2018 Clinical Practice Guidelines Hyperglycemic Emergencies ...

2018 Clinical Practice Guidelines Hyperglycemic Emergencies ...

Y L 2018 Clinical Practice Guidelines N O E S U L A Hyperglycemic N O S R Emergencies in Adults E P Chapter 15 Jeannette Goguen MD MEd FRCPC Jeremy Gilbert MD FRCPC Disclaimer All Content contained on this slide deck is the property of Diabetes Canada, its content suppliers or its licensors as the case may be, and is protected by Canadian and international copyright, trademark, and other applicable laws. Diabetes Canada grants personal, limited, revocable, non-transferable and non-exclusive license to access and read content in this slide deck for personal, non-commercial and not-for-profit use only. The slide deck is made available for lawful, personal use

only and not for commercial use. S R PE S U L A ON Y L N O E The unauthorized reproduction, distribution of this copyrighted work is not permitted. For permission to use this slide deck for commercial or any use other than personal, please contact [email protected] 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults 2018 Key Changes New information on Diabetic ketoacidosis with SGLT2 Y L

inhibitor therapy ON S R PE L A ON E S U PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Hyperglycemic Emergencies DKA = Diabetic Ketoacidosis HHS = Hyperosmolar Hyperglycemic State LY Common features: N O E S

U L Insulin deficiency hyperglycemia urinary loss of A N water and electrolytes O S R Volume depletion + electrolyte deficiency + PE hyperosmolarity Insulin deficiency (absolute) + increased glucagon Ketoacidosis (in DKA) PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Suspect DKA or HHS in an ILL Patient with Hyperglycemia (usually) HHS DKA Ketoacidosis ECFV contraction Minimal acid-base

Y L problem N O E ECFV contraction Milder hyperosmolarity S U L A Hyperosmolarity Normal to high glucose N O S Marked hyperglycemia May have LOC R E P Beware hypokalemia Marked LOC Must use insulin Beware hypokalemia Absolute insulin deficiency + increased

glucagon May need insulin Relative insulin DKA, diabetic ketoacidosis; ECFV, extracellular fluid volume; HHS, hyperosmolar hyperglycemic state; deficiency LOC, level of consciousness PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Suspect DKA if pH 7.3 Bicarbonate 15 mmol/L Anion gap >12 mmol/L Y L N O E S U L bicarbonate) = Serum sodium (chloride + A N O Positive serum Ror

S urine ketones E P Plasma glucose 14 mmol/L (but may be lower) Precipitating factor DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Clinical presentation of DKA Symptoms Hyperglycemia polyuria, polydipsia, weakness Acidosis Precipitating condition Signs Y L N contraction O ECFV E S

U L A air hunger, nausea, vomiting N Opain and abdominal S R alteredE sensorium P Kussmaul respiration, acetone-odoured breath altered sensorium See list of conditions Slide 20 DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Be Aware of Conditions that may make DKA Diagnosis Difficult Conditions that bicarbonate (eg. vomiting) Mixed acid-hydroxy

base so pH not as low Pregnancy RS SGLT2 inhibitor L A ON E S U Normal PE or mildly glucose (euglycemic DKA) Significant Y L osmotic ON diuresis Loss of keto anions

Normal anion gap -hydroxyhydroxy butyrate Negative serum ketones Order serum -hydroxyhydroxy butyrate DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Management of DKA in Adults S R PE S U L A ON Y L

N O E DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Fluids, Potassium, Acidosis are the Pillars of Treatment S R PE IV fluids S U L A ON Serum Potassium Y L N O E

Acidosis PERSONAL USE ONLY Replace Fluids with IV 0.9% NaCl until Euvolemic S R PE S U L A ON Y L N O E PERSONAL USE ONLY Once euvolemic, consider plasma Na+ and glucose to determine IV fluid type S R PE S

U L A ON Y L N O E PERSONAL USE ONLY Replace Potassium: Hypokalemia is an avoidable cause of death in DKA PE RS S U L A ON Y L N O E Correct K+ first THEN

start insulin PERSONAL USE ONLY Management of Acidosis with Insulin Insulin should Y maintained be L N O until the anion E S U gap normalizes L S R PE A N O Insulin used to treat the acidosis, not the glucose! PERSONAL USE ONLY

2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Identify and Treat the Precipitating Factor Insulin omission MOST COMMON CAUSE of DKA New diagnosis of diabetes S U L A Myocardial infarction ON S R Small rise in E Ptroponin may occur without overt Infection / Sepsis Y L N O E ischemia ECG changes may reflect hyperkalemia Thyrotoxicosis Drugs DKA, diabetic ketoacidosis

PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Prevention of DKA / HHS Type 1 diabetes Y Education around sick day management L ONnot eating Continuation of insulin even when E S Frequent monitoring when U ill L A N Type 2 diabetes O S R sick day management Education around E P Frequent monitoring when ill DKA, diabetic ketoacidosis;, HHS, hyperosmolar hyperglycemic state PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults

Priorities* to be addressed in the management of adults presenting with hyperglycemic emergencies Metabolic Precipitating cause of DKA/HHS ECFV contraction Potassium deficit and abnormal concentration Metabolic acidosis Hyperosmolality (water deficit leading to increased corrected sodium concentration plus hyperglycemia) S R PE Y L N O E New diagnosis of diabetes Insulin omission Infection Myocardial infarction Stroke ECG changes may reflect hyperkalemia A small increase in

troponin may occur without overt ischemia Thyrotoxicosis Trauma Drugs S U L A ON Other complications of DKA/HHS Hyper/hypokalemia ECFV overexpansion Cerebral edema Hypoglycemia Pulmonary emboli Aspiration Hypocalcemia (if phosphate used) Stroke Acute renal failure Deep vein thrombosis *Severity of issue will dictate priority of action DKA, diabetic ketoacidosis; ECFV, extracellular fluid volume; HHS, hyperosmolar hyperglycemic state

PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Recommendation 1 1. In adults with DKA or HHS, a protocol should be followed that incorporates the Y L N following principles of treatment fluid O E of resuscitation, avoidance S U L hypokalemia, insulin administration, A N O avoidance ofRSrapidly falling serum PEand search for osmolality, precipitating cause (as illustrated in Figure 1) [Grade D, Consensus] DKA, diabetic ketoacidosis; HHS, hyperosmolar hyperglycemic state PERSONAL USE ONLY

2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Recommendation 2 2. Point-of-care capillary betahydroxybutyrate may be measured in Y L N the hospital or outpatientOsetting [Grade E S D, Level 4] in adults with U type 1 diabetes L A with CBG >14.0 N mmol/L to screen for O S DKA, and a Ebeta-hydroxybutyrate R P >1.5 mmol/L warrants further testing for DKA [Grade B, Level 2]. Negative urine ketones should not be used to rule out DKA [Grade D, Level 4] CBG, capillary blood glucose; DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults

Recommendation 3 3. In adults with DKA, intravenous 0.9% LY sodium chloride should N be O mL/h for 4 administered initially Sat E 500 U for 4 hours [Grade hours, then 250 mL/h L A N B, Level 2] withSO consideration of a higher R L/h) in the presence of initial ratePE (1-2 shock [Grade D, Consensus]. For adults with HHS, intravenous fluid administration should be individualized [Grade D, Consensus] DKA, diabetic ketoacidosis; HHS, hyperosmolar hyperglycemic state PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Recommendation 4 4. In adults with DKA, an infusion of short-acting intravenous insulin of Y L

N 0.10 units/kg/h shouldObe used [Grade E S B, Level 2]. The insulin infusion rate U L A should be maintained until the N O S resolutionERof ketosis [Grade B, Level 2] P by the normalization of as measured the plasma anion gap [Grade D, Consensus]. Once the PG concentration falls to 14.0 mmol/L, intravenous dextrose should be started to avoid DKA, diabetic ketoacidosis; PG, plasma glucose hypoglycemia [Grade D, Consensus] PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Recommendation 5 2018 5. Individuals treated with SGLT2

Y DKA L inhibitors with symptoms of N O should be assessed for Ethis condition S U even if BG is not L elevated [Grade D, A Consensus] R E P N O S DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Key Messages Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) shouldLY

be Ndiabetes. If suspected in ill persons with O E precipitating either DKA or HHS is diagnosed, S U treated factors must be soughtL and A N O S R E medical emergencies that DKA and HHSPare require treatment and monitoring for multiple metabolic abnormalities and vigilance for complications PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Key Messages A normal or mildly elevated blood glucose does not rule out diabetic ketoacidosis in Y L N

certain conditions such as pregnancy or with O SGLT2 inhibitor use SE S R PE U L A N O PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Key Messages DKA requires intravenous insulin administration (0.1 units/kg/h) for resolution; Y L bicarbonate therapy may be considered only for N extreme acidosis (pH 7.0) E O S R PE

S U L A ON DKA, diabetic ketoacidosis PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Key Messages for People with Diabetes When you are sick, your blood glucose levels may fluctuate and be unpredictable: Y L N idea to check During these times, it is a good O E more often than your blood glucose levels S U 2 to 4 hours) usual (for example, every L A N Drink plenty of O sugar-free fluids or water

S R If you have E type 1 diabetes with blood P glucose levels remaining over 14 mmol/L before meals, or if you have symptoms of diabetic ketoacidosis (see chapter) check for ketones by performing a urine ketone test or blood ketone test. Blood ketone testing is preferred over urine testing PERSONAL USE ONLY 2018 Diabetes Canada CPG Chapter 15. Hyperglycemic Emergencies in Adults Key Messages for People with Diabetes Develop a Sick Day plan with your diabetes Y information L healthcare team. This should include N O on: E S U L A N which diabetes medications

you should O S continue and which ones you should R E P stop; temporarily guidelines for insulin adjustment if you are on insulin; and advice on when to contact your health-care provider or go to the emergency room PERSONAL USE ONLY Visit guidelines.diabetes.ca S R PE S U L A ON Y L N O

E PERSONAL USE ONLY Or download the App S R PE S U L A ON Y L N O E PERSONAL USE ONLY Diabetes Canada Clinical Practice Guidelines Y L http://guidelines.diab N O etes.ca E health-care

S for U L A providers R E P N O S 1-800-BANTING (2268464) http://diabetes.ca for people with diabetes PERSONAL USE ONLY

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