Hyperglycemic Crises

in Diabetes Mellitus
Yoshiaki Uda
ICU Training

Hyperglycemic Crises in DM
DKA

HHS (previously HONK)

Absolute insulin deficiency

Relative insulin deficiency

Predominantly T1DM
Younger adults

Predominantly T2DM
Elderly, debilitated +/- dementia
Higher mortality

Ketonemia, acidosis, hyperglycemia

(usually BSL<44)

Hyperosmolality, Hyperglycemia (BSL

usually >56), Dehydration

Early presentation (24/24)

Late presentation (several days,

week)

Hyperglycemia
Polyphagia, polydypsia, polyuria
Ketoacidosis
Abdo pain, n+v,
Kussmaul breathing, Fruity
breath
Dehydration
Altered conscious state

Hyperglycemia
Polyuria
Severe Dehydration
Diuretic use, reduced access to
water, impaired thirst perception
Hyperosmilality
Altered conscious state
(Osm>320)
Focal neurological signs,
seizure, visual
Risk of thromboembolic
complication

DKA and HHS Trigger

Infection
Insulin omission
CVA
Pancreatitis
MI
ETOH/drug abuse
Pregnancy
Eating disorder (recurrent DKA)
Substance abuse
Medication affecting carbohydrate metabolism corticosteroid,
thiazide, beta-blocker, second generation antipsychotic
Restricted water intake from illness, immobilization, altered thirst
mechanism in the elderly (HHS)
Mechanical problems with insulin pump (DKA)

DKA and HHS: Diagnostic Criteria

Confounding acid-base disturbances

e.g. Metabolic alkalosis from vomitting/diuretic use
e.g. Lactic acidosis from hypoperfusion

American
Diabetes
association
06

Testing for Ketone

Insulin required to
suppress lipolysis
is 1/10th of that
required to
promote glucose
utilization

Pathogenesis Spectrum of disease

Kitabchi et
al

Ketosis
and
acidosis

Extreme
hyperglycem
ia without
ketosis/acido
sis

Kitabchi et
al
Leukocytosis
Raised lipase, amylase
Beware of pseudohyponatremia/pseudohypo-normoglycemia
that can occur in severe hyperlipidaemia

Corrected serum Na

Corrected serum Na is used to estimate the magnitude of

water loss that has occurred in the development of
hyperglycemia
Corrected serum Na =

Elevated corrected sodium concentration means dehydration

Normal corrected sodium concentration means either patients

maintained adequate water intake or the onset of
hyperglycemia was very acute

Measured sodium level should rise as glucose fall

Measured sodium should be used in calculating plasma

osmolality or anion gap
Lawrence
2001

DKA and HHS management goals

1.

Improving circulatory volume and tissue perfusion

2.

Decreasing serum glucose and plasma osmolality towards

normal levels

3.

Clearing the serum and urine ketones at a steady state

4.

Correcting electrolyte imbalances

5.

Identifying and treating precipitating cause

Fluid therapy

In DKA and HHS, all of intravascular, interstitial, and intracellular compartments are contracted.

Estimated typical water deficit

DKA 100ml/kg (~6 to 7L)

HHS up to 200ml/kg (up to 10-12L)

It is recommended to start fluid resus with 0.9% NaCl. (No K) This will
Restore intravascular volume to restore tissue perfusion
Decrease counter-regulatory hormones and lower blood glucose
By improving hyperosmolar state, insulin therapy become more effective
K+ level can be obtained in the meantime
Once intravascular volume is restored, some experts switch to half normal saline (hypotonic
solution) depending on corrected serum Na values

Fluid therapy
Kitabchi 2009
DKA

HHS

Insulin therapy

Insulin therapy
Kitabchi 2009

Insulin therapy

Potassium
Kitabchi 2009

?Bicarbonate in DKA
Kitabchi 2009
Prospective randomized studies so
far has not shown advantage of alkali
therapy in terms of neuro,
cardiovascular function or rate of
recovery of ketoacidosis
No prospective randomized study
concerning use of bicarbonate in
DKA with pH<6.9 has been reported
In patients with pH<6.9 bicarbonate
therapy may be indicated because
severe acidosis can lead to impared
myocardial contractility, cerebral
vasodilatation, coma, GI
complications

Transition to SC insulin
Kitabchi 2009

Other important points

Complications from therapy

Hypoglycemia
Hypokalaemia
Hyperchloraemic metabolic acidosis
Cerebral oedema

Reference

Kitabchi, AE, Umpierrez, GE, Miles, JM, Fisher, JN. Hyperglycemic crises in
adult patients with diabetes: a consensus statement from the American
Diabetes Association. Diabetes Care 2009; 32:1335

Kitabchi, AE, Nyenwe EA, Hyperglycemic Crisis in Diabetes Mellitis: diabetoc

Ketoacidosis and Hyperglycemic Hyperosmolar State. Endocrinol Metab Clin
N Am 23 (2006) 725-751

Hillman, K, Fluid resuscitation in diabetic emergencies a reappraisal.

Intensive Care Med 1987: 13:4

Brenner ZR, Management of hyperglycemic emergencies. AACN Clin Issues

2006: 17: 56-65

Scherer Clinical Communications 2005: Management of Diabetic

Ketoacidodsis and Hyperosmolar Hyperglycemic State

American Diabetes Association: Hyperglycemic Crises in patients with

diabetes mellitus

Southern Health Protocol: Management of Diabetic Ketoacidosis in Adults

Protocol

Thank You!