1

SURVIVING DIABETIC
EMERGENCY
Case Based Scenario
Main Reference:
Discussion
Joint British Diabetes Societies In Patient Care Group
The Management of DKA in Adults (2nd Edition,
September 2013)
Joint British Diabetes Societies In Patient Care Group
Dr See
Chee Keong
The Management of HHS in Adults (August
2012)
2
MD (UPM) MRCP (UK)

30 MINUTES SESSION
3 SCENARIOS
15 MINUTES
5 MINUTES
5 MINUTES

PRACTICAL AND PROBLEM

SOLVING APPROACH
LAST 5 MINUTES DISCUSSION
3

DIABETES EMERGENCY I

HYPERGLYCEMIC CRISES IN
HRPZII JANUARY MARCH 2016
65 admission over 3 months
Incidence rate: 87 per 1000 diabetes
related admission
92% were Diabetes Ketoacidosis admission
90% had Type 2 DM
43% were severe DKA, 33% required
ventilation
40% had HbA1c > 10%
21% non compliance to medication
Mortality mainly due to sepsis 12.3%
5

CASE 1
Mr LM, 35 years old, self employed
Presented with diarrhea, abdominal pain
and vomiting for 2 days
Unable to tolerate orally and developed
fever on the day he presented to hospital
Had been well prior to this illness
Denies any osmotic symptoms
Parents have diabetes mellitus and
hypertension
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CASE 1
Upon presentation to A&E
BP 90/50, PR 110/min
Temperature: 38oC, Respiratory rate: 26
breaths/min, SpO2 90% under RA
Weight: 48kg
Dehydrated, No acanthosis nigricans
Lungs and cardiovascular unremarkable
Abdomen soft, tender over epigastrium
and renal punch positive
GM: HI
8

Question 1: What else do you

want to do?
Arterial or venous blood gas
pH, Bicarbonate

Random blood sugar

Degree of hyperglycemia

Blood ketone or Urine ketone

Ketonemia is important

Renal profile
Sodium, Potassium, Renal impairment
9

Investigations
Arterial blood gas: pH 7.2, Bicarbonate 13
Random blood sugar: 24 mmol/L
Blood Ketone: 6.2 mmol/L
Renal profile:
Urea: 12 mmol/L, Sodium 128 mmol/L,
Potassium 3.2 mmol/L, Creatinine 150 mmol/L
10

Question 2: What is the

diagnosis?
1. Diabetes Ketoacidosis
pH 7.2/ HC03 13, Ketone 6.2, GM HI/ RBS 24
No hyperosmolarity: calculated serum osmolarity: 310

2. Mild hypokalemia
3. Pseudohyponatremia Corrected sodium for
hyperglycemia: 134 mmol/L
4. Acute Kidney Injury
5. Possible Acute Pyelonephritis
11

Diagnosis of Diabetes
Ketoacidosis (DKA)
Triad of
Hyperglycemia (known diabetic, GM
> 11.0 mmol/L)
Ketonemia/ Ketosis (Blood ketones >
3.0 or Urine Ketone > 2+)
Acidemia/ Acidosis (HCO3 < 15,
venous pH < 7.3)

12

Facts on DKA
Not exclusively for Type 1 DM, may occur in
Type 2 as well
4.6 8 episodes per 1000 patients with
diabetes
Rising occurrence but reducing mortality
(7.96% 0.67% over past 20 years)
Large number of patient develop DKA while in
ward and not at the first presentation to
hospital
Diabetes emergency may be first
presentation of diabetes
Onset occurs of hours to days
13

SEVERE DKA
One or more of the following

Blood ketones over 6 mmol/L

Bicarbonate level below 5 mmol/L
Venous/arterial pH below 7.0
Hypokalemia on admission (under
3.5mmol/L)
GCS less than 12
Oxygen saturation below 92% on air
(assuming normal baseline respiratory function)
Systolic BP below 90mmHg
Pulse over 100 or below 60bpm
Anion gap above 16

Question 3: What is
severe DKA?

14

Question 4: How would you

manage DKA?
AIMS OF TREATMENT
1. Correction of hydration (fluid
resuscitation)
2. Correction of hyperglycemia
3. Treatment of underlying cause
4. Correction of electrolyte imbalance
15

Question 5: How much fluid

deficit is there when a patient is
admitted for DKA?
Deficit in DKA adults
Water deficit : 100ml/kg

16

Question 6: What is the aims

of fluid deficit replacement?
Aims of fluid replacement:
Restoration of circulatory volume
Clearance of ketones
Correction of electrolyte imbalance
Adequate correction of fluid deficit
improved sugar by more than 30-40%

17

Fluid Management
A.Fluid resuscitation if
hypotensive
0.5 1L given over 10-15 minutes
If sBP > 90mmHg consider 1L over 1h
Choice of fluids: Normal saline (0.9%
sodium chloride)
If BP still not improving consider
colloids
If BP still not improving consider septic
shock or cardiogenic shock
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Fluid Management
B. Fluid deficit replacement
1L normal saline over 2 hours
1L normal saline over 4 hours
1L normal saline over 6 hours
1L normal saline over 8 hours
Drip regime adjusted according vital
signs monitoring and actual fluid deficit
Consider additional fluids if required

19

FLOW OF MANAGEMENT
Aims of
treatment:
Blood ketones
reduction at
least 0.5
mmol/L/hr
Bicarbonate
rise 3
mmol/L/hr
Blood glucose
fall 3-5
mmol/L/hr
Maintain
serum
potassium in
normal range
Avoid
hypoglycaemi
a

Aims:
Ensure clinical
and
biochemical
parameters
improving
Continue IV
fluid
replacement
Avoid
hypoglycaemia
Assess for
complications
of treatment
e.g. fluid
overload,
cerebral
oedema
Treat
precipitating

Aims:
Ensure that clinical
and biochemical
parameters are
continuing to
improve
Continue IV fluid
replacement if not
eating and drinking
If ketonaemia
cleared and patient
is not eating and
drinking, titrate
insulin infusion rate
accordingly
Reassess for
complications of
treatment
Continue to treat
precipitating factors
Change to
subcutaneous
insulin if patient is
eating and drinking
normally

Question 7: What are the aims

of insulin infusion therapy?
Aims of insulin therapy:
Suppression of ketogenesis
Reduction of blood glucose
Correction of electrolyte disturbance

Metabolic treatment targets:

Ketone reduction: 0.5 mmol/L per hr
Increment of venous bicarbonate 3 mmol/L
per hr
Blood glucose reduction: 3 5 mmol/L per hr
Maintenance of potassium 4 5 mmol/L
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Insulin Therapy Initiation

Initiation dose of intravenous
infusion:
0.1 unit/ kg/ hour
i.e if patient 80kg initiation dose will
be 8 unit per hour
Fixed dose infusion rate
Local protocol using insulin infusion
scale sliding scale
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Question 8: Is there a need to

correct potassium or bicarbonate?
Correction of potassium
< 3.5 mmol/L additional potassium correction
3.5 5.5 3gm KCL in drip
> 5.5 no need for potassium addition

Correction of bicarbonate
No added correction needed
Using bicarbonate may delay fall of lactate :
pyruvate ratio and ketone
Risk of cerebral oedema
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Back to the case

Weight: 48kg
Patient was resuscitated with 1L normal saline over
15 minutes
Subsequently with 1L normal saline over 1hr
Insulin infusion rate was initiated at 5 unit/hr and
thereafter ordered to follow insulin sliding scale 3
Fluid deficit correction as follows: (deficit 5L)
*given 1L over 1hr
1L over 2hrs
1L over 4hrs
1L over 6hrs
1L over 8hrs
To maintain thereafter with maintenance fluid: 1.5
ml/kg/hr

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INSULIN INFUSION RATE:

INSULIN SLIDING SCALE
Blood
sugar

Scale 1
(U/hr)

Scale 2
(U/hr)

Scale 3
(U/hr)

Scale 4
(U/hr)

Scale 5
(U/hr)

Scale 6
(U/hr)

Scale 7
(U/hr)

>22

3.0

4.0

5.0

6.0

7.0

8.0

10.0

18
21.9

2.5

3.5

4.0

5.0

6.0

6.0

8.0

14
17.9

2.0

3.0

3.0

4.0

5.0

5.0

6.0

12
13.9

1.5

2.5

2.5

3.0

4.0

4.0

4.0

10
11.9

1.0

2.0

2.0

2.0

2.0

3.0

3.0

8 9.9

1.0

1.5

1.5

1.5

2.0

2.0

2.5

6 7.9

0.5

1.0

1.0

1.0

1.5

1.5

2.0

4 5.9

0.5

1.0

1.0

1.5

<4

STOP INSULIN INFUSION AND INFORM DOCTOR

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At the 6th hour of admission

GM 12.2 mmol/L
Ketone repeated: 2.5 mmol/L
pH 7.32, HCO3 16

Question 9
What is the next step of
management?
26

Next Step
GM has dropped below 15 mmol/L
Still in fluid deficit replacement
Need to add Dextrose 5% or 10% while
patient is still on insulin infusion
1L of Dextrose 5% over 24hours

What is the reason?

Prevention of hypoglycemia
Facilitating further reduction of blood ketone
27

 After 24 hours of admission:

GM 9.4 mmol/L
Ketone had initially dropped to 0.5 mmol/L
after 18 hours of admission but now has risen
to 3.5 mmol/L
pH 7.28, HCO3 15

Question 10
What could be the reason?
Consider adequate insulin administration
Need to increase calorie intake either with higher
dextrose drip 10% or adding nourishing fluid
28

Question 11: How to determine

DKA has resolved?
pH > 7.3
Bicarbonate > 15.0 mmol/L
Blood ketone level < 0.6
Clinically able to tolerate orally and
vitals are stable

29

Question 12: How and when do you

consider to basal bolus insulin?
Improvement clinically
Contemplating feeding parenteral or oral
feeding
Switching to subcutaneous insulin
therapy
Methods: Total daily infusion requirement (50:50)
or back to basic basal bolus

Need for overlapping insulin infusion

with bolus insulin during meals
Overlap insulin infusion for 1-2 hours after starting
bolus subcutaneous insulin
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DIABETES EMERGENCY
II

31

Case 2

Madam Chikgu, 54 years old, Teacher

Returned from Umrah 3 days ago
Underlying hypertension, diabetes mellitus
Developed fever with shortness of breath,
had been having reduced effort tolerance
Glucometer on admission: HI
Random blood sugar: 35 mmol/L
VBG: pH 7.35, HCO3 16, Blood Ketone: 1.4
FBC: TWCC 15.0, Hb 12, Platelet 14
Renal profile: Urea 10, Sodium 130,
32
Potassium 3.2, Creatinine 150

Case 2 : Practical
Corrected Sodium for
Hyperglycemia
Measured sodium + 0.016 (Glucose
100) (Katz, 1973)
Measured sodium + 0.024 (Glucose
100) (Hillier, 1999)
*Glucose in mg/dl

Measured serum osmolarity

2 (Na + K) + Urea + Glucose

33

Case 2 : Practical
Serum Sodium: 130 mmol/L, Glucose: 35
mmol/L
Corrected Sodium for Hyperglycemia
Corrected sodium: 138 mmol/L (Katz, 1973)
Corrected sodium: 143 mmol/L (Hillier, 1999)

Measured serum osmolarity

Sodium 138 mmol/L Osmolarity 2 (138 + 3.2)
+ 10 + 35 = 327.4
Sodium 130 mmol/L Osmolarity 2 (130 + 3.2)
+ 10 + 35 = 311.4
34

Assessment
1. Hyperglycemia Hyperosmolar State
precipitated by Pneumonia (? MERSCOV)
Elevated osmolarity, high sugar, no elevated
ketones, no acidosis

2. Pseudohyponatremia
Corrected sodium for hyperglycemia is normal

3. Thrombocytopenia secondary to Sepsis

4. Acute Kidney Injury
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Hyperglycemic Hyperosmolar State

Definition

36

Background of HHS
Typically occurring in elderly but
increasing presentation In younger adults
and teenagers (Rosenbloom 2010)
Initial presentation of type 2 DM
(Ekpebergh 2010)
Mortality is as high as 15 20% (Chung
2006)
DKA occur within hours of onset, HHS
onset is over days leading to extreme
dehydration and metabolic disturbances
37

Goals of Treatment
To gradually and safely:
Normalize serum osmolality
Replace fluid and electrolyte losses
Normalize blood glucose

Treat underlying cause

Prevention of:
Arterial or venous thrombosis
Cerebral oedema or central pontine
myelinolysis
Foot ulceration

38

Severe HHS
One or more of the following

Osmolality > 350 mosmol/kg

Sodium > 160 mmol/L
Venous/ arterial pH < 7.1
Hypokalemia (<3.5) or Hyperkalemia (> 6) on admission
GCS < 12
SpO2 < 92% on air
Systolic blood pressure < 90 mmHg
Pulse rate of <60 or > 100 beats per minute
Urine output < 0.5 mls/kg/hr
Serum creatinine > 200 umol/L
Hypothermia
Macrovascular event (MI or stroke)
Other serious comorbidity
39

Principles of Treatment
Serum osmolality measurement for assessment
IV fluids with normal saline gradual correction
of fluids (avoid being too rapid correction)
IV insulin for gradual sugar reduction (0.05 unit/
kg/ hr)
Early restoration of oral intake
Prevention of complications cerebral oedema/
central pontine myelinolysis
Prophylactic anticoagulation risk of thrombosis
Foot examination for ulceration
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REMEMBER THE FLUID AND

ELECTROLYTE LOSSES

41

RECOVERY FROM HHS

Unlikely to occur within 24hours
Too rapid correction is harmful
Clinical status + Ability for oral intake
Discontinuation of insulin infusion

Switching from insulin infusion is the

same as DKA
42

COMMON DISCHARGE
PLAN
1. Insulin and medication regimen fully
explained to patient
2. Insulin technique and compliance scrutinized
3. Follow up plan determined with appropriate
discharge summary
4. Rescue plan in case of complications (i.e
hypoglycemia)
5. Screening for microvascular complications
6. Diabetes educator appointment*
7. Dietitian advice given
8. Foot care education
43

DIABETES EMERGENCY
III

44

Hypoglycemia
Whipples triad:
Symptomatic Neuroglycopenic and/or
neurogenic
Low plasma glucose level
Symptomatic relief after administration of
carbohydrates (glucose rescue)

Diagnosis blood glucose level of 3.0 - 3.9

mmol/L - ADA, CDA, EMEA
In hypoglycemia, the alert level if treated with
a secretagogue or insulin is 3.9 mmol/L
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Symptoms of
Hypoglycemia
Neurogenic1,2
Adrenergic
Palpitations
Tremor
Anxiety/arousal

Cholinergic
Sweating
Hunger
Paresthesia

Neuroglycopenic1,2
Cognitive
impairments
Behavioral changes
Psychomotor
abnormalities
Seizure
Coma

Factors affecting glycemic thresholds are poorly controlled type 1 and

type 2 diabetes, tight glycemic control in type 1 diabetes, and older
2,3
age.
1. Cryer PE.. J Clin Invest. 2007;117(4):868870.
2. Cryer PE.. Diabetes Care. 2003;26(6):19021912.
3. Meneilly GS et al. J Clin Endocrinol Metab. 1994;78(6):13411348.

46

Severity of
Hypoglycaemia
Mild - Autonomic symptoms present and
individual is able to self-treat
Moderate - Autonomic and neuroglycopenic
symptoms present and individual is able to selftreat
Severe - Unconsciousness may occur. Plasma
glucose is typically < 2.8 mmol/L and individual
requires the assistance of another person
47

Asymptomatic
Hypoglycaemia
Presence of a biochemically low
glucose level without any symptoms
Hypoglycaemic unawareness
Occurs in some insulin-treated
patients with
Advanced duration of diabetes
Frequent exposure to hypoglycemic
episodes
Autonomic dysfunction

48

Risk factors for

Hypoglycemia
Use of insulin secretagogues and insulin therapy
Missed or irregular meals
Alcohol consumption (in the absence of sufficient
carbohydrate intake)
Excessive physical activity
Advanced age
Longer duration of diabetes
Impaired renal or liver function
Impaired awareness of hypoglycemia
Lack of patient and care-giver education on
hypoglycemia
49

WARD ROUND CASE 1

Cik June, 28 years old
Type 1 DM admitted to ward for pneumonia
On treatment with:
SC Actrapid 6 unit TDS
SC Insulatard 10 units ON

Noted blood sugar 3.2 incidentally pre-lunch

Patient complaints of palpitation and giddiness
What do you

Treat the hypoglycemia

do? Repeat GM every 15 minutes till GM >
5.6 mmol/L
Since its before lunch, if patient wants to
eat to serve a reduce dose of actrapid for
lunch i.e 4 units
50

WARD ROUND CASE 2

Encik Ramlee, 60 years old
Type 2 DM admitted to ward for pneumonia
On treatment with
PO Glicazide 160mg BD, PO Metformin 1gm BD
SC Insulatard 42 units ON

Patient was found unconscious with GM of LO

at 3am
What do you do next?
IV Line, RBS, IV bolus 50mls 50%
Treatment

Dextrose
Look for immediate recovery and recheck
given GM within 1-2minutes
If still <4 and unconscious, to repeat
bolus D50%
51

WARD ROUND CASE 3

Puan Jumah, 55 years old
Admitted for DKA and on insulin infusion
2unit/hr
GM taken 3.1 mmol/L and patient talking
to you when checking blood sugar
What do you do next?
Stop insulin infusion and re-assess patient for
symptoms (consider bolus if any symptoms)
Monitor patient and re-check sugar within 1
hour
52

Treatment of Hypoglycemia
1. Assess the cause and severity of hypoglycaemia.
2. Treat hypoglycaemia according to BG level
Mild (BG 3.3 3.9 mmol/L): Give 15g carbohydrate
4 ounces (120mls) orange juice or other fruit juices OR
Hard candy OR
3 glucose tablets
Moderate (BG 2.5 3.2mmol/L ): Give 20g carbohydrate
6 ounces (180mls) orange juice or other fruit juices OR
4 glucose tablets OR
Dextrose 50% 40 ml iv
Severe (BG < 2.5 mmol/L): Give 30g carbohydrate
8 ounces (240ml) orange juice or other fruit juices OR
6 glucose tablets OR
Dextrose 50% 60 ml iv
Unconscious with severe hypoglycemia (BG< 2.5 mmol/L)
Dextrose 50% 25 ml IV OR
Glucagon 1 mg subcutaneous or intramuscular (0.5 mg
for child)
3. Monitor BG level every 15 minutes until > 5.6 mmol/L
4. Re-dose glucose replacement as above every 15 minutes as necessary (PRN)
53

CONCLUSION
Important to clearly define DKA and HHS
condition to facilitate appropriate therapy
HHS and DKA patient has significant fluid deficit
but correction fluid deficit defer in both situation
Judicious and proper insulin infusion is
important in management of DKA and HHS
Initiating basal insulin prior to stopping insulin
infusion reduces risk of rebound of sugar control
Hypoglycemia remains a major concern in
diabetic management and measures to prevent
and manage its presentation is vital
54

THANK YOU
Any questions??

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