11/13/2012 Diabetic Emergencies Goals James Hardy, MD Assistant Clinical Professor Department of Emergency • DKA treatment guidelines (Peds vs Medicine, UCSF Adult) • Interesting pathophysiology • Cerebral Edema • Controversies Diabetic Ketoacidosis Insulin Stress Hormones (DKA) • Hyperglycemia (glc>250) Feast <-----> Famine • Ketonemia • Metabolic Acidosis (pH<7.3 HCO3<15) Normal Glucose 1
11/13/2012 Get Sick / No Insulin Cortisol Catechol Goals of Treatment Insulin << Stress Hormones GLUCAGON • ABCs FFA Muscle Tissues LIVER Fat • Underlying Cause • Volume deficit and dehydration Keto ACIDS Hyperglycemia ! • Correct electrolytes, especially K+ KETONES • Reverse acidosis and treat glucose • Treat Cerebral edema Osmotic Diuresis • Do no harm Dehydration Acidemia Electrolytes Renal Impairment 16 y F h/o IDDM IV, 02, Monitor • ABC ’ s and D • BP =153/84 P = 146 R = 30 T = 97 • Glucometer = “ high ” Sat = 97% Wt =175 lbs • Move to appropriate room in your ED • Complains of “ pain all over ” • Order tests • Looks sick, ?AMS, smells of ketones 2
11/13/2012 Why? More on labs… • Ca, Mg, Phos Urine • EKG Xrays • Beta hydroxybutyrate? Cultures/Lactate • ABG or VBG Tox? Pregnant? PE, MI, Pancreatitis,Thyroid, Zebras? VBG vs ABG What do you want to do? 1. Insulin SQ, 1-2 liter NS bolus • pH - 0.05 lower than arterial pH 2. Insulin IV bolus, 1-2 liter NS bolus 3. Insulin IV bolus followed by insulin • pO2 - 40-50 instead of 100 drip, 1-2 liter NS bolus 46% 42% 4. 1-2 liter NS bolus, wait for study results • pCO2 - about 5 higher than arterial pCO2 (45 rather than 40) for further care 8% 5% . . . . . . . . . . . 1 l l b . o o b b S Q , N V V S I I r n n n e i i i t u l u l u l i l 2 s s s n n n - I I I 1 3
11/13/2012 ADA Guidelines for Adult Hyperglycemic Crises There is universal agreement that the most important initial therapeutic intervention in DKA is appropriate fluid replacement followed by insulin administration. Joint British Diabetes Societies Inpatient Care Group The Management of Diabetic Ketoacidosis in Adults March 2010 Kitabchi et al, Hyperglycemic Crises in Adult Patients with Diabetes, Diabetes Care , 2009 Get Sick / No Insulin Cortisol Catechol Fluids in DKA Part 1 GLUCAGON Insulin << Stress Hormones FFA Muscle Tissues LIVER Fat • Typical adult is 6 liters down • Volume = Normal Saline Keto ACIDS Hyperglycemia ! • For adults, start with 1- 1.5 liter bolus KETONES over 1 hour. More if in shock, less if heart dz Osmotic Diuresis • For kids, start with 10-20ml/kg bolus over 1 hr. Dehydration Acidemia Electrolytes Renal Impairment 4
11/13/2012 Know your serum K+ level before giving insulin • Stat K+ • EKG But serum K+ is usually Total Body K+ is Low… normal or high • Vomiting • Due to low pH? • Osmotic diuresis • Hypovolemia-->hyperaldosteronism • Due to insulin deficiency mostly • Typical deficit = 3-5mmol/kg • Adroque et al, Medicine, 1986 5
11/13/2012 Hypokalemia Hyperkalemia •Must replete before •Best treatment is fluids insulin if K+ < 3.3 and insulin •Add 20mEq to 1 liter •Consider bicarb and NS if hemodynamically calcium for life-threatening unstable hyperkalemia (ekg •If stable, add 40- changes) 60mEq to 1 liter 1/2 •You will probably still NS and run over 2 hrs. have to give potassium •Oral load? later on! Kitabchi, AE, Umpierrez, GE, Murphy, MB, Kreisberg, RA. Hyperglycemic crises in adult patients with diabetes: a consensus Kitabchi, AE, Umpierrez, GE, Murphy, MB, Kreisberg, RA. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care 2006; 29:2739. statement from the American Diabetes Association. Diabetes Care 2006; 29:2739. ADA Guidelines for Adult Hyperglycemic Crises Goals of Treatment If K+ is normal, add 20mEq to your IVF • ABCs • Underlying Cause Recheck lytes q 2 hrs • Volume deficit and dehydration • Correct electrolytes, especially K+ • Reverse acidosis and treat glucose Kitabchi et al, Hyperglycemic Crises in Adult Patients with Diabetes, Diabetes Care , 2009 6
11/13/2012 ADA Guidelines for Adult Hyperglycemic Crises 2009 Insulin when K+ is OK • 0.1unit/kg bolus for adults followed by 0.1unit/kg/hr drip • OR 0.14 units/kg drip without bolus • If glc not down 10% in 1st hour of tx, give 0.14 units/kg bolus and resume previous tx (also consider � ivf) • Children do not get bolus…just the drip at 0.1 • When glc < 200, cont insulin gtt at 0.05- 0.1units/hr; add 5% dextrose to the1/2NS. Kitabchi et al, Hyperglycemic Crises in Adult Patients with Diabetes, Diabetes Care , 2009 The cure for acidosis is insulin… Your Studies Come Back Not a normal sugar! • WBC =31, Hgb =13.3, Plt =422 FFA Muscle Tissues LIVER Fat • Na =123, K =5.9, Cl =87, bicarb = 5, BUN = 20, Cr 1.3, glc = 812. Keto ACIDS Hyperglycemia ! • Large acetone KETONES • Gap = 31 • UA, preg, utox, LFTs, cxr = neg • EKG = sinus tach, o/w neg 7
11/13/2012 How ’ s our Patient? ABG • BP = 120 ’ s/70 ’ s HR =130 ’ s RR = 30 • Therapy so far = 2 liters NS • pH = 6.855 • pCO2 = 9.7 • Altered? • PO2 = 126 • Bicarbonate = 1.7 Cerebral Edema What do you want to do? 1. One more liter NS, start insulin, give • 0.3% to 1% of pediatric DKA bicarb • 21% to 24% mortality 2. Two more liters NS, start insulin • 21% to 26% permanent neuro 3. NS at 200ml/hr, start insulin 38% 36% morbidity 4. Give mannitol, send to CT scanner • 57% to 87% of all DKA deaths 16% 10% . . . . . . . . . . . . r r r , e e h o l t t / t l i l i l i m n e e n o r o r 0 a 0 m m m 2 e o t e n w a v S i O T N G 8
11/13/2012 Who ’ s at risk? When does it happen? • Younger • New onset DKA (67%) • Typically becomes clinical 4-12 hours after initiation of treatment • Higher BUN • Some are already symptomatic when • Low pCO2 they arrive… • Low pH • Failure of Na to rise appropriately Glaser et al, NEJM, 2001 Krane et al, NEJM, 1985 Edge et al, Diabetologia, 2006 Hoffman et al, American Journal of Neuroradiology, 1988 Hoorn et al, J Pediatr, 2007 Lawrence et al, J Pediatr, 2005 Symptoms and Signs of Cerebral Edema Should I get a CT? • Headache • Recurrence of vomiting • If you are really concerned, CT can help • Inappropriate slowing of heart rate establish baseline or reveal other sequelae • Rising blood pressure • Decreased oxygen saturation • CE is clinical diagnosis • Change in neurological status: -Restlessness, irritability, increased drowsiness, incontinence • CT has false positives and negatives -Specific neurologic signs, e.g., cranial nerve palsies, abnormal pupillary responses, posturing Muir et al, Diabetes Care , 2004 • http://care.diabetesjournals.org/cgi/content/full/29/5/1150 Krane et al, NEJM , 1985 Wolfsdorf, J, Glaser, N, Sperling, MA. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. Diabetes Care 2006; 29:1150. Hoffman et al, American Journal of Neuroradiology , 1988 9
11/13/2012 Treatment of Cerebral Edema Did I cause • Mannitol 0.25-1g/kg bolus the cerebral • 3% NaCl 5-10mL/kg over 30 minutes edema? Wolfsdorf et al, Diabetes Care , 2006 Dunger et al, Pediatrics , 2004 Jeha et al, UpToDate , 2008 Levin et al, Pediatr Crit Care Med , 2008 Vasogenic Edema Theory Osmotic Edema Theory • Hypoperfusion-->injury-->reperfusion • Treatment drops intravascular injury • Supported by MRI studies osms-->water shifts into brain • No link between rate of fluid or insulin -->swelling administration. • Aggressive IVF and insulin BAD • Strong link with severity of illness Edge et al, Diabetologia, 2006 Glaser et al, J Pediatr, 2004 Figueroa et al, Endocrine Research, 2005 Hoorn et al, J Pediatr, 2007 Glaser et al, J Pediatr, 2008 Glaser et al, NEJM, 2001 Levin et al, Pediatr Crit Care Med, 2008 Lawrence et al, J Pediatr, 2005 Hom et al, Annals Emerg Med, 2008 10
11/13/2012 Pediatric Fluids Summary Should I give her bicarb? • Treat shock and sepsis with NS boluses • If stable after 10-20ml/kg…. • Increased risk of cerebral edema • Start NS (+/-K) at 1.5- 2x maintenance • May cause other bad things • Switch to dextrose + NS or 1/2 NS (+K) • No evidence that it helps when serum glc < 300. (4-6hrs of NS) • ARF or diarrhea? • Aim to keep glc between 150-200 mg/dl Wolfsdorf et al, Diabetes Care , 2006 Dunger et al, Pediatrics , 2004 Jeha et al, UpToDate Should I give Bicarb to Adults? Yeah, but what about that pH? • May cause bad things • Treat perfusion problems with fluids • No evidence that it • Treat infection with fluids and abx helps • Treat ketoacidemia with insulin • Diarrhea or ARF? • Consider in low pH and • Watch for hyperchloremic acidosis severe cardiac dz? Kitabchi et al, Hyperglycemic Crises in Adult Patients with Diabetes, Diabetes Care , 2009 11
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