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Recommendations Grading ? Initiate insulin therapy according to recommendations in position statement.
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) should be suspected in ill patients with diabetes. DKA and HHS are medical emergencies that require treatment and monitoring for multiple metabolic abnormalities and vigilance for complications. Note to readers: Although the diagnosis and treatment of diabetic ketoacidosis (DKA) in adults and in children share general principles, there are significant differences in their application, largely related to the increased risk of life-threatening cerebral edema with DKA in children and adolescents.
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are diabetes emergencies with overlapping features. Risk factors for DKA include new diagnosis of diabetes mellitus, insulin omission, infection, myocardial infarction, abdominal crisis, trauma and, possibly, treatment with insulin infusion pumps, thyrotoxicosis, cocaine, atypical antipsychotics and, possibly, interferon. The clinical presentation of DKA includes symptoms of hyperglycemia, Kussmaul respiration, acetone-odoured breath, ECFV contraction, nausea, vomiting and abdominal pain. Sick day management that includes capillary beta-hydroxybutyrate monitoring reduces emergency room visits and hospitalizations in young people (5). DKA or HHS should be suspected whenever patients have significant hyperglycemia, especially if they are ill or highly symptomatic (see above). Point-of-care capillary blood beta-hydroxybutyrate measurement in emergency is sensitive and specific for DKA and, as a screening tool, may allow more rapid identification of hyperglycemic patients at risk for DKA (10–15). Pregnant women in DKA typically present with lower glucose levels than nonpregnant women (19), and there are case reports of euglycemic DKA in pregnancy (20,21).
Patients with DKA and HHS are best managed in an intensive care unit or step-down setting (6,16,17) with specialist care (22,23). After hypotension has been corrected, switch normal saline to half-normal saline (with potassium chloride). Similar doses of IV insulin can be used to treat HHS, although subjects are not acidemic, and the fall in plasma glucose concentration is predominantly due to re-expansion of ECFV and osmotic diuresis (45).
Use of IV sodium bicarbonate to treat acidosis did not affect outcome in RCTs (47–49). There is currently no evidence to support the use of phosphate therapy for DKA (53–55), and there is no evidence that hypophosphatemia causes rhabdomyolysis in DKA (56). In Ontario, in-hospital mortality in patients hospitalized for acute hyperglycemia ranged from <1% at ages 20 to 49 years to 16% in those over 75 years (61).
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A ? Unless the episode of DKA is mild, regular insulin by continuous intravenous infusion is preferred. The specific issues related to treatment of DKA in children and adolescents are addressed in the Type 1 Diabetes in Children and Adolescents chapter, p.
With insulin deficiency, hyperglycemia causes urinary losses of water and electrolytes (sodium, potassium, chloride) and the resultant extracellular fluid volume (ECFV) depletion.
The issues that must be addressed in the patient presenting with DKA or HHS are outlined in Table 1. Protocols, when followed, may be beneficial (24,25), but there can be challenges with achieving adherence (26,27).
Restoring ECFV improves tissue perfusion and reduces plasma glucose levels both by dilution and by increasing urinary glucose losses. There have been no randomized trials that have studied strategies for potassium replacement. Insulin has been withheld successfully in HHS (46), but generally its use is recommended to reduce plasma glucose levels (6,16). However, because hypophosphatemia has been associated with rhabdomyolysis in other states, administration of potassium phosphate in cases of severe hypophosphatemia may be considered for the purpose of trying to prevent rhabdomyolysis. For persons with a HHS, IV fluid administration should be individualized based on the patient's needs [Grade D, Consensus].
The insulin infusion rate should be maintained until the resolution of ketosis [Grade B, Level 2 (42)] as measured by the normalization of the plasma anion gap [Grade D, Consensus]. Devalia Adherence to protocol during the acute management of diabetic ketoacidosis: would specialist involvement lead to better outcomes? Potassium is shifted out of cells, and ketoacidosis occurs as a result of elevated glucagon levels and absolute insulin deficiency (in the case of type 1 diabetes) or high catecholamine levels suppressing insulin release (in the case of type 2 diabetes). In addition to the precipitating factors noted above for DKA, HHS also has been reported following cardiac surgery and with the use of certain drugs, including diuretics, glucocorticoids, lithium and atypical antipsychotics. In HHS, there is often more profound ECFV contraction and decreased level of consciousness (proportional to the elevation in plasma osmolality). Arterial blood gases may be required for sicker patients, when knowing the adequacy of respiratory compensation and the A-gradient is necessary.
Volume status (including fluid intake and output), vital signs, neurological status, plasma concentrations of electrolytes, anion gap, osmolality and glucose need to be monitored closely, initially as often as every 2 hours (6,16,17). ECFV re-expansion, using a rapid rate of initial fluid administration, was associated with an increased risk of cerebral edema (CE) in 1 study (30) but not in another (31). Insulin is used to stop ketoacid production; IV fluid alone has no impact on parameters of ketoacidosis (34). The concentration of sodium needs to be corrected for the level of glycemia to determine if there is also a water deficit ( Figure 1 ). In HHS, recent studies found mortality rates to be 12% to 17%, but included patients with mixed DKA and hyperosmolality (1,3,65).


After history and physical examination, obtain arterial blood gases, complete blood count with differential, urinalysis, blood glucose, blood urea nitrogen (BUN), electrolytes, chemistry profile, and creatinine levels STAT as well as an electrocardiogram. In DKA, ketoacidosis is prominent, while in HHS, the main features are ECFV depletion and hyperosmolarity. In addition, in HHS, there can be a variety of neurological presentations, including seizures and a stroke-like state that can resolve once osmolality returns to normal (2–4). Potential risks associated with the use of sodium bicarbonate include hypokalemia (50) and delayed occurrence of metabolic alkalosis.
Delaney Are blood ketones a better predictor than urine ketones of acid base balance in diabetic ketoacidosis? Strachan Does an integrated care pathway enhance the management of diabetic ketoacidosis? Spencer Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis? Although the use of an initial bolus of IV insulin is recommended in some reviews (6), there has been only 1 randomized controlled trial (RCT) in adults examining the effectiveness of this step (38).
Mortality is usually due to the precipitating cause, electrolyte imbalances (especially hypo- and hyperkalemia) and CE.
Therefore, to avoid the occurrence of cerebral edema, follow the recommendations in the position statement regarding a gradual correction of glucose and osmolality as well as the judicious use of isotonic or hypotonic saline, depending on serum sodium and the hemodynamic status of the patient. If there is an elevated anion gap and serum ketones are negative, beta-OHB levels should be measured. Typically, after volume re-expansion, IV fluid is switched to half-normal saline because urinary losses of electrolytes in the setting of osmotic diuresis are usually hypotonic. In children, using an initial bolus of IV insulin does not result in faster resolution of ketoacidosis (39,40) and increases the risk of CE. If osmolality falls too rapidly despite the administration of glucose, consideration should be given to increasing the sodium concentration of the infusing solution (6,16).
The dose of insulin should subsequently be adjusted based on ongoing acidosis (44), using the plasma anion gap or beta-OHB measurements. Plasma glucose levels will fall due to multiple mechanisms, including ECFV re-expansion (45), glucose losses via osmotic diuresis (34), insulin-mediated reduced glucose production and increased cellular uptake of glucose. Central pontine myelinolysis has been reported in association with overly rapid correction of hyponatremia in HHS (52).



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