HYPERGLYCEMIC CRISIS

INTERNAL MEDICINE EMERGENCY & LIFE SUPPORT

(IMELS)

Ruang Kuliah Penyakit Dalam RSCM-FKUI

30 November 2019

Dicky L. Tahapary
dicky.tahapary@ui.ac.id
1Division
of Metabolism and Endocrinology, Department of Internal Medicine,
Dr. Cipto Mangunkusumo National Referral Hospital, Faculty of Medicine Universitas Indonesia
2The Indonesian Medical Education and Research Institute (IMERI), Cluster of Metabolic, Cardiovascular, and Aging
 HYPERGLYCEMIC CRISIS
Crude and Age-Adjusted Death Rates
Incidence of DKA 1980-2009
for Hyperglycemic Crises as Underlying
Cause per 100,000 Diabetic Population,
United States, 1980–2009

Gosmanov, Gosmanova, Kitabchi. Endotext 2018. https://www.ncbi.nlm.nih.gov/books/NBK279052/

HYPERGLYCEMIC CRISIS

Mortalitas dalam 72 jam adalah 28,57%

Gosmanov, Gosmanova, Kitabchi. Endotext 2018. https://www.ncbi.nlm.nih.gov/books/NBK279052/

Siregar 2017. Tesis. Retrospective Cohort n=301. JAFES Nov18 (In Press)
Mortalitas pasien KAD di RSCM

Mortalitas dalam 72 jam adalah 28,57%

Siregar 2017. Tesis. Retrospective Cohort n=301. JAFES Nov18 (In Press)
Sistem Skoring Prediksi Mortalitas pasien KAD

Siregar 2017. Tesis. Retrospective Cohort n=301. JAFES Nov18 (In Press)
 HYPERGLYCEMIC CRISIS
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)
represent two extremes
in the spectrum of acute decompensated diabetes.

Gosmanov, Gosmanova, Kitabchi. Endotext 2018. https://www.ncbi.nlm.nih.gov/books/NBK279052/

Pathogenesis of DKA and HHS

French et al. BMJ 2019

Precipitating Factors of Hyperglycaemia Crises
Precipitating Factors of Hyperglycaemia Crises

Fayman. Med Clin N Am 101 (2017) 587–606

Precipitating Factors of Hyperglycaemia Crises

Fayman. Med Clin N Am 101 (2017) 587–606

Precipitating Factors of Hyperglycaemia Crises

Siregar 2017. Tesis. Retrospective Cohort n=301. JAFES Nov18 (In Press)
Clinical Features of DKA and HHS
Clinical Features of DKA and HHS

Fayman. Med Clin N Am 101 (2017) 587–606

Diagnostic Criteria for DKA and HHS
Diagnostic Criteria for DKA and HHS

Fayman. Med Clin N Am 101 (2017) 587–606

Diagnostic Criteria for DKA and HHS

French et al. BMJ 2019

Diagnostic Criteria for DKA and HHS

French et al. BMJ 2019

Diagnostic Criteria for DKA and HHS

French et al. BMJ 2019

Diagnostic Criteria for DKA and HHS

French et al. BMJ 2019

Management of DKA ?
Management of DKA ?

Insulin

IV fluids Bicarbonate

Potassium

Kitabchi 2009
Management of DKA ?
IV fluids
*Corrected serum Na
Measured Na + 0.016 (BG - 100)
Determine
hydration status

Severe Hypovolemia Mild Dehydration Cardiogenic Shock

Administer 0.9% Evaluate corrected serum Hemodynamic

NaCl (1.0L/hr) Na* monitoring/pressors

Serum Na High Serum Na Normal Serum Na Low

0.45% NaCl 0.9% NaCl

(250-500 ml/hr) (250-500 ml/hr) Insulin
depending on depending on
hydration state hydration state
Potassium
When serum glucose reaches 200
mg/dL, change to 5% dextrose with Bicarbonate
0.45% NaCL at 100-150 ml/hr
Kitabchi 2009
Management of DKA ?
IV fluids
*Corrected serum Na
Measured Na + 0.016 (BG - 100)
Determine
hydration status

Severe Hypovolemia Mild Dehydration Cardiogenic Shock

Administer 0.9% Evaluate corrected serum Hemodynamic

NaCl (1.0L/hr) Na* monitoring/pressors

Serum Na High Serum Na Normal Serum Na Low

0.45% NaCl 0.9% NaCl

(250-500 ml/hr) (250-500 ml/hr) Insulin
depending on depending on
hydration state hydration state
Potassium
When serum glucose reaches 200
mg/dL, change to 5% dextrose with Bicarbonate
0.45% NaCL at 100-150 ml/hr
Kitabchi 2009
Management of DKA ?
IV fluids
*Corrected serum Na
Measured Na + 0.016 (BG - 100)
Determine
hydration status

Severe Hypovolemia Mild Dehydration Cardiogenic Shock

Administer 0.9% Evaluate corrected serum Hemodynamic

NaCl (1.0L/hr) Na* monitoring/pressors

Serum Na High Serum Na Normal Serum Na Low

0.45% NaCl 0.9% NaCl

(250-500 ml/hr) (250-500 ml/hr) Insulin
depending on depending on
hydration state hydration state
Potassium
When serum glucose reaches 200
mg/dL, change to 5% dextrose with Bicarbonate
0.45% NaCL at 100-150 ml/hr
Kitabchi 2009
 Management of DKA ?

Potassium

Establish adequate renal

function (urine output 50 ml/hr)

If serum K is <3.3 mEq/L,

hold insulin and give 20-30
mEq K/hr until K>3.3 mEq/L

If serum K is >5.3 mEq/L, do

not give K, but check serum
K every 2 hours
IV fluids

If serum K is is >3.3 but <5.3

Insulin
mEq/L, give 20-30 mE1 K in
each liter of IV fluid to keep
serum K between 4-5 mEq/L
Bicarbonate
Check electrolytes, BUN, venous pH, creatinine and glucose every 2-4 hours until stable
DLT’s Slide Kitabchi 2009
 Management of DKA ?

Potassium

Establish adequate renal

function (urine output 50 ml/hr)

If serum K is <3.3 mEq/L,

hold insulin and give 20-30
mEq K/hr until K>3.3 mEq/L

If serum K is >5.3 mEq/L, do

not give K, but check serum
K every 2 hours
IV fluids

If serum K is is >3.3 but <5.3

Insulin
mEq/L, give 20-30 mE1 K in
each liter of IV fluid to keep
serum K between 4-5 mEq/L
Bicarbonate
Check electrolytes, BUN, venous pH, creatinine and glucose every 2-4 hours until stable
DLT’s Slide Kitabchi 2009
 Management of DKA ?

Bicarbonate

Assess need for Bicarbonate

pH <6.9 pH 6.9-7.0 pH >7.0

Dilute NaHCO3 (100 Dilute NaHCO3 (50 No HCO3

mmol) in 400 ml H2O mmol) in 200 ml H2O
with 20 mEq KCl. Infuse with 20 mEq KCl. Infuse
for 2 hours for 2 hours
IV fluids
Repeat NaHCO3 administration every 2 hours until
pH >7.0. Monitor serum K Insulin

Potassium
Check electrolytes, BUN, venous pH, creatinine and glucose every 2-4 hours until stable

DLT’s Slide Kitabchi 2009

 Management of DKA ?

Bicarbonate

Assess need for Bicarbonate

pH <6.9 pH 6.9-7.0 pH >7.0

Dilute NaHCO3 (100 Dilute NaHCO3 (50 No HCO3

mmol) in 400 ml H2O mmol) in 200 ml H2O
with 20 mEq KCl. Infuse with 20 mEq KCl. Infuse
for 2 hours for 2 hours
IV fluids
Repeat NaHCO3 administration every 2 hours until
pH >7.0. Monitor serum K Insulin

Potassium
Check electrolytes, BUN, venous pH, creatinine and glucose every 2-4 hours until stable

DLT’s Slide Kitabchi 2009

Management of DKA Insulin

Insulin : Regular 0.1 U/

kgBW as IV bolus*
0.1 U/kg/hr IV continuous insulin
infusion
*It is important to point out that the IV use of fast-acting insulin
analogs is not recommended for patients with severe DKA or
HHS, as there are no studies to support their use. (Gosmanov,
Gosmanova, Kitabchi. Endotext 2018)

If serum glucose does not fall 50-70

mg/dL in first hour, increase the IV
insulin
IV fluids

When serum glucose reaches 200 mg/dL, reduce Potassium

regular insulin infusion to 0.05-0.1 U/kg/hr IV.
Keep serum glucose between 150-200 mg/dL
until resolution of DKA Bicarbonate
Check electrolytes, BUN, venous pH, creatinine and glucose every 2-4 hours until stable

Kitabchi 2009
Management of DKA Insulin

Insulin : Regular 0.1 U/

kgBW as IV bolus*
0.1 U/kg/hr IV continuous insulin
infusion
*It is important to point out that the IV use of fast-acting insulin
analogs is not recommended for patients with severe DKA or
HHS, as there are no studies to support their use. (Gosmanov,
Gosmanova, Kitabchi. Endotext 2018)

If serum glucose does not fall 50-70

mg/dL in first hour, increase the IV
insulin
IV fluids

When serum glucose reaches 200 mg/dL, reduce Potassium

regular insulin infusion to 0.05-0.1 U/kg/hr IV.
Keep serum glucose between 150-200 mg/dL
until resolution of DKA Bicarbonate
Check electrolytes, BUN, venous pH, creatinine and glucose every 2-4 hours until stable

Kitabchi 2009
French et al. BMJ 2019
French et al. BMJ 2019
Contoh Protokol KAD di RSCM
 Resolution for DKA and HHS

The criteria for DKA resolution: The criteria for HHS resolution

serum glucose level <200 mg/dL
and two of the following:
serum bicarbonate level ≥15 mEq/L,
pH >7.3, and
anion gap ≤12 mEq/L
serum osmolality is < 320 mOsm/kg
with a gradual recovery to mental alertness.
The latter may take twice as long as to achieve
blood glucose control.
gradual reduction in osmolality not
exceeding 3 mOsm/kg H2O per hour

Ketonemia typically takes longer to clear than hyperglycemia.

Gosmanov, Gosmanova, Kitabchi. Endotext 2018. https://www.ncbi.nlm.nih.gov/books/NBK279052/

 Resolution for DKA and HHS

Once DKA has resolved,

(1) patients who are able to eat

can be started on a multiple dose insulin regimen with long acting insulin and
short/rapid acting insulin* given before meals as needed to control plasma glucose.

Intravenous insulin infusion should be continued for 2 hours after giving the
subcutaneous insulin to maintain adequate plasma insulin levels.

(2) patient is unable to eat

it is preferable to continue the intravenous insulin infusion and fluid replacement.

Gosmanov, Gosmanova, Kitabchi. Endotext 2018. https://www.ncbi.nlm.nih.gov/books/NBK279052/

 Resolution for DKA and HHS

can be started on a multiple dose insulin regimen with long acting insulin and
short/rapid acting insulin* given before meals as needed to control plasma glucose.
New onset diabetes

a multi-dose insulin regimen should be started at a dose of 0.5-0.8 U/kg per day,
including regular or rapid-acting and basal insulin until an optimal dose is established

Known diabetes

- may be given insulin at the dose they were receiving before the onset of hyperglycemic
crises.
- calculate insulin requirement in the last 24-hour — switch to a multi-dose insulin regimen

Gosmanov, Gosmanova, Kitabchi. Endotext 2018. https://www.ncbi.nlm.nih.gov/books/NBK279052/

Priorities to be addressed in Hyperglycemic Crisis
TERIMA
KASIH