#25 Master hyperglycemia and DKA

February 6, 2017 | By Matthew Watto, MD

Master the management of hyperglycemia, DKA, and learn to avoid common pitfalls. This episode is packed with clinical pearls from repeat guest, Endocrinologist, Dr. Jeffrey Colburn.

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Clinical Pearls:

1. Type 1 diabetes (DM1) occurs by autoimmune destruction of beta cells
   • occurs at any age
   • Typically lean body type and normal lipid profiles
2. Type 2 diabetes (DM2)
   • Typically obese and insulin resistant
   • Eventually fat deposition in pancreas destroys insulin production 15-20 years after onset of DM2 leading to absolute insulin deficiency
3. Triad of DKA = hyperglycemia, ketonemia, acidemia
4. DKA occurs w/total lack of insulin leads to inability to utilize glucose (hyperglycemia)
   • Simulated starvation occurs
   • Counter regulatory hormones kick in
   • Free fatty acids are broken down for fuel
   • Keto acids are made as a by product (ketonemia)
   • Acidemia occurs
5. DKA can occur in DM2 if overwhelming infection, or infarction (MI or CVA)
6. Even just a little bit of insulin can keep patient out of DKA!
7. Dehydration is a cardinal issue in DKA from osmotic diuresis
   • Often 6-8 liters depleted!
8. Sick day rules for Type 1 diabetes
   • Early contact with healthcare team
   • Reduce, but do not discontinue insulin during the illness (see #9)
   • Check frequent fingersticks
   • Use antipyretics to manage fever
   • Push the fluids
   • Educate family members about signs/symptoms of DKA
9. If sick, then drop basal insulin by 20% whether SQ or basal rate on insulin pump
   • Keep mealtime insulin dose the same, but skip if not eating
10. Ketones
    • Beta hydroxybutyrate is the predominant ketone in DKA
    • Urine ketones measure acetoacetate (strongly) and acetone (weakly) NOT beta hydroxybutyrate
    • Serum ketones measure acetoacetate and acetone NOT beta hydroxybutyrate
    • Thus, check a direct blood beta hydroxybutyrate level if available
11. Follow an algorithm when treating DKA!
12. IVF fluids first line therapy in DKA, hyperglycemia
    • Make sure to replete potassium above at least 3.3 before giving insulin!
13. Insulin drip – insulin out of system in minutes when drip stopped
14. Subcutaneous insulin – lasts 4 hours and can “stack” if repeat doses given
15. SGLT2 inhibitors can lower blood glucose in the absence of insulin leading to possible “euglycemic DKA”

Goal: Listeners will be able to confidently evaluate, and manage the patient with severe hyperglycemia and/or DKA.

Learning objectives:

By the end of this podcast listeners will:

1. Differentiate between type 1 and type 2 diabetes
2. Review the pathophysiology of DKA
3. Utilize basic laboratory data to diagnose DKA and differentiate it from other common conditions
4. Initiate management of hyperglycemia and/or DKA in the acute setting
5. Formulate a plan for sick day management in type 1 diabetes
6. Describe the mechanism of DKA in setting of SGLT2 inhibitor use

Disclosures:

Dr. Colburn is a member of AACE and helped develop the AACE Algorithm for Type 2 Diabetes.

Time Stamps

00:00 Intro

02:06 Rapid fire questions

07:30 Definitions and classification of diabetes

10:12 DKA in type 2 diabetes?

11:16 Pathophysiology of DKA

13:00 Severe hyperglycemia mislabeled as DKA

14:22 Which type 2 diabetics get DKA?

15:40 The cardinal issue is dehydration

17:11 Starvation ketosis vs DKA vs other

18:33 How to handle severe hyperglycemia in outpatients

22:18 Sick day management in type 1 diabetes

27:48 Initial testing for diagnosis of DKA

31:00 Subcutaneous or IV insulin for DKA

33:35 Initial evaluation and management in ER

36:50 Fluids and electrolyte management

40:12 SGLT2 inhibitors and euglycemic DKA

Links from the show:

1. Walden by Henry David Thoreau
2. AACE Type 2 Diabetes Management Algorithm on iTunes.
3. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care 2009 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699725/

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