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Policy Name: Hyperglycemic Emergencies Management Guideline

Policy # Pharmacy 5.2.6


Contact: Paul Szumita, PharmD, Marie McDonnell, MD
Sponsor: Diabetes Subcommittee of the P&T Committee
Effective Date: 02/2017
Approved By: Reviewed 10/10, Updated 5/16, 2/17
Department of Pharmacy
P&T Committee

Background

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia state (HHS) are the most common serious
complications of diabetes, with HHS having a consistently high mortality rate of 15%. The morbidity
increases significantly with coexisting medical conditions. DKA can be seen with glucose values lower
than 250 mg/dL in some clinical situations such as pregnancy or with use of some oral diabetes
medications.

Classification of patients *

Please note classification is based on either serum bicarbonate or pH and patients may present with
abnormalities of both DKA and HHS;

Effective osmolality (Osmeff )is calculated (not measured) from plasma chemistry results: 2[NA]+
Glucose/18. The Osmeff is a required criterion for HHS diagnosis.
Triage

Considerations in determining appropriate level of care (ICU vs. intermediate care vs floor)

1. Continuous IV insulin may be administered on intermediate care units. Please refer to Nursing
policy on continuous infusion of IV insulin
2. If patients present with HHS or moderate/severe DKA, use IV insulin instead of SC insulin.
3. Patients presenting with severe DKA or HHS require ICU care.
4. Patients with moderate DKA may require ICU care if appropriate monitoring or treatment
cannot safely be administered in the intermediate care setting. Please refer to Guidelines for
care on an intermediate unit.

a. Note: Phlebotomy support is available 24/7. There are scheduled rounds that occur 5
times a day from 12am to 8pm. Timed lab draws as well as STAT draws are available in
addition to these round times. Physician staff may be required to draw blood (on both
intermediate care and ICU) if additional monitoring is required and the patient does not
have an arterial line or central venous catheter.
b. If adequate phlebotomy support is not available, patients should be transferred to a unit
that can perform timely blood draws

5. Patients with mild DKA may be treated on the floor with subcutaneous insulin regimen if unit is
able to provide adequate POC testing (q 2 hours)

Order Sets:

The ED Hyperglycemic Emergencies Order EntryTemplate should be used for all emergency department
patients who present with DKA or HHS (In EPIC, go to Order Sets DKA/HHS)

Monitoring

Point of Care (POC) vs. Plasma Glucose Testing

POCT allows for rapid assessment of whole blood glucose. The FDA considers 20% variability between
the POCT and plasma glucose values to be acceptable. POCT glucometers cannot accurately measure
blood glucose >500 mg/dL thus plasma blood glucose is the test of choice in these patients. It is
recommended that plasma blood glucose be less than 500 mg/dL for 2 results and that POCT be
confirmed by lab glucose or glucose off ABG before POCT is used. Laboratory testing of plasma glucose
provides the most accurate measurement of glucose and remains the gold standard.
Lab Test DKA HHS
Plasma glucose Immediately then every 2 hrs Immediately then every 2 hrs
until glucose <400 x 2 until glucose <400 x 2
Finger stick glucose (POCT) Immediately then at a minimum Immediately then as clinically
of every 2 hours until gap closes warranted until osmolality
(<12) <315
Chem 7 Every 2-6 hrs (q2h if patient is Every 2-6 hrs (q2h if patient has
critically ill K < 3.3, pH < 7.0, altered mental status, coma)
hemodynamic instability, coma)
Potassium Every 2 hrs if < 4 until stable or Every 2 hrs if < 4 until stable or
as warranted based on as warranted based on
repletion (K < 3.3 must be repletion (K < 3.3 must be
urgently repleted) urgently repleted)
Serum beta-hydroxybutyrate Baseline and as clinically Only if acidotic or as clinically
warranted warranted
Effective Osmolality ^(calculate x1 x 1 then every 2-6 hrs until
using formula) stable
Serum acetone test or serum x1 x1
ketones

Blood gases VBG or ABG at baseline VBG or ABG at baseline

VBG every 2-4 hrs as clinically


warranted
Magnesium, Calcium Baseline and as warranted Baseline and as warranted
based on phosphate repletion based on phosphate repletion
(phosphate can decrease (phosphate can decrease
calcium) calcium)
Phosphate Baseline and as clinically Baseline and as clinically
warranted warranted
Urinalysis x 1 and as clinically warranted x 1 and as clinically warranted
Hemoglobin A1C x1 x1
Bacterial cultures if suspicion of x1 x1
infection
Chest X-ray for suspected x 1 and as clinically warranted x 1 and as clinically warranted
pneumonia
Pulse oximetry monitoring Continuous Continuous

^Effective osmolality (Osmeff) is calculated (not measured) from plasma chemistry results:2(NA)+
Glucose/18. The OSMeff is a required criterion for HHS diagnosis.

Management

1. IV fluids
a. Fluid repletion to expand intravascular, interstitial, and intracellular volume, all of which
are reduced in hyperglycemic crises
b. Bolus fluids
i. Infuse 0.9% NaCl 500-2000 mL over first hour
ii. May need to adjust fluid/electrolyte management in patients with co-
morbidities such as CHF, renal dysfunction, hypoxemia or age over 65 years
c. Maintenance fluids
i. 0.9%NaCl 500 mL/hour until hemodynamically stable(urine output and blood
pressure)
ii. Fluid rate based on physiologic parameters to maintain hemodynamic stability
(e.g. heart rate, blood pressure, urine output) and repletion of intravascular
and extravascular volume
1. Corrected Na = Measured Na + 0.016 x (Serum glucose - 100)
iii. If corrected Na is high or normal infuse 0.45% NaCl at 100-500 ml/hr
iv. If corrected Na is low infuse 0.9% NS at 100-500 ml/hr
v. Consider switching from 0.9% NS to Lactated Ringers in the case of
hyperchloremia and persistent hypobicarbonatremia
1. Change to D5W 0.45%NS or D5W0.9%NS at 100-500 ml/hr when:
DKA: Blood Glucose <250 mg/dL and adjust rate to maintain
glucose 100-200 mg/dL until anion gap < 12 or until patient is
eating or on enteral feeding
HHS: Blood Glucose <300 mg/dL and adjust rate to maintain
glucose 150-250 mg/dL until effective osmolality < 315
mOsm/kg and until patient mentally alert or eating or on
enteral feeding
Stop fluids containing D5W when patient eating and
hyperglycemic crisis is resolved using above criteria
Sodium bicarbonate
i. If pH > 7.0 do not administer bicarbonate
ii. If pH < 7.0 and hemodynamic instability refractory to NS
repletion, change IVF to 1 L D5W with 150 mEq
bicarbonate (approximately 3 amps sodium
bicarbonate). Infuse over 2 hours. Strongly consider
intubation and mechanical ventilation if respiratory
compensation is inadequate.
2. II. Insulin
a. Intravenous vs. Subcutaneous Insulin regimens
i. Intravenous infusion of regular insulin is the treatment of choice in HHS and
most cases of DKA.
ii. Subcutaneous insulin has been shown to be safe and effective in mild and
uncomplicated DKA.
iii. The underlying etiology (e.g. infection, pancreatitis and trauma) for the
hyperglycemic crisis should be carefully assessed before selecting route of
administration.
iv. Severe DKA can lead to poor tissue perfusion, thus regular insulin by continuous
infusion is the treatment of choice instead of the subcutaneous route.
v. *** If K+ less than 3.3 mEq/L, replete K+ urgently before initiating insulin, if
using iv insulin and K < 4 consider holding insulin bolus***
vi. ****Insulin rate must be SET, do not titrate per critical care IV insulin protocol
(BHIP is not appropriate for DKA/HHS treatment)****
vii. When insulin rate change is required, a new order is required per responding
clinician with new adjusted insulin infusion rate
3. Infusion recommendation:

Intravenous Insulin *

Please Note: All insulin regular continuous


infusion orders must be entered in EPIC
with the dose in units/hr for smart pump
compatibility

Initial Dose 0.1 units/kg up to 10 units IV bolus


Initial Rate 0.1 unit/kg/hr

Max 7 units/hr for patients with a new


diagnosis of DM and no clinical suspicion of
insulin resistance

Max 10 units/hr for all other patients


If BG by < 50 mg/dl per hr Repeat 0.1 units/kg bolus then resume
infusion at 0.1 unit/kg/hr

If BG fails to drop after 2nd bolus, check


integrity of line and increase rate to 0.14
units/kg/hr
If BG by > 100 mg/dl per hr Decrease rate to 0.05 unit/kg/hr
DKA: Blood glucose <250 mg/dl 0.05 units/kg/h until anion gap has closed
(<12)
HHS: Blood glucose 250-300 mg/dl 0.05 units/kg/h until effective osmolality <
315 mOsm/kg

*Subcutaneous long-acting insulin glargine can be simultaneously administered once


hydration is adequate at a dose of 0.25 units/kg/day (normal renal function) or 0.15
units/kg/day (impaired renal function) to improve transition to subcutaneous regimen

Journal of Clinical Endocrinology and Metabolism 31:3132, 2012

f. Subcutaneous insulin recommendation: for use only in mild, uncomplicated DKA

Subcutaneous Insulin Aspart Subcutaneous Insulin


Glargine
Initial Dose 0.3 units/kg 0.25 units/kg if GFR >40; 0.15
maximum 20 units units/kg if GFR <40
Subsequent Dose 0.2 units/kg every 2 hours Redose in 24 hours based on
maximum 10 units response to initial dose
Blood glucose <250 mg/dl 0.05-0.1 units/kg every 2 hours
g. Transition to maintenance insulin regimen

i. OVERLAP SUBCUTANEOUS INSULIN (BASAL AND RAPID ACTING) WITH INSULIN DRIP FOR
AT LEAST 2 HOURS FOR BASAL AND RAPID ACTING SC INSULIN GIVEN TOGETHER OR AT LEAST
4 HOURS FOR BASAL ALONE BEFORE TURNING OFF DRIP.(Note: if using insulin glargine Toujeo
(U-300 units/mL) must overlap with insulin infusion for 6 hours) An abrupt discontinuation of IV
insulin coupled with a delayed onset of SC insulin regimen may lead to ketone formation and
rebound hyperglycemia

ii. When treatment goals are met, consider changing to subcutaneous insulin
regimen:

DKA: blood glucose range 150-200 mg/dL, anion gap < 12 and
bicarbonate > 18)

HHS: blood glucose range 250-300 mg/dL, plasma osmolality < 315
mOsm/kg and patient mentally alert

iii. Transition to home regimen if considered satisfactory or if uncomplicated


DKA

iv. Use Adult basal-bolus insulin order set in EPIC

v. Basal insulin: NPH QAM/QHS or Glargine QHS

vi. Meal time: Aspart QAC plus Aspart sliding scale in addition to basal insulin

vii. NPO: Regular sliding scale Q6H in addition to basal insulin

viii. Order correctional insulin q 6 hours or qac/qhs once off either IV insulin or
apspart q 2 protocols as per Basal-Bolus insulin order sets in EPIC

III. Electrolytes

Electrolyte repletion to avoid major shifts in potassium with insulin therapy, correction of
acidosis and achievement of volume expansion

a. Potassium replacement

i. Confirm urine output >0.5 cc/kg/hr before repletion of potassium (i.e. may
start treatment just with NS)

ii. Consider central line if K+ < 3.3 mEq/L, must replete K+ and undertake careful
and frequent monitoring with EKGs ; ICU monitoring recommended

iii. Maximum dose is 20 mEq/hr IV (from all IV sources) through a central


catheter using an infusion pump and 40 mEq immediate release potassium
orally

iv. Cardiac monitoring for all infusion rates of >10 mEq/hour


v. For patients with decreased renal function replete as clinically warranted

vi. Initial repletion:

KCl Administration, mEq/L


Blood K+, mEq/L Peripheral or enteral Central
>5 or/Urine output None None
<0.5cc/kg/hr
4-5 10 mEq IV x 2 doses or 20 mEq enterally 20 mEq IV
3-4 10 mEq IV x 4 doses or 40 mEq enterally 20 mEq IV x 2
<3 10 mEq IV x 6 doses or 40 mEq enterally 20 mEq IV x 3
then 20 mEq 2 hrs after

vii. Maintenance repletion:

See Potassium replacement scales in EPIC order sets

b. Phosphate replacement

i. Suggested Repletion:

Severe: (serum level < 1 mg/dL): 15 mmol over 6-12 hours (max dose:
30mmol q6h)

Patients only need IV repletion for severe hypophosphatemia

Recheck phosphate as clinically warranted, usually daily if

moderate depletion, q6h if severe

Recheck calcium as clinically warranted

c. Magnesium replacement

i. See Magnesium Replacement Scales in EPIC order sets

IV. Follow-up care

a. Consider endocrine consult (for Medicine service) or Diabetes Management Service


(DMS, for surgical services) for complicated DKA/HHS or new diagnosis of diabetes for
management assistance and to help transition to outpatient care.

V. Diabetes education

a. Primary nurse to perform diabetes teaching to reinforce medication adherence and


recognition of potential signs and symptoms of hypoglycemia or hyperglycemia. Ensure
prompt follow-up and close monitoring after discharge (e.g. VNA services every day or
every other day, appointment with diabetes educator within 3 days, follow-up with MD
within 7 days).