Metabolic & Electrolyte emergencies

Dr G R Letchuman

Contents:
Hyperglycaemia Hypoglycaemia Hyperkalemia

Hyperglycaemic emergencies
diabetic ketoacidosis (DKA) hyperosmolar hyperglycaemia state (HHS) Mortality %: < 5 DKA ( more ketosis) ~ 15 HHS (more dehydration)
Worse if extreme ages, hypotension, hypothermia & coma

ADA in Diabetes Care, vol 27, supp 1, Jan 2004

Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, Wall BM: Management of hyperglycemic crises in patients with diabetes. Diabetes Care 24:131153, 2001

 25 y.o. lady. Accounts clerk. Single T1DM since age of 14 years old On basal bolus insulin regime, actrapid 12/8/19 & insulatard 12 u ON but not compliant to treatment Admitted to hospital on 20/5/08 c/o nausea, vomitting, blurred vision, fever, abdominal discomfort, polyuria and polydipsia 2 days LMP: Mid may. PMH: multiple admissions for hyperglycaemia

Clinically alert. wt~45kg PR 120/min, BP 106/74 mmHg. 37.5C CV and Resp system normal. Abdomen soft, nontender

Diagnosis :
The patient: Urine ketone 3+ RBS 30.3 VBG pH 7.14, HCO3 8 mmol/L Anion Gap 27

Diagnosis :
The patient: Urine ketone 3+ RBS 30.3 VBG pH 7.14, HCO3 8 mmol/L ADA Urine ketone Glucose pH bicarbonate Serum ketone + > 14 7.3 18 +

Diagnosis
Urine acetone maybe negative because beta hydorxybutyrate is not measured by urine ketone strip)

Blood ketone testing> urine

ADA. Tests of glycaemia. Diabetes Care
2003:26(supp.1)S106-8

When glucose 16.7 Blood ketone Action: mmol/l Assess clinical status <0.6 0.6-1.5 >1.5 assess. Kiv discharge Recheck in 2-4 hours Immediate treatment

> sensitive than urine ketone Assist in decision making for admission and discharge. S. Beta-hydroxybutyrate 3.8mmol/l maybe superior than HCO3 Diabetes
Care 31:643-647,2008

Differential Diagnosis:
Starvation ketosis Alcohol ketoacidosis Lactic acidosis

 BUSE 6.9/ 127/ 4.8/ 92 Hb 10.6 TW 6.4 UFEME Leucocyte 3+

creat 65.8

 Diagnosis: DKA with UTI

sodium
Na+ = 127

sodium
Na+ = 127 (+1.6 for every 5.5mmol rise above 5.5)
Corrected Na+ = 127 + (30.3-5.5)/5.5 X 1.6 = 134 mmol/l

What about serum osmolality?

Coma in HHS/DKA
Conscious level correlates to serum osmolality. Diabetes Care 3:53-56,1980, Arch Intern Med 157:669675,1997

If osmolality < 320, look for other causes.

Management at casualty:
1430 i/v NS one pint i/v s. insulin 10 unit stat FBC/Renal profile/RBS/Urine FEME/VBG Admit

Management in ward
3.50 pm
Run 2 pints of NS fast over 1 hour To review one hour post fluid challenge. If still tachycardia, another fluid challenge Then 6 pints of drip over 24 hours I/V s. insulin 10 unit stat. Then sliding scale. i/v antibiotics (2nd cephalosporin)

Inform doctor about K+ level Blood glucose 2 hrly Use NS if BS >15 and use D5% if BS <15 Strict I/O KIV KCL ECG/RBS/FBC/RP/Urine FEME/Urine C&S Lipids cm

Therapy :
1. 2. 3. 4. Fluid Insulin Potassium Underlying precipitating factor

Therapy :
1. 2. 3. 4. Fluid Insulin Potassium Underlying precipitating factor MONITORING!

ADA:Fluid therapy :
1st hour : 0.9% NaCl 15-20ml/kg
(50kg~1L) (50kg~500mls/hr) if corrected S. Na+ is normal or high Use 0.9% NaCl if corrected S Na+ is low Beware in renal or cardiac failures

Then : 0.45% NaCl 4-14ml/kg/hr

ADA Standards of Medical Care in Diabetes2007 Diabetes care in the hospital Patients controlled with continuous intravenous insulin typically require hourly blood glucose testing until the blood glucose levels are stable, then every 2 h.

Insulin therapy
Insulin Sliding Scale
CBS < 4 CBS 4 7 CBS 7.1- 11 CBS 11.1- 15 CBS 15.1 20 CBS 20.1 25 CBs > 25 omit 1 unit/hr 2 unit/hr 3 unit/hr 4 unit/hr 5 unit/hr 6 unit/hr

Monitor CBS 2-hourly

 CBS trend and insulin infusion rate

HI 8.3 5.4 18.2 9.2 4.8 3.1 15.2 1800 2000 2200 12mn 0200 0400 0600 0800 6 unit/hr 3 unit/hr 1 unit/hr 4 unit/hr 2 unit/hr 1 unit/hr omit 4 unit/hr

Subsequently changed to basal-bolus regime

ADA Standards of Medical Care in Diabetes2007 Diabetes care in the hospital

Scheduled prandial insulin doses should be given in relation to meals and should be adjusted according to point-of-care glucose levels. The traditional sliding-scale insulin regimens are ineffective as monotherapy and are not recommended. (C)

ADA: Insulin therapy

Once hypokalemia K+ < 3.3 is ruled out, Bolus I/V S. insulin 0.1/kg Then S. insulin infusion 0.1/kg/hr Glucose reduction - 3-4 mmol/l per hour If above not achieved, double dose

Potassium
Time taken K+ 1430 6.6 Action Doctor informed at 2100. ECG. Triple regime. Rpt BUSE KCL 1g alternate pint

1530 2300 0930 22/5

4.8 3.3 3.9 4.2

ADA: Potassium
Total body depletion Insulin, correction of acidosis & volume expansion decreases potassium Start K+ when serum < 5.3 & adequate urine output ~50ml/hr. Generally 1.0 1.5 g KCL in 500 mls. If first K+<3.3, Correct with K+ & fluids. Delay insulin therapy until K+>3.3 Check electrolytes every 2 -4 hours

Bicarbonate:
VBG pH 7.14, HCO3 8 mmol/L Treat?

ADA :Bicarbonate
Bicarbonate therapy did not alter recovery outcomes in adults with moderate DKA (pH 6.97.14).
Kitabchi, Abbas E.; Umpierrez, Guillermo E.; Fisher, Joseph N.; Murphy, Mary Beth; Stentz, Frankie B.

< 6.9 prudent to treat but be careful of hypokalemia. 100 mmol sodium bicarbonate in 400 ml an isotonic solution with 20 mEq KCl administered at a rate of 200 ml/h for 2 h until the venous pH is >7.0.

Bicarbonate:
VBG pH 7.14, HCO3 8 mmol/L Treat? By 16 hours : VBG pH 7.28 HCO3 17 mmol/l

Precipitating factor:
UTI? Missed dose? Urine C&S no growth

Management:
By 16 hours : B/P stable. P/R 83/min BG: 3.1 VBG pH 7.28 HCO3 17 mmol/l Plan: Off sliding scale Basal bolus insulin. S/C S. Insulin 14 tds Intermediate insulin 12 units ON

Management:
Date 21/5 Time Pre lunch Pre dinner Pre bed Pre BF Pre lunch Pre dinner Pre bed Pre BF glucose 14 12.1 25.0 3.7 4.7 3.5 17.3 7.0 Insulin SI 14 tds Interm 12

22/5

omit Long act 8

23/5

ADA: Glucose < 11mmol/l :

5%DW +/- 0.45%NaCl at 150-250ml/hr (~500mls every 2 -3 hrs) Insulin 0.05-0.1/kg/hr (2-5 unit per hour) KCL in drip as previous Keep glucose 8-11mmol/l Monitor BUSE & glucose 2-4 hourly until stable

Once patient able to eat

Change to basal bolus regime Dose will depend on previous dose required Continue insulin infusion for 1-2 hours after s/c insulin. (consider s/c basal early)

Complications:
hypoglycemia and hypokalemia due to overzealous treatment with insulin Cerebral edema is a rare but frequently fatal complication of DKA noncardiogenic pulmonary edema

Diagnosis of DKA / HHS:

DKA Glucose mmol/l > 14 pH 7.3 bicarbonate 18 Urine ketone + Serum ketone + S osmolality variable mOsm/kg Anion gap > 12 Mental state Alert/ drowsy HHS > 33 >7.3 > 15 small small > 320 variable Stupor/coma

Summary
DKA & HHS medical emergencies Diagnosis role of blood ketone Fluid Insulin Potassium Precipitating cause

Pitfalls:
Delay in tracing electrolytes & hence K+ replacement Inadequate fluids Not correcting Na+ Dependence on sliding scale Non overlap of insulin infusion & S/C insulin Inadequate intensive MONITORING

Second case

 77 year old patient with T2DM and Hypertension C/O lethargy and weakness for 2 days. Drowsy, B/P 150/90 P/R 96/min

 Glucometer : 1.1 mmol/l I/V dextrose 50% 20mls stat I/V DW 10% infusion

medication
Metformin 1g tds Glibenclamide 10mg bd Nifedipine 10mg tds Perindopril 8mg daily Hydrochlothiazide 50mg daily Aspirin 150mg daily Lovastatin 20mg daily

What to do now?
Send home? Admit? Find out cause of hypoglycaemia?

 Patient admitted

31.8/6.5/137 creat 890 Hb 11.6 wbc 21.7 platelets 236. pH 6.74 HCo3 2 Ca 2.25 PO4 4.46 Alb 20

What is your diagnosis

Hypoglycamia precipitated by CRF? Hypoglycamia precipitated by ARF? Addisonian Crisis?

I/V DW 10% I/V calcium I/V Sodium Bicarbonate I/V hydrocortisone 100mg tds

Hyperkalemia

Signs & Symptoms: neuromuscular in nature. ECG=Tall T loss of P QRS sine wave VF/asystole/heart block. widening of Rx:: Immediate; Calcium chloride or gluconate several amp of 10ml of 10% solution antagonism of K+ at cardiac membrane. Effect lasts 40mins Regular insulin 10 units i/v + 20%Dextrose water (to prevent hypo). Effect lasts 4hr. Sodium bicarbonate 40mmols by slow i/v push over 5-15 mins. Effect lasts 2 hours. Oral K+ exchange resins.

Conclusion
In hypoglycaemia, find ppt cause & monitor hourly initially. High index of suspicion for hyperK

What was the pre admission sequence of events?

Summary
Hyperglycaemia Hypoglycaemia Hyperkalemia

 Thank you

Thirty Years of Personal Experience in Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State
Kitabchi, Abbas E.; Umpierrez, Guillermo E.; Fisher, Joseph N.; Murphy, Mary Beth; Stentz, Frankie B. The Journal of Clinical Endocrinology & Metabolism Issue:Volume 93(5), May 2008, pp 1541-1552 Division of Endocrinology, Diabetes, and Metabolism University of Tennessee Health Science Center, Memphis,Tennessee 38163 Division of Endocrinology (G.E.U.), Emory University School of Medicine, Atlanta, Georgia 30322

Insulin therapy
High-Dose (263 +/- 45 U) vs. Low-Dose (46 +/- 5 U) Insulin in Adult DKA. Resolution of acidosis, hyperglycaemia similar but high dose group had higher hypoglycemia & hypokalaemia.

Route of insulin :
I/V vs I/M vs S/C i/v faster at 2 hours but by 8 hours it is similar

 Not necessary to add albumin to the insulin infusate, as done in previous protocols. Use of Phosphate Therapy in DKA no difference in outcome concluded that bicarbonate therapy did not alter recovery outcomes in adults with moderate DKA (pH 6.9-7.14)

 Concluded that the use of sc rapid-acting insulin analogs every 1 or 2 h represents a safe and effective alternative to the use of iv regular insulin in uncomplicated DKA.

Future studies:
1) Efficacy of bicarbonate in DKA for a pH <6.9; 2) Need for a initial bolus insulin dose in DKA; 3) Mechanisms for the absence of ketosis in HHS; 4) Reasons for elevated proinflammatory cytokines and cardiovascular risk factors; 5) Cost benefit of using sc regular insulin vs. analogs for DKA.
Division of Endocrinology, Diabetes, and Metabolism University of Tennessee Health Science Center, Memphis,Tennessee 38163 Division of Endocrinology (G.E.U.), Emory University School of Medicine, Atlanta, Georgia 30322

Management in ward
8.55pm K+ = 6.6 Cardiac monitor Triple regime Rpt BUSE 1 hour 1030pm K+ 4.8 KCL 1g alternate pints Use NS if CBS >15 and use D5% if CBS <15

Management in ward
21/5 9.30am K+ 3.3 0.5 g KCL per pint

management
Fluid Therapy

Potassium supplement
Add 1g KCL in alternate pint of drip

insulin

 Potassium trend while on insulin infusion

4.8 ( prior to insulin infusion ) -> 6.6 -> 3.3 -> 3.9

 Treat precipitating cause

IV Augmentin for UTI Ensure compliance even during sick days

Diagnosis
Most imp: 1. Increased Anion gap usually > 20 ( N = < 14 mEq/l). 2. HCO3 < 10 Urine acetone maybe negative because beta hydorxybutyrate is not measured by urine ketone strip)

Serum osmolality
Osmolality = 2(Na+ + K+) + glucose + urea This patient = 2(134 + 3.3) + 30.3 + 6.9 = 311.8

Management in ward
21/5 s/c lantus 10 units sweating early morning