What is the management of acute complications of Diabetes Mellitus (DM)?

Management of Acute Complications of Diabetes Mellitus

The management of acute complications of diabetes mellitus requires immediate recognition and aggressive treatment with insulin, fluids, and electrolyte replacement to prevent significant morbidity and mortality. 1

Diabetic Ketoacidosis (DKA)

Diagnostic Criteria

• Plasma glucose >250 mg/dL
• Arterial pH <7.30
• Serum bicarbonate <15 mEq/L
• Significant ketonuria and ketonemia 1

Treatment Protocol

1. Intravenous Fluid Replacement

   • Initial bolus of 0.9% saline at 15-20 mL/kg/hr for the first hour
   • Continue IV fluids based on hydration status and electrolyte levels

2. Insulin Therapy

   • IV regular insulin bolus of 0.1 units/kg followed by continuous infusion at 0.1 units/kg/hr
   • Target glucose decrease of 50-75 mg/dL per hour
   • Once glucose reaches 200-250 mg/dL, reduce insulin rate and add dextrose to IV fluids 1

3. Electrolyte Replacement

   • Potassium: Add when serum levels <5.2 mEq/L (if renal function adequate)
   • Phosphate: Replace if serum phosphate <1.0 mg/dL
   • Bicarbonate: Consider only if pH <6.9 2

4. Monitoring

   • Hourly blood glucose measurements
   • Electrolytes every 2-4 hours
   • Monitor for cerebral edema, especially in pediatric patients

Hyperglycemic Hyperosmolar State (HHS)

Diagnostic Criteria

• Plasma glucose >600 mg/dL
• Arterial pH >7.30
• Serum bicarbonate >15 mEq/L
• Minimal ketonuria/ketonemia
• Effective serum osmolality >320 mOsm/kg 1

Treatment Protocol

1. Aggressive Fluid Replacement

   • More aggressive than DKA due to greater dehydration
   • Initial 0.9% saline at 15-20 mL/kg/hr
   • Adjust based on hemodynamic status and electrolytes

2. Insulin Therapy

   • Lower doses than DKA: 0.05-0.1 units/kg/hr IV
   • Target glucose decrease of 50-70 mg/dL per hour 1

3. Electrolyte Management

   • Similar to DKA but with greater attention to sodium levels
   • Monitor for thrombotic complications

Hypoglycemia Management

Diagnostic Criteria

• Blood glucose <70 mg/dL with or without symptoms
• Severe: requiring assistance from another person

Treatment Protocol

1. Conscious Patient

   • Oral glucose 15-20g (preferred treatment)
   • Any carbohydrate containing glucose will work, but pure glucose is most effective
   • Recheck blood glucose in 15 minutes; repeat treatment if still <70 mg/dL 2

2. Unconscious Patient

   • Glucagon 1 mg IM/SC for adults and children ≥20 kg
   • Glucagon 0.5 mg or 20-30 mcg/kg for children <20 kg
   • IV dextrose 25g if available (healthcare setting) 3

3. Post-Treatment

   • Once conscious, provide oral carbohydrates
   • Evaluate for cause of hypoglycemia
   • Monitor for recurrence for several hours 2

Management During Acute Illness

For Type 1 Diabetes

• Never discontinue insulin during illness, even if not eating
• Increase monitoring of blood glucose and ketones
• Maintain hydration (150-200g carbohydrate daily)
• Adjust insulin doses as needed 2

For Type 2 Diabetes

• Continue oral medications unless contraindicated
• May require temporary insulin therapy during severe illness
• Monitor blood glucose more frequently 2

Hospital Management

Critical Care Setting

• Continuous IV insulin infusion for persistent hyperglycemia >180 mg/dL
• Target glucose range of 140-180 mg/dL
• Use validated written or computerized protocols 2

Non-Critical Care Setting

• Basal-bolus insulin regimen is preferred for patients with good nutritional intake
• Basal-plus-correction insulin for patients with poor oral intake or NPO
• Avoid sliding scale insulin alone as it is strongly discouraged 2

Transition from IV to Subcutaneous Insulin

• Give subcutaneous insulin 1-2 hours before discontinuing IV insulin
• Convert to basal insulin at 60-80% of daily infusion dose 2

Common Pitfalls to Avoid

1. Delaying insulin therapy in suspected DKA
2. Inadequate fluid replacement
3. Omitting insulin during acute illness in type 1 diabetes
4. Failing to monitor for hypoglycemia during treatment
5. Using sliding scale insulin as the sole regimen in hospitalized patients 1, 2

Discharge Planning

• Begin discharge planning at admission
• Obtain HbA1c if none available within prior 3 months
• Schedule outpatient follow-up within 1 month of discharge
• Provide structured education on sick-day management 2

By following these protocols, the morbidity and mortality associated with acute diabetic complications can be significantly reduced, improving patient outcomes and quality of life.