Diabetic Emergencies in Pregnancy. Brian A. Mason, MS, MD

Transcription

1 Diabetic Emergencies in Pregnancy Brian A. Mason, MS, MD

2 Objectives Recognize the three major risks of major morbidity in the diabetic gravida. Treat these 3 risks promptly and effectively.

3 Diabetic Emergencies Severe Hypoglycemia Diabetic Ketoacidosis (DKA) Hyperosmolar Hyperglycemia State (HHS)

4 Does This Matter? >2,000,000 reproductive-age women with DM 1 in 3 is unaware Most common metabolic disease in pregnancy 14% of all pregnancies 2011: >280,000 ER visits hypoglycemia 2010: 2,400 deaths from hyperglycemia conditions (fetuses not included)

5 Why Do We Care? 1 in 20 gravidas with DM are pre-gestational Incidence of DKA in diabetic gravidas: 3% Nearly 1 in 10 fetuses die during DKA 80% DKA 2 nd, 3 rd trimester

6 Causes of Hypoglycemia Mismatch of Glucose: Intake Uptake Metabolic Consumption

7 Causes of Hypoglycemia Fasting NPO Medications: Hypoglycemics Accelerated metabolism Exercise, stress

8 Hypoglycemia Symptoms Confusion/dizziness Tremor/anxiety Headache Irritability Tachycardia/PVCs Weakness Diaphoresis Syncope/seizure/coma

9 Treatment of Hypoglycemia (Rule of 15) Mild: BG mg/dl Hold insulin D5 200 ml per hour Check BG every 15 minutes When BG >= 70 mg/dl, resume lower dose insulin Or, if tolerating PO: 15 grams CHO, wait 15 minutes Check BG, repeat until BG >= 70

10 HHS vs. DKA HHS Medical emergency DKA Medical emergency

11 HHS vs. DKA HHS Medical emergency Slower onset DKA Medical emergency Fast onset

12 HHS vs. DKA HHS Medical emergency Slower onset Severe hyperglycemia DKA Medical emergency Fast onset Moderate hyperglycemia

13 HHS vs. DKA HHS Medical emergency Slower onset Severe hyperglycemia No Ketoacidosis DKA Medical emergency Fast onset Moderate hyperglycemia Ketoacidosis

14 HHS vs. DKA HHS Medical emergency Slower onset Severe hyperglycemia No Ketoacidosis More neurologic change DKA Medical emergency Fast onset Moderate hyperglycemia Ketoacidosis Less neurologic change

15 HHS vs. DKA HHS Medical emergency Slower onset Severe hyperglycemia No Ketoacidosis More neurologic change Rarely abdominal pain DKA Medical emergency Fast onset Moderate hyperglycemia Ketoacidosis Less neurologic change Often N+V and abdominal pain

16 HHS vs. DKA HHS Medical emergency Slower onset Severe hyperglycemia No Ketoacidosis More neurologic change Rarely abdominal pain No ketone breath DKA Medical emergency Fast onset Moderate hyperglycemia Ketoacidosis Less neurologic change Often N+V and abdominal pain Ketone breath

17 HHS vs. DKA HHS Medical emergency Slower onset Severe hyperglycemia No Ketoacidosis More neurologic change Rarely abdominal pain No ketone breath No Kussmaul breathing DKA Medical emergency Fast onset Moderate hyperglycemia Ketoacidosis Less neurologic change Often N+V and abdominal pain Ketone breath Kussmaul breathing

18 Clinical Presentation DKA Tachypnea (Kussmaul) Abdominal pain Mild neurologic signs/symptoms Signs of dehydration/hypovolemia Fruity acetone odor Nausea/Vomiting

19 Clinical Presentation HHS Profound neurologic signs/symptoms Signs of dehydration/hypovolemia

20 This is Your Body

21 This is Your Body with Pre- Diabetes

22 This is Your Body with DKA/HHS

23 Pathophysiology DKA Switch from CHO->fat catabolism

24 Pathophysiology DKA Switch from CHO->fat catabolism FFA production

25 Pathophysiology DKA Switch from CHO->fat catabolism FFA production Break down to ketoacids

26 Pathophysiology DKA Switch from CHO->fat catabolism FFA production Break down to ketoacids Anaerobic production of lactate

27 Pathophysiology DKA Switch from CHO->fat catabolism FFA production Break down to ketoacids Anaerobic production of lactate Overwhelms Buffer system

28 Pathophysiology DKA Switch from CHO->fat catabolism FFA production Break down to ketoacids Anaerobic production of lactate Overwhelms Buffer system Metabolic Acidosis

29 More Bad News Intracellular hypoglycemia

30 More Bad News Intracellular hypoglycemia Releases glucagon

31 More Bad News Intracellular hypoglycemia Releases glucagon Inhibits glycolysis, increases gluconeogenesis

32 More Bad News Intracellular hypoglycemia Releases glucagon Inhibits glycolysis, increases gluconeogenesis Increased glucose + ketone bodies = hyperosmolarity

33 More Bad News Intracellular hypoglycemia Releases glucagon Inhibits glycolysis, increases gluconeogenesis Increased glucose + ketone bodies = hyperosmolarity Osmotic diuresis/intracellular desiccation

34 The Hits Keep Rollin Osmotic Diuresis/Intracellular Desiccation

35 The Hits Keep Rollin Osmotic Diuresis/Intracellular Desiccation Circulatory collapse

36 The Hits Keep Rollin Osmotic Diuresis/Intracellular Desiccation Circulatory collapse Decreased C.O., peripheral hypo-perfusion

37 The Hits Keep Rollin Osmotic Diuresis/Intracellular Desiccation Circulatory collapse Decreased C.O., peripheral hypoperfusion More lactic acid secondary to anaerobic metabolism

38 The Hits Keep Rollin Osmotic Diuresis/Intracellular Desiccation Circulatory collapse Decreased C.O., peripheral hypoperfusion More lactic acid secondary to anaerobic metabolism H + K + ion exchange

39 The Hits Keep Rollin Osmotic Diuresis/Intracellular Desiccation Circulatory collapse Decreased C.O., peripheral hypoperfusion More lactic acid secondary to anaerobic metabolism H + K + ion exchange Intracellular hypokalemia

40 When You Thought It Couldn t Get Any Worse Na + excreted to maintain osmolarity

41 When You Thought It Couldn t Get Any Worse Na + excreted to maintain osmolarity Na +, K +, other ions excreted

42 When You Thought It Couldn t Get Any Worse Na + excreted to maintain osmolarity K +, other ions, glucose excreted Diuresis up to 150 ml/kg body weight

43 DKA More Likely and Worse for Pregnant Women Normal increase minute ventilation

44 DKA More Likely and Worse for Pregnant Women Normal increase minute ventilation Respiratory alkalosis

45 DKA More Likely and Worse for Pregnant Women Normal increase minute ventilation Respiratory alkalosis Renal HCO 3 - excretion

46 DKA More Likely and Worse for Pregnant Women Normal increase minute ventilation Respiratory alkalosis Renal HCO 3 - excretion Lower Buffering Capacity

47 Other Pregnancy DKA Factors Normal emesis/anorexia Accelerated Starvation Physiologic decreased insulin sensitivity Dehydration Increased FFA, increased hydroxybuterate HPL, cortisol, HGH 14 hour fast

48 DKA Effects on Fetus Decreased uterine perfusion secondary to CV collapse

49 DKA Effects on Fetus Decreased uterine perfusion secondary to CV collapse Glucose/ketones freely diffuse per placenta Decreased maternal and fetal placental perfusion

50 DKA Effects on Fetus Decreased uterine perfusion secondary to CV collapse Glucose/ketones freely diffuse per placenta Decreased maternal and fetal placental perfusion H + ions decrease fetal ph

51 DKA Effects on Fetus Decreased uterine perfusion secondary to CV collapse Glucose/ketones freely diffuse per placenta Decreased maternal and fetal placental perfusion H + ions decrease fetal ph Hypokalemia, hyponatremia

52 Suspect DKA/HHS in Any Diabetic Hyperglycemia or Ketoacidosis or Neurologic changes or N+V or Abdominal pain or Ketone breath or Kussmaul breathing or Signs of dehydration Gravida With:

53 In Published Series 90% of Pregnant DKA Pts had N/V 46% had profound abdominal pain 1 in 3 had BGs LESS than 200 mg/dl!

54 DKA/HHS Immediate Response 1. ABCs (CABD) 2. Volume status 3. Laboratory evaluation 4. Mental Status 5. Seek precipitating events

55 ABCs (CABD) Circulation Breathing Airway Defibrillate

56 Volume Resuscitation Establish IV access Draw initial labs plus finger-stick BG 0.9 saline 1000 cc over 1 hour then: 0.9 saline cc over next hour then: Next 4-6 hours cc/hour Vs. 0.9 D5 and additives based on labs

57 Initial Laboratory Evaluation Serum glucose and finger-stick BG Serum electrolytes with anion gap CBC with differential BUN/creatinine UA with urine ketones (dipstick) Serum ketones (if negative urine ketones) ABG if low bicarb or suspect hypoxia ECG

58 Insulin Bolus Based on sliding scale from finger-stick BG IV route Short-acting insulin (Regular or Humalog)

59 Insulin Sliding Scale Capillary BG (mg/dl) Units Insulin or ml/hour (1 unit/ml) < >190 Call MD, check urine ketones

60 Quick Neuro Assessment Level of consciousness Airway protection Metric of severity Suggests HHS Vs. DKA

61 Precipitating Events Severe acute illness (sepsis, pancreatitis, pneumonia, UTI) New onset Type I DM Established Type I DM with Gastroenteritis Patient self D/C s insulin Drugs altering CHO metabolism Corticosteroid, Terbutaline Cocaine use Poor insulin compliance

62 Serum Glucose Dx and Tx Don t be fooled! 1 in 3 gravidas with DKA had BG < 200 mg/dl! Give R or log insulin IV Bolus, then infusion per sliding scale D cc/hour when BG <=200

63 Serum Electrolytes Anion Gap Our lab Na + - (Cl - +HCO 3- ) Normal=3-10 meq/l Serum K + 1 in 20 hypokalemic 1 in 3 elevated serum K + on admission

64 Serum Electrolytes Total body K + (deficits meq) If K meq/l: put 10 meq in 1 L infusion x 2 L If K + <3 meq/l: Supplement in addition meq/l KCl in 1000 cc NS, infuse at 150 cc/hour

65 Serum Electrolytes Na + : generally hyponatremic Adjust after 1 st 2 Liters 0.9 Other ions (Ca ++, Mg ++, PO 4- ) supplement PRN

66 CBC with Differential Assess for possible infection WBC/ Differential Leukocytosis normal in DKA WBC > 25k or > 10% bands suggests infection

67 BUN/Creatinine Assess renal failure Pre Intra Post Adjust fluid and electrolyte replacement

68 UA and Urine Ketones Urine ketones lag serum Beta hydroxybutyrate Check serum if urine ketones negative UA UTI If suggestive, send C&S

69 ABG Not needed in every case Suspect hypoxia Low bicarb

70 ECG 12 lead R/o dysrhythmia Sensitive measure of effective K + levels

71 Additional Testing CXR Serum amylase Glycated hemoglobin Plasma osmolality

72 Fetal Management Treat mom quickly and effectively Monitor fetus Baby recovers with mom Delivery ONLY if maternal/fetal indication Maternal code > 4 minutes Fetal bradycardia Prolonged non-reassuring fetal status

73 Case Study

74 Patient Presents to Triage 22 year-old G2P0010, 29 weeks EGA History of Type I diabetes, on insulin 2 day H/O abdominal pain/anorexia Held insulin secondary to decreased PO intake Knows she s not dehydrated, she s Drinking and peeing a lot.

75 Physical Exam Thin, gaunt gravida. Lethargic, but appropriate. Pt weighs 70 Kg S<D, 25 cm FH BP: 105/65, P: 113, RR: 28, Temp: 99.3 F, SpO 2 : 100% Next move?

76 Admit L and D FS BG: 189 mg/dl FHR tracing: Minimal variability, late decels with contractions every 3-5 minutes Next move?

77 Admit L and D FS BG: 189 mg/dl FHR tracing: Minimal variability, late decels with contractions every 3-5 minutes Next move? Cervix: 1 cm, long, high Next move?

78 Admit L and D IV access Labs 1 L 1000 cc/hour IV bolus insulin plus: D5 100 cc/hr Give insulin bolus (dose?) Start insulin infusion (rate?)

79 Admit L and D IV access Labs 1000 cc/hour plus D5 o cc/hr IV bolus insulin and start insulin infusion Bolus 5 units Humalog Infusion 5 units/hour Humalog Next move?

80 One Hour Later Check BG on 5 units/hour Repeat BG: 154 mg/dl Next move?

81 One Hour Later Check BG on 5 units/hour Repeat BG: 154 mg/dl Next move? Decrease insulin, 4 units/hour IV fluids, continue NS 1000 cc/hour, D NS 100 cc/hour

82 Labs Return Serum glucose: 179 mg/dl (action?)

83 Labs Return Serum glucose: 179 mg/dl (action?) Continue same insulin dose Na + : 133 meq/l (action?)

84 Labs Return Serum glucose: 179 mg/dl (action?) Continue same insulin dose Na + : 133 meq/l (action?) Continue NS K + : 4.5 meq/l (action?)

85 Labs Return Serum glucose: 179 mg/dl (action?) Continue same insulin dose Na + : 133 meq/l (action?) Continue NS K + : 4.5 meq/l (action?) Add 10 meq KCl to each bag UA: Ketones 3+, Nitrates, Leukocytes, Bacteria (action?)

86 Labs Return Serum glucose: 179 mg/dl (action?) Continue same insulin dose Na + : 133 meq/l (action?) Continue NS K + : 4.5 meq/l (action?) Add 10 meq/l KCl to each bag UA: Ketones 3+, Nitrates, Leukocytes, Bacteria (action?) Add IV Abx Anion Gap: 21 meq/l

87 Fluids One Hour Later (Hour 3) 500 cc 500 cc/hour + D cc/hour Repeat BG 138 mg/dl Action?

88 Fluids One Hour Later (Hour 3) 500 cc 500 cc/hour + D cc/hour Repeat BG 138 mg/dl Action? Decrease insulin drip to 3 units/hr Repeat labs

89 One Hour Later (Hour 4) Adjust fluid 0.45 cc/hr plus D cc/hr Labs return

90 Labs from Hour 3 Return Na + : 138 meq/l K + : 3.1 meq/l UA: Ketones 1+ Anion Gap: 11 meq/l Action?

91 Labs from Hour 3 Return Na + : 138 meq/l K + : 3.1 meq/l UA: Ketones 1+ Anion Gap: 11 meq/l Action? Infuse KCL 40 meq in 1 L 150 cc/hr

92 One Hour Later (Hour 5) Pt c/o HUNGRY! Abdominal pain and nausea resolved Feed Pt ADA diet Give scheduled insulin Last effective regime plus sliding scale subq

93 When Patient tolerating PO D/C glucose and insulin infusions after 1 st scheduled insulin dose Strict I/O until fluid deficit replaced Follow up on precipitating causes

94 Congratulate yourselves You and your patients have just dodged a bullet because: You quickly and accurately identified the problem You acted quickly and appropriately