What is the appropriate workup for a patient with diabetes (Diabetes Mellitus) in the Emergency Department (ED)?

From the Guidelines

A comprehensive medical evaluation should be performed at the initial visit to confirm the diagnosis and classify diabetes, evaluate for diabetes complications, and develop a plan for continuing care, as recommended by the 2023 standards of care in diabetes 1. When evaluating a patient with diabetes in the emergency room, it is essential to consider the following key components:

• A thorough assessment of vital signs, including blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation
• Initial laboratory tests, such as fingerstick blood glucose measurement, serum glucose, complete blood count, basic metabolic panel, urinalysis, and hemoglobin A1C
• Additional tests for patients with suspected diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), including serum ketones, arterial or venous blood gas, serum osmolality, and anion gap calculation
• An electrocardiogram to assess for cardiac complications
• Intravenous access and fluid resuscitation using normal saline for dehydrated patients
• Insulin therapy, typically starting with an IV insulin drip at 0.1 units/kg/hour for DKA after an initial bolus of 0.1 units/kg, with close monitoring of potassium levels The underlying cause of hyperglycemia should be investigated, including infection workup with cultures if indicated, and frequent reassessment of glucose levels and electrolytes is essential to guide ongoing management, as supported by the 2021 standards of medical care in diabetes 1. It is also important to note that the use of bicarbonate in patients with DKA is generally not recommended, as it has been shown to make no difference in resolution of acidosis or time to discharge 1. Overall, a comprehensive approach to diabetes care in the emergency room is crucial to stabilize the patient, identify and address the underlying cause of the diabetic emergency, and improve morbidity, mortality, and quality of life outcomes.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Diabetes Workup in the Emergency Room

• The emergency department (ED) evaluation and management of hyperglycemic adult patients without a history of diabetes who do not have evidence of a hyperglycemic crisis is a challenge 2.
• A new diagnosis of type 2 diabetes can be established in the ED by the American Diabetes Association (ADA) criteria in patients with a random plasma glucose ≥ 200 mg/dL (11.1 mmol/L) and symptoms of hyperglycemia 2.
• The diagnosis should be considered in patients with an elevation in random blood glucose > 140 mg/dL (7.8 mmol/L) 2.

Hyperglycemic Emergencies

• Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus, confirmed by elevated blood glucose levels, presence of high urinary or blood ketoacids, and high anion gap metabolic acidosis 3.
• Hyperglycemic hyperosmolar state (HHS) is another hyperglycemic emergency that commonly presents to the ED 4.
• Early diagnosis and management of DKA and HHS are paramount to improve patient outcomes 3, 4.

Management Strategies

• Treatment of hyperglycemia in the ED may begin with metformin, long-acting insulin, or deferring for close outpatient management 2.
• The mainstays of treatment for DKA include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 3.
• Optimization of hyperglycemia management in the ED may improve clinical outcomes, but more clinical trial data on the outcomes and cost-effectiveness of various management strategies or protocols are needed 4.

Physical Examination and Diagnosis

• The physical examination of the patient with diabetes may reveal findings that confirm the diagnosis, classify the type of diabetes, and begin to evaluate for the macro- and microvascular complications of diabetes and significant comorbid conditions 5.
• Screening for the diagnosis of diabetes occurs with assessment for abnormal blood glucose, and utilization of the physical examination plays a key role in identifying patients at risk for the complications of diabetes 5.