious and able to take adequate oral fluids.
•  Intravenous insulin, fluids and electrolytes is required to restore the metabolic equilibrium.
• Administer IV normal saline initially. If the patient is in shock, give 1–2 L/h initially to correct shock; otherwise, give 500 mL/h for 4 hours, then 250 mL/h for 4 hours.
• Add potassium immediately if patient is normo- or hypokalemic. Otherwise, if initially hyperkalemic, only add potassium once serum potassium falls to <5 to 5.5 mmol/L and patient is diuresing.
• Once plasma glucose reaches 14.0 mmol/L, add glucose to maintain plasma glucose at 12.0–14.0 mmol/L.
• After hypotension has been corrected, switch normal saline to half-normal saline (with potassium chloride). However, if plasma osmolality is falling more rapidly than 3 mmol/kg/h and/or the corrected plasma sodium is reduced, maintain IV fluids at higher osmolality (i.e. may need to maintain on normal saline).

REFERENCES

• Anonymous. (n.d.). Hyperglycaemic Emergencies . Retrieved 05 08, 2015, from www.nhslothian.scot.nhs.uk: http://www.nhslothian.scot.nhs.uk/Services/A-Z/DiabetesService/InformationHealthProfessionals/DiabetesHandbookForPrimaryCare/Hyperglycaemic%20Emergencies.pdf

• D.Candace, M.Naughton,H.Wesley, S.Corey . (2011, April). Diabetes in the Emergency Department: Acute Care of Diabetes Patients. Retrieved May 08, 2015, from clinical.diabetesjournals.org: http://clinical.diabetesjournals.org/content/29/2/51.full

• J.Goguen, J. G. (2013). Hyperglycemic Emergencies in Adults. Retrieved 05 07, 2015, from anadian Diabetes Association : http://guidelines.diabetes.ca/browse/Chapter15