Diabetic ketoacidosis and hyperosmolar hyperglycaemic state

1. Diabetic ketoacidosis andhyperosmolar hyperglycaemic state Slides current until 2008

2. What is DKA? High blood glucose, ketones, acidosis and dehydration • Absolute or relative insulin deficiency • Increase in counter-regulatory hormones • Breakdown of fat and muscle • Biochemical triad • hyperglycaemia • ketoacids • metabolic acidosis Slides current until 2008

3. Incidence of DKA • Varies • Death mainly from cerebral oedema • Most common at onset in type 1 diabetes • Recurrent episodes • Can occur in type 2 diabetes • Kitabchi et al 2001, Joslin 2005 Slides current until 2008

4. DKA – cause or trigger Booth 2001, Joslin 2005 Slides current until 2008

5. Diabetic ketoacidosis Insulin deficiency Lipolysis Glucose uptake Glycerol Free fatty acids Hyperglycaemia Gluconeogenesis Ketogenesis Glucosuria Ketonemia Electrolyte depletion Ketonuria Osmotic diuresis Dehydration Urinary water losses Acidosis Adapted from Davidson 2001 Slides current until 2008

6. Ketones • Used as fuel when calories are restricted • Physiological ketosis when fasting or with prolonged exercise • Insulin deficiency  lypolysis and ketone production  acidosis • beta-hydroxybutyrate • acetoacetate • acetone Slides current until 2008

7. Ketones • Beta-hydroxybutyrate predominant – not detected by test strips or acetone tablets • Ketoacidosis may be present without detectable urinary ketones • Blood ketone testing may enable early identification of DKA Slides current until 2008

8. Earlier clinical symptoms and signs of DKA • Polyuria • Polydipsia • Polyphagia • Tiredness • Muscle cramps • Flushed facial appearance Slides current until 2008

9. Later clinical symptoms and signs of DKA • Weight loss • Nausea and vomiting • Abdominal pain • Dehydration • Acidotic breath • Hypotension • Shock • Altered consciousness • Coma Slides current until 2008

10. DKA – investigations Immediate for diagnosis • Capillary blood glucose, urinary glucose and ketones Urgent for assessment and treatment • Blood glucose • Blood gases • Electrolytes, urea, creatinine • WBC Consider • Cardiac monitor • Blood culture, urine culture • Chest X-ray Slides current until 2008

11. DKA – laboratory findings Slides current until 2008

12. DKA – treatment Kitabchi et al 1976 Slides current until 2008

13. DKA – treatment Slides current until 2008

14. DKA – complications • Hypoglycaemia +/- hypokalaemia • Acidosis not improving – consider continuing dehydration or infection • Aspiration pneumonia • Headache +/- falling level of awareness – consider cerebral oedema and urgent treatment with Mannitol Joslin 2005 Slides current until 2008

15. DKA – recovery • Rapid improvement • Continue IV insulin while ketosis present • Oral intake when possible • Rapid-acting insulin 30-60 minutes before discontinuing IV insulin • Usual insulin regimen • Consider drinks and food containing potassium Slides current until 2008

16. What is HHS? • Ketosis may be present • Coma not always present • Primarily in older people with/without history of type 2 diabetes • Always associated with severe dehydration and hyperosmolar state • Develops over weeks Kitabchi et al 2001 Slides current until 2008

17. HHS – incidence and features • 0.5% of primary diabetes hospital admissions • ~15% mortality rate • Can occur in type 1 diabetes and younger people • Kitabchi et al 2001 Slides current until 2008

18. HHS – key features • Marked hyperglycaemia • Hyperosmolarity • Absence of severe ketosis • Altered mental awareness Joslin 2005 Slides current until 2008

19. HHS – causes or triggers Booth 2001 Slides current until 2008

20. Signs and symptoms of HHS • Initially polyuria and polydipsia • Altered mental status • Profound dehydration • Precipitating factors Slides current until 2008

21. HHS – biochemical findings Jones 2001 Slides current until 2008

22. Treatment Slides current until 2008

23. HHS – complications Meltzer 2004 Slides current until 2008

24. DKA and HHS – prevention is key • Identify and treat underlying cause • Can be prevented by • better public awareness • improved access to medical care • improved education in treating hyperglycaemia during illness • emergency communication with healthcare provider Slides current until 2008

25. Managing diabetes during illness Slides current until 2008

26. Diabetes and illnesses • People with adequate glycaemic control not at increased risk of infection • Poor metabolic control increases risk - decreases immunity - leads to persistent glycosuria and dehydration Slides current until 2008

27. Impact of illness • Infective illness • increased stress hormones  gluconeogenesis + insulin insensitivity  hyperglycaemia + ketones • Nausea, vomiting, diarrhoea • poor gastric emptying + rapid intestinal transit + poor food absorption  hypoglycaemia • Milder illnesses • little or no effect Slides current until 2008

28. Mismanagement of illness • Mismanagement of illness a common cause of increasing hyperglycaemia and ketoacidosis • Omission of insulin because food not taken or vomiting • Inadequate hydration during hyperglycaemia, polyuria and fever • Poor glucose intake during gastroenteritis causing hypoglycaemia • Inadequate education and written guidelines for management Slides current until 2008

29. Illnesses and hyperglycaemiaGeneral management • Identify and treat cause of illness • Treat symptoms such as fever with paracetamol • Adequate fluids – frequent diet drinks • More frequent blood glucose tests • Check urine for ketones • Blood ketone tests if available Laffel et al 2005 Slides current until 2008

30. Insulin management • Never stop insulin (fever and stress increase insulin needs) • Continue intermediate- or long-acting insulin • Shorter-acting insulin (soluble or rapid acting) should be adjusted according to blood glucose values • People with type 2 diabetes may need short-term insulin treatment if illness severe Hanas 2004 Slides current until 2008

31. Algorithm for guidance Slides current until 2008

32. Blood glucose >15mmol/L (270 mg/dL), ketones present Usual insulin PLUS Short- or rapid-acting insulin 10-20% of total daily dose every 2-4 hours(short-acting insulin) or every 1-2 hours (rapid-acting insulin) Glucose tests every 1-2 hours Eg: blood glucose 20 mmol (360 mg/dL) normal doses insulin Rapid acting =10 + 8 + 12 NPH = 22 Total = 52 units/day Give 20% ~10 units of rapid acting Insulin correction doses Give additional doses every 1 to 4 hours until blood glucose <12mmol/L (216mg/dL) and ketones reduced (urine or blood <1.0mmol/L) Slides current until 2008

33. Sick days and pump therapy • Rapid-acting insulin; no long-acting • If pump problem, no insulin after 3 hours • Become sick very quickly • Need to carry or able to access a new infusion set and insulin pen at all times • Need to be able to test ketones Slides current until 2008

34. Insulin pump therapy •  basal (25% to 100%) • Know effect of a unit of insulin on blood glucose • Correction dose for ketones up to double usual correction • Test in 1 hour and 1–2 hourly thereafter • If no change suspect site problem • Use pen • Re-site cannula Slides current until 2008

35. Food tolerance Insulin must be given but may be reduced Eg: blood glucose 10-12 mmol/L (180-216 mg/dL) • About 150 ml sweetened fluids each hour to hydrate and avoid hypoglycaemia • If feverish, additional 150 ml low-calorie fluid each hour may be needed for re-hydration Slides current until 2008

36. Food tolerance If unable to tolerate food Eg: blood glucose >15 mmol/L (270 mg/dL) (additional insulin needed as above) • Give 150 ml to 300 ml of low-calorie fluid each hour for hydration and to help blood glucose to fall • Monitor blood glucose every 1-2 hours Slides current until 2008

37. Provide a list of drinks easily available in your community that are suitable for an ill person with diabetes who is nauseated and unable to eat food. Slides current until 2008

38. When to seek professional help Advise to call the physician or nurse if... • Uncertain of diagnosis • Persistent vomiting or diarrhoea (3 episodes or more within 6 hours) • Unwell for 2 days and not getting better • Blood glucose remains above 15 mmol/L (270 mg/dL) despite extra fluid and insulin • Moderate to large ketones persist, despite extra fluid and insulin Slides current until 2008

39. Hospital transfer Transfer to hospital if... • Abdominal pain worsening • Breathing difficulty or hyperventilation • Co-existing serious diseases • Person looking increasingly unwell/exhausted • Care-givers exhausted or uncertain of diagnosis Slides current until 2008

40. Type 2 diabetes • Mr M: 20 years, type 2 diabetes • maximal sulphonylureas and metformin • twice a day intermediate acting insulin • Presented with 12 hours diarrhoea, nausea, no appetite • What do you do? Stop tablets, remain on insulin, or stop insulin and remain on tablets? Slides current until 2008

41. Type 2 diabetes • Metformin can aggravate gut problems • Often easier to cease medication and continue insulin • Easier to control glucose levels with insulin; may need reduced dose • Re-introduce oral medication when food intake normal and symptoms subside Slides current until 2008

42. Type 2 diabetes Metformin • Cease 24 hours before surgery • Restart! Slides current until 2008

43. Develop clear plans for sick days • Make written guideline available and review plans with all people with diabetes regularly • Determine when healthcare provider should be contacted or alerted • Establish blood glucose goals for sick days Adapted from: Diab Care 2004; 27 Suppl 1 Slides current until 2008

44. Develop clear plans for sick days • Define how to use supplemental short-acting insulin • Explain how to use a fluid diet when unable to eat • Explain what equipment is required Slides current until 2008

45. Education tips • Under-treated sick days are a common cause of diabetic ketoacidosis and hospitalization • At each annual complication assessment, ask your patient to solve a sick-day scenario • Access a 24-hour hotline Slides current until 2008

46. Summary – diabetes and illness • Never stop insulin • Do more blood glucose tests • high blood glucose levels means more insulin • In case of loss of appetite, eat foods that are easy to digest and drink more sugar-free fluids • In case of vomiting, drink frequent small volumes of carb-containing fluids Slides current until 2008

47. Summary – diabetes and illness • Call for help in case of • persistent or severe vomiting • exhaustion or confusion • rapid breathing • worsening abdominal pain • uncertainty Slides current until 2008

48. Review question • Which of the following is the most important ketone body in DKA? • Acetone • Acetoacetate • Beta-hydroxybutyrate • None of the above Slides current until 2008

49. Review question • Which feature is more indicative of HHS than DKA? • Extreme hyperglycaemia • Extreme insulin deficiency • Large anion gap • Acetone breath Slides current until 2008

50. Review question • 3. Which of the following strategies should always be a part of the treatment plan for a person with DKA? • Insulin therapy and magnesium replacement • Possible insulin therapy and re-hydration • Insulin therapy and re-hydration • Possible insulin therapy and sodium bicarbonate replacement Slides current until 2008