According to the 2017 Journal of Endocrinology, Metabolism and Diabetes of South Africa guidelines, hyperglycaemic emergencies, diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS), should be suspected whenever patients have hyperglycaemia, especially if they are systematically unwell or are known to have diabetes. “Significant morbidity and mortality are attached to these conditions and emergency treatment with intravenous fluids and insulin is essential.”
Types of emergencies
Diabetic ketoacidosis (DKA)
DKA is characterised by uncontrolled hyperglycaemia, high anion gap metabolic acidosis and an increased total body ketones. In SA, DKA carries a higher mortality than in the developed world. Although it can present at any age, it is more common in young patients.
The diagnosis of KDA can be made on the following criteria:
- Hyperglycaemia – plasma glucose prior to insulin administration > 13.9 mmol/l
- Acidosis – indicated by blood ph < 7.3 or bicarbonate below 18 mmol/litre
- Ketonaemia – indicated by blood beta-hydroxybutyrate > 3 mmol/litre
Hyperglycaemic hyperosmolar state (HSS)
The hyperglaecemic hyperosmolar state (HHS) is characterised by the slow development of marked hyperglycaemia (usually >50 mmol/l), hyperosmolality and severe dehydration. Ketonuria may be slight or absent. The condition usually affects middle-aged or older patients and carries a high mortality. The initial treatment is the same as for DKA.
Treatment of hyperglycaemic emergencies in a primary-care setting
Rapid treatment is essential, and should not be delayed, emphasises the authors of the SEMDSA guideline.
- Confirm diagnosis and initiate treatment as per SEMDSA treatment algorithm
- Intravenous (IV) fluids
- IV fluid administration should ideally be started with normal saline, but if not available can be achieved with other isotonic solutions, advices Kitabchi et al, Management of hyperglycaemic crises in patients with diabetes. In a young patient with suspected DKA, infuse one litre of normal saline over the first hour. In older patients, change fluid to half normal saline after the first litre
- Administer hourly boluses of ten (10) units of regular insulin IV, until the patient is transferred to a hospital. If IV access is problematic, insulin can be given intramuscularly (IM) or subcutaneously (SC) in the interim
- Arrange transfer to a hospital experienced in the management of hyperglycaemic emergencies
- Clear instruction should be provided for the continued management during the transport.
The following general information is highlighted as essential by SEMDSA:
- Patients should be managed in a high care/ICU setting, but management should not be delayed until a bed becomes available
- Mild DKA has been managed in an outpatient setting by means of insulin. This is not recommended as the South African primary health care context differs markedly from those where this practice is accepted
- A thorough investigation for precipitating factors such as infective processes and myocardial ischaemic etc. should be undertaken
- If infection is suspected, antibiotics should be initiated. The choice of antibiotics will be determined on the specific guidelines of the specific institution
- Should there be a delay in the resolution of KDA (usually resolves < 48 hours) a meticulous search for occult infections should be undertaken
- Prompt surgical intervention should not be delayed even in the presence of metabolic derangements
- An elevated white cell count should not be over-interpreted as this may be solely on the basis of the KDA
- Prophylactic antithrombotic treatment is essential
- Aspiration must be anticipated and prevented. Insert a nasogastric tube if the patient is comatose or has gastric dilatation
- The responsive doctor must keep a meticulous flow chart of the hourly recordings of clinical and biochemical progress and treatment. Frequent reassessment of the patients’ condition is necessary
- The rate of insulin infusion needs to be adjusted hourly until the expected rate of decline in blood and glucose has been achieved.
- DKA: The average fluid deficit in an adult presenting with DKA is five to 10 litres. Patients should receive one to 1.5 litres of fluid in the first hour, and thereafter 250 to 500 ml per hour. The aim is to replace 50% of the remainder within the first 12 to 16 hours. Normal saline or Ringer lactate are good choices for initial fluid resuscitation. According to Kitabchi et al, hyperglycaemia is corrected faster than ketoacidosis and 5% dextrose solution should be used once the glucose falls to < 14 mmol/l to prevent hypoglycaemia. If hyperchloraemic (normal anion gap) acidosis occurs in the recovery phase of DKA, minimise hyperchloraemic by using .45% saline or 5% dextrose water
- HHS: If there is no cardiac compromise, the patient can be given one litre of normal saline in the first hour. The subsequent choice of fluid replacement and the rate of infusion depends on serum sodium, state of hydration and urinary output. In patients with renal or cardiac compromise, frequent monitoring of serum electrolytes, central venous pressure and urine output is necessary to avoid fluid overload. The fluid replacement guideline is specific to adult patients, said the authors.
Intravenous short or rapid acting insulin is preferred for the treatment of hyperglycaemic emergencies. Serum potassium should always be checked before insulin infusion, state the guidelines.
“IV insulin is generally reserved for the critical care environment. Caution should be exercised before implementing IV therapy outside the critical care setting,
since inadequate monitoring and poorly trained staff can lead to morbidity and mortality from hypoglycaemia,” said author, Imran Paruk.
“With respect to the selection of insulin type, most studies of IHH have employed the use of analogue insulins. Short-acting human insulins are likely to have similar efficacy but slower onset of action compared to rapid-acting insulin analogues. Rapid-acting insulin analogues, such as insulin aspart, lispro and glulisine, which can be injected just a few minutes before the meal, would
be beneficial in in the hospital setting where the timing of mealsmay vary.”
Continuous insulin infusion at a rate of 0.14 units/kg/hour in a high care/ICU setting with intensive glucose monitoring is the standard of care for the management of DKA, states the study, Hyperglycaemic crisis in adult patients with diabetes.
Treatment of DKA, however, should not be delayed when ICU is not available. It is not advised to use an insulin infusion outside of this setting, due to the high risk of hypoglycaemia. Other insulin regiments (IM or IV boluses of ten units of regular insulin hourly as per Juvan et al) may be used if the patient is nursed in the general ward. Capillary glucose should be measured hourly to detect and prevent hypoglycaemia and to assist guiding the rate of insulin infusion. Insulin infusion should be titrated hourly in order to address the degree of hyperglycaemia appropriately and to prevent hypoglycaemia.
The switch to subcutaneous insulin can only be made when the hyperglycaemic emergency has been resolved.
- The patient is conscious and eating
- Anion gap normalised, acidosis resolved (pH > 7.3 Bicarbonate > 18 mmol/l)
- Blood glucose < 15 mmol/l
- BOHB < 1 mmol/l
According to Kitabchi et al, withhold potassium initially if the ECG and/or the serum potassium level reveal marked hyperkalaemia. Start potassium therapy immediately if serum potassium is normal or low and/or the ECG is normal and the patient is passing urine. If the initial potassium is < 3.5 mmol/l, start replacement before the insulin infusion to avoid severe hypokalaemia and its complications of arrhythmias or respiratory muscle weakness. Four-hourly potassium monitoring will guide the need for replacement.
The use of bicarbonate in the treatment of DKA is controversial, studies have shown that there is no difference in cardiac, or neurological function, incidence of hypokalemua ir hypoglycaemia or rate of recovery from ketoacidosis, states Morris et al.
There are no prospective randomised studies that have used bicarbonate in patients with a pH < 6.9. To date, evidence does not justify the use of bicarbonate in the treatment of DKA in general.
The Society for Endocrinology, Metabolism and Diabetes of South Africa Type 2 Diabetes Guidelines Expert Committee. “Glucose Management” in SEMDSA 2017 Guidelines for the Management of Type 2 diabetes mellitus. Journal of Endocrinology, Metabolism and Diabetes of South Africa. Vol 22(1)
International Diabetes Federation. IDF Diabetes Atlas, 7th Edition. Brussels, Belgium: International Diabetes Federation, 2015.
Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19·2 million participants. Lancet; 2016
The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 20:1183–1197, 1997