Diabetes Emergencies

Dr Stella George
Consultant Diabetes and
Endocrinology
 Case 1- Presentation
• 48 year old female
• 4 day history of abdominal pain, loss of
appetite
• Similar episode 6 weeks previously
• 2 episodes of vomiting
 Past Medical History
• Type 2 diabetes diagnosed 10 years ago
• Obesity
• Hypertension
• TAH/BSO for endometrial carcinoma 2008
 Medication
• Metformin 1000mg b.d
• Gliclazide 80mg b.d.
• Canagliflozin 100mg od
• Tramadol and Cyclizine started a few days ago
by GP for acute symptoms
 Examination
• Temp 37.7 Celsius
• HR 126
• BP189/97
• RR 18
• Sats 96% RA
• CBG 10.4 mmol/l

• Tender RUQ abdomen, no rebound tenderness,

no guarding, bowel sounds normal
• Rest of clinical examination noted as normal
 Initial Blood results
Biochemistry Haematology
Na 137 133-146 mmol/L Hb 175 115-160 g/dL

K 4.3 3.5-5.3 mmol/L Total WC 14.6 4-11 109/L

Urea 3.7 2.7-7.8 mmol/L Platelets 347 150-400 109/L

Creatinine 46 45-84 umol/L

Fibrinogen 8.4 2-4 g/dL

Bilirubin 141 0-21 umol/L

Alkaline 360 30-130 IU/L

Phosphatase
ALT 1029 7-40 IU/L

CRP 70 <5
 Review by surgical SpR
• Diagnosis- cholangitis
• Teicoplanin and Metronidazole IV
• VTE prophylaxis
• Water only in preparation for USS though felt
MRCP might be needed because of patients
body habitus.
• Analgesia
• Transfer to surgical ward
 Day 2- on the surgical ward
• Patient uncomfortable and required analgesia
overnight.
• CBGs stable overnight and within acceptable
range of 4-12
• Surgical ward staff carry out an urine dip
• Result- Positive for Glucose; BR and 4+Ketones
• CST review
 Investigations
• USS abdomen- multiple gall stones; Fatty liver
infiltration, Dilated common bile duct ( 15mm)
and intrahepatic ducts. Normal appearances of
kidneys, spleen and pancreas

• BP 147/44
• HR 116
• RR 26
• Urine output 40mls/hr
 CST review 1600
• Noted ‘ ketones on breath’
• ABG
– pH 7.05
– pO2 17.6
– pCO21.2
– HC03 2.4
– BE -25.7

• Capillary Ketones 6.3

• Capillary Glucose 10.7
 What is the diagnosis?

105
A. Worsening sepsis
B. Ketosis related to ‘
clear fluids only’ 14 20
C. DKA
A B C
 Correct Answer
A. Worsening sepsis
B. Ketosis related to ‘ clear fluids only’
C. DKA
 Euglycaemic DKA
• First reported in 1973
• Spectrum of DKA
• ‘Partially treated’ DKA –
Decreased CHO intake e.g. starvation,
Ramadan, Depression, Chronic Liver Disease,
pregnancy or sick day rules not followed fully.
Patients managed to maintain a degree of hydration
and insulin intake but
glucose levels may be normal but ketone
formation continues
Possible mechanism of Euglycaemic DKA by SGLT2 -i

Taylor et al JCEM 2015; 100 (8):2859-2852

 Next treatment ?
A. 10 units Actrapid stat
B. 1 litre 0.9% NaCl over 1 hour
43
C. 1 litre of Hartmann’s over an 39
hour
D. Variable rate intravenous 21
insulin infusion (VRIII) at 1
units per hour 7 10
E. Fixed rate intravenous insulin 2
infusion (FRIII) at 0.1 units
/kg/hr A B C
D E F
F. FRIII at 0.5 units/kg/hr
 Correct Answers
A. 10 units Actrapid stat
B. 1 litre 0.9% NaCl over 1 hour
C. 1 litre of Hartmann’s over an hour
D. Variable rate intravenous insulin infusion
(VRIII) at 1 unit per hour
E. Fixed rate intravenous insulin infusion (FRIII)
at 0.1 units /kg/hr
F. FRIII at 0.5 units/kg/hr
 2 hours later
• pH 7.1
• pC02 2.3
• pO2 17.7
• HCO3- 4.4
• Glucose 8.7

• K+ 3.9
• Capillary Ketones 5.9
 What do you do next? Choose 2

A. IV bicarbonate
B. Continue 0.9% NaCl with 61
40mmol KCl only
C. Add in 10% dextrose 25
18
D. Increase the rate of IV 10
insulin

A B C D
 Targets for ongoing treatment 1-6 hrs
• Decrease in Ketones by 0.5 mmol/l per hour
In the absence of Capillary ketones
• Increase in bicarbonate by 3 mmol/l per hour
• Decrease in glucose by 3 mmol/l per hour
• Maintain serum potassium in the normal
range
• Avoid hypoglycaemia
 Correct Answers
A. IV bicarbonate
B. Continue 0.9% NaCl with 40mmol KCl only
C. Add in 10% dextrose
D. Increase the rate of IV insulin
 Case 1 – Patient’s progress
• Diagnosis of eu-DKA was made
• Transferred to ITU
• DKA resolved within 2 days.
• Started on subcutaneous insulin – Twice daily
premixed
• ERCP day 6- stent inserted.
 Key Changes 2013 edition
• Real world evidence informed changes
• Continue human basal insulins as well as
Analogue insulins on top of FRIII
• Maximum dose 15 units per hour on
FRIII
• Resolution of DKA is
pH >7.3;
Bicarbonate >15mmol/L and
Capillary ketones <0.6 mmol/L
( cf <0.3 mmol/L in 2010)
• Newly presenting type 1 patients should be given Levemir ®
or Lantus ® at 0.25 units per kg
 DKA- the statistics
• 4.8-8 episodes per 1000 patients with diabetes (1,2)
• Admission linked to social deprivation, high HbA1c,
reduced concordance with insulin and female
gender and use of antidepressants(5)
• Mortality dropped from 7.6% to 0.67% (3,4) as
inpatient but there is a higher risk of death post
discharge particularly if recurrent DKA (5).
• NaDIA audits show a significant proportion occurs
AFTER admission to hospital ( approx. 3400 in UK
per year) (6)
 Case 2
• 73 year old male
• Routine clinic follow-up for prostate cancer
• Had radiotherapy and given the ‘ all clear’.
• Complained of feeling tired for the past 2 weeks
• Polyuria and polydypsia
• No other symptoms on direct questioning
• Urologists arranged for some routine bloods
And patient went home
 Past history
• Epilepsy
• Hypertension
• Prostate cancer- treated with radiotherapy
• Hiatus hernia

• Medication : Tamsulosin 400mcg OD;

Lansoprazole 30mg od; Losartan 100mg OD;
Carbamazepine MR 200mg TDS
 Later that evening..

• OOH GP contacted medical registrar saying

That lab had called him with results of bloods
lab glucose 42mmol
• Patient called back to hospital
 Examination findings
• Dry mucous membranes
• BP 133/81
• HR 89
• Temp 36.5
• Sats 96% RA

• Clinical Examination – Normal

• Weight 80kg
 Initial Bloods
Biochemistry Haematology
Na 138 133-146 mmol/L Hb 124 115-160 g/dL
K 4.3 3.5-5.3 mmol/L Total 5.7 4-11 109/L
Urea 9.2 2.7-7.8 mmol/L WC
Platelets 142 150-400 109/L
Creatinine 89 45-84 umol/L

Bilirubin 8 0-21 umol/L

Alkaline 153 30-130 IU/L
Phosphatase
ALT 17 7-40 IU/L

CRP 10 <5 mg/L

Glucose 42 3.5-8 mmol/L
 What do you do next (top 3)?

A. Venous Blood Gas

B. Capillary Ketones 40
38 38
C. Urine Dip
D. ECG
E. Serum osmolality
6 4

A B C D E
 Correct Answers

A. Venous Blood Gas

B. Capillary Ketones
C. Urine Dip
D. ECG
E. Serum osmolality
 Results
• VBG
pH 7.4
pCO2 4.61
pO2 8.27
HCO3 22.8
BE -1.9

• Capillary Ketones 1.7

 Osmolality- which formula would you
use ?
A. (2x Na) + Gluc + Urea
18 2.8
B. 2(Glucose) + Urea + Na 75
C. 2(Na) + Urea + Glucose
D. 2(Na +K)+ Urea + Glucose
E. 2(Na+K) +Glucose 21
13 18
5

A B C D E
 Correct Answer

A. (2x Na) + Gluc + Urea

18 2.8
B. 2(Glucose) + Urea + Na
C. 2(Na) + Urea + Glucose
D. 2(Na +K)+ Urea + Glucose
E. 2(Na+K) +Glucose
 Calculated Osmolality
• 327 mOsm/kg
 Diagnosis- HHS. What are the next
steps in management? ( choose 2)
A. Start variable rate
intravenous insulin at 8
units per hour
47
B. Start fixed rate intravenous
insulin at 8 units per hour
C. Start fixed rate intravenous 25
insulin at 4 units per hour 16 16 19
D. Start 0.9% NaCl – 1 litre over
30 minutes
E. Start 0.9% NaCl- 1 litre over
60 minutes A B C D E
 Correct Answers
• A. Start variable rate intravenous insulin at 8
units per hour
• B. Start fixed rate intravenous insulin at 8
units per hour
• C. Start fixed rate intravenous insulin at 4 units
per hour
• D. Start 0.9% NaCl – 1 litre over 30 minutes
• E. Start 0.9% NaCl- 1 litre over 60 minutes
The spectrum of DKA and HHS

English P, Williams G. Postgrad Med J

2004; 80(943):253-261
 If ketones were 0.4 mmol/L how
would that change your management?
A. Start variable rate
intravenous insulin at 8
units per hour
67
B. Start fixed rate intravenous
insulin at 8 units per hour
C. Start fixed rate intravenous
insulin at 4 units per hour 27
17
D. Start 0.9% NaCl – 1 litre over 7 9
30 minutes
E. Start 0.9% NaCl- 1 litre over
60 minutes A B C D E
 Correct Answer
A. 1. Start variable rate intravenous insulin at 8
units per hour
B. 2. Start fixed rate intravenous insulin at 8
units per hour
C. 3. Start fixed rate intravenous insulin at 4
units per hour
D. 4. Start 0.9% NaCl – 1 litre over 30 minutes
E. 5. Start 0.9% NaCl- 1 litre over 60 minutes
Why insulin can make things worse
A. Normoglycaemia and normal
hydration

B. Early in HHS:ECF is hyperosmolar.

Fluid shifts from ICF to ECF

C. Late: Continued osmotic diuresis

causes dehydration, volume loss
and hyperosmolality in both ECF
and ICF

D. Insulin therapy without adequate

fluid replacement shifts glucose
and water from ECF to ICF causing
vascular collapse and hypotension
 0-60 mins
• Start 0.9% NaCl 1 litre over 1 hour
• ONLY start insulin
IF ketones >1.0 @0.05 units/kg/hr
• Look at feet
• Start hourly monitoring and calculate osmolality
every hour for 1st 6 hours then 2 hourly if achieving
target
• Target is a fall in osmolality of 3-8 mosmol/kg/hr
• Catheter/ LMWH/Antibiotics
Case 2 – 3 hours post start of Rx.

1 litre over 1 hour

1 litre over 2 hours
IV insulin 0.05 units/kg/hr
Biochemistry
Na 138 158 133-146 mmol/L
Urea 9.2 6 2.7-7.8 mmol/L
Glucose 42 18 3.5-8 mmol/L
Calc. Osmol 327 320 mosmol/kg/hr
 What would you do?

A. Increase the rate of

intravenous insulin
20
B. Switch to 0.45% NaCl 17
C. Increase the rate of 0.9% 14
11
NaCl
D. Decrease the rate of 0.9%
NaCl 2

E. Add in 5% Dextrose
A B C D E
 Correct Answer

A. Increase the rate of intravenous insulin

B. Switch to 0.45% NaCl
C. Increase the rate of 0.9% NaCl
D. Decrease the rate of 0.9% NaCl
E. Add in 5% Dextrose
 60 mins- 6 hours
0.9% NaCl 500ml-1000ml /hr
Aim 2-3 L positive balance in 6 hours
AIM decrease in Osmolality 3-8msoml/kg/hr

Na Osmolality
Na and Na and Osmolality
(or not decreased enough)
Osmolality but ADEQUATE fluids
but INADEQUATE fluids

Continue 0.9% NaCl Increase rate of 0.9% NaCl Switch to 0.45% NaCl
at same rate

Aim to keep Glucose at 10-15mmol/l. If <14 ADD 5% or 10 % glucose @125ml/hr

Watch K and replace as needed
 6-72 hours
• Gradual fall in osmolality
• Monitor response to treatment- making
adjustments to rates of fluid and insulin
• Watch for cerebral oedema, central pontine
myelinolysis ( dropping GCS), fluid overload
• Ensure referral to diabetes team
• Convert to subcutaneous insulin- may need
for several months
• Continue LMWH till discharge if not beyond
 Summary1- DKA
• Euglycaemic DKA is an increasing
phenomenon
• High index of suspicion in unwell pts on SGLT2i
• Treat as normal DKA but add in 10% dextrose
to avoid hypoglycaemia
• JBDS 2013 guidelines
 Summary 2- HHS
• Monitor closely
• Target osmolality
• Avoid rapid shifts
• Hypernatraemia is almost inevitable- follow
guidelines and only use 0.45% NaCl if enough
fluids have been given
• Only give insulin if Ketones >1.0 mmol/l
• Level 2 care if at all possible