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Diabetic Emergencies, Diagnosis and Clinical Management: Sick-Day Rules in Diabetes, Part 1

Konstantinos Makrilakis, Nikolaos Katsilambros
During an acute illness, blood sugar levels usually rise. Illness causes a greater than normal demand for insulin due to the release of stress hormones such as adrenaline (epinephrine), cortisone, and growth hormone.
These hormones can be triggered by any kind of stressful condition such as an infection, a cardiovascular or cerebrovascular ischemic event, gastroenteritis, dehydration, etc. As a result of this increase, the body may require more insulin to cope with the increased demand.1

In diabetic persons, with an already compromised pancreatic insulin reserve (completely absent in Type 1 or diminished in Type 2 diabetes), this increased insulin requirement may not be met unless insulin is given exogenously.2 If diabetic control is not attended to under these circumstances it may seriously deteriorate and lead to potentially fatal complications such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS).

DKA and HHS are acute, potentially life-threatening complications of diabetes, the occurrence of which can be prevented. Although major advances have improved diabetes care, DKA remains the leading cause of hospitalization, morbidity, and death in young people with Type 1 diabetes (T1DM), and HHS is a serious, potentially lethal complication of diabetes, usually in elderly persons.3

To prevent these complications, it is important to address outpatient educational approaches directed at sick-day management and early identification and treatment of impending DKA or HHS.

Epidemiology

People with diabetes are no more likely than non-diabetic ones to get sick. However, when they do, their blood sugar levels may deteriorate because of the underlying illness (see “Potential causes” below).

Diabetic_EmergenciesRegarding infections, for example, there are no sufficient data in the literature to substantiate the opinion that diabetic persons, as a whole, have a higher susceptibility to infections. However, some infections are more common and some may have a more severe clinical course and manifest a higher frequency of complications in diabetic persons. These include fungal infections, malignant otitis externa, necrotizing fasciitis, rhinocerebral mucormycosis, and emphysematous cholecystitis. The increased susceptibility that patients with diabetes have to certain infections is due to many factors. The polymorphonuclear neutrophils of diabetic patients have been found to have decreased chemotactic and phagocytic abilities. Furthermore, it seems that the ability of leukocytes to destroy microorganisms after the process of phagocytosis is diminished.

Potential causes

The usual causes involve any kind of a multifactorial etiology for an acute illness — infectious, vascular, metabolic, etc. — that could gradually precipitate a hyperglycemic crisis in a patient with either Type 1 or Type 2 diabetes. The most common etiologies are infectious (respiratory or urinary tract infections, soft tissue infections, gastrointestinal, etc.).4 Cardiovascular events are also quite common in elderly individuals. Initiation or increase of corticosteroid therapy is another cause of acute deterioration of diabetic control.5

DKA can also be the first manifestation of Type 1 diabetes in previously healthy persons, and this occurrence may be less amenable to prevention.4

Diagnosis 

There should be a high level of suspicion and awareness among the lay and medical community regarding the early manifestations of hyperglycemic crises, so that appropriate measures can be taken to prevent them.6 Early identification and management of impending hyperglycemic crises would definitely help to lower the mortality of these conditions. 7 In people with known diabetes this can be relatively straightforward, whereas in persons with the first manifestations of diabetes it may be more complex. The usual symptoms and signs of diabetes (polyuria, polydipsia, and weight loss) should alert patients and their family members to the possibility of an impending deterioration of diabetic status. DKA as an initial manifestation of T1DM may be less amenable to prevention unless there is increased awareness by the lay and medical communities of the symptoms of diabetes and surveillance in high-risk populations, potentially identified by family history or genetic susceptibility.4 New bed-wetting in a child without known diabetes or nocturnal enuresis (bed-wetting) in a known Type 1 diabetic child may be the first sign of diabetes or its deterioration and should alert the family.8

The risk for T1DM development for the first time cannot be easily predicted and identified, especially by lay people. Clues towards this prediction are highly significant. Thus, studies referenced here8,9 found that an incidental finding of a blood glucose level > 100 mg/dl (5.6 mmol/L) in a child without a history of DM may denote increased risk for the development of T1DM in the future and should alert physicians and parents towards this possibility, so that DKA may perhaps be anticipated and prevented.

Clinical management 

In the case of an acute illness, instructions are individualized and depend on a variety of factors including the type of diabetes, the kind of therapy that the patient receives (pills or insulin, intensity of insulin regimen), the presence of complications, and the type of the acute illness. It is essential that appropriate instructions have been given beforehand so that patients and family on the one hand do not panic and on the other hand do not neglect the condition. It is of paramount importance that treatment of the acute illness is timely, appropriate, and effective. It should always be kept in mind that inappropriate management might lead to significantly poor metabolic control that could increase the risk of an acute complication such as DKA or hyperglycemic hyperosmolar coma.

General instructions for an acute illness at home are (Figure 8.1):10

  1. Insulin should never be omitted (in patients treated with insulin). Even when there is a feeding problem (nausea, vomiting), it is more likely that additional insulin will be needed (due to the stress that the acute illness has caused) rather than a reduction. This rule is more relevant to persons with T1DM. Additional doses of soluble insulin are likely to be needed and should be given as necessary to bring blood sugar down and suppress ketone production (e.g., rapid-acting insulin every 4 hours).
  2. An increase in the frequency of capillary blood glucose measurements (at least every 3-4 hours) is recommended.
  3. People with Type 1 diabetes (but also sometimes those with Type 2) should check their urine for ketones every 4-6 hours, depending also on blood glucose levels (most authors recommend ketone measurement when blood glucose levels exceed 270 mg/dl [15.0 mmol/L]). Some blood glucose meters allow testing for ketones in the blood as well (e.g., MediSense Xtra), and this is quite acceptable.11 However, testing for ketones in the urine is a very sensitive test and there is no necessity to demonstrate ketone bodies in the blood. Self-monitoring of ketone bodies during hyperglycemia can provide important, complementary information on the metabolic state. Both methods for self-monitoring of ketone bodies at home are clinically reliable and there is no published evidence favoring one method with respect to DKA prevention.12 It should be kept in mind, though, that ketones do not necessarily signify impending DKA because they can also be produced when people have not eaten anything for some time (starvation ketosis).13 Therefore, only the coexistence of high blood glucose levels and urine positive for ketones represents a true metabolic deterioration.

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4. Ample intake of non-carbohydrate fluids (water) is advised (at least half a glass [100-150 ml] every hour). Food should be light.
5. Rest is advised. Exercise should be avoided.
6. Communication between the patient (family) and the treating physician is essential, so that appropriate instructions for coping with any special situation can be given at any time.
7. The goal should be to bring blood sugar down to acceptable levels (for example 80-180 mg/dl [4.4-10 mmol/L]) and to suppress urinary ketones to “small, trace, or negative” if they are positive.
 
Summary box

Insulin should never be omitted (in patients treated with insulin). Even when there is a feeding problem (nausea, vomiting), it is more likely that additional insulin will be needed (due to the stress that the acute illness has caused) rather than a reduction.

 

 
 
 
 
Next Excerpt: Sick-Day Rules in Diabetes, Part 2
References
  1. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes: A consensus statement from the American Diabetes Association. Diabetes Care 2009; 32: 1335-43.
  2. Katsilambros N, Tentolouris N. Type 2 diabetes: an overview. In: Pickup JC, Williams G (ed), Textbook of Diabetes Mellitus, 3 rd edn, Oxford, UK: Blackwell Publishing, 2003: 4.1-19.
  3. Kitabchi, AE, Umpierrez, GE, Murphy, MB, Barrett EJ, Kreisberg RA Malone JI, Wall BM. Management of hyperglycemic crises in patients with diabetes (technical review). Diabetes Care 2001; 24: 131-53.
  4. Bismuth E, Laffel L. Can we prevent diabetic ketoacidosis in children? Pediatr Diabetes 2007; 8 ( Suppl 6 ): 24-33.
  5. Clore JN, Thurby – Hay L. Glucocorticoid – induced hyperglycemia. Endocr Pract 2009; 15: 469-474.
  6. Cohen AS, Edelstein EL. Sick – day management for the home care client with diabetes. Home Healthc Nurse 2005; 23: 717-24.
  7. Wang J, Williams DE, Narayan KMV, Geiss LS. Declining death rates from hyperglycemic crisis among adults with diabetes, U.S., 1985-2002. Diabetes Care 2006; 29: 2018-22.
  8. Vanelli M, Scarabello C, Fainardi V. Available tools for primary ketoacidosis prevention at diabetes diagnosis in children and adolescents. ” The Parma campaign “. Acta Biomed 2008; 79: 73-8.
  9. Lorini R, Alibrandi A, Vitali L, et al. Risk of Type 1 diabetes development in children with incidental hyperglycemia. An incidental Italian study. Diabetes Care 2001; 24: 1210-6.
  10. Liatis S. Acute illness in diabetes In: Katsilambros N, Diakoumopoulou E, Ioannidis I, Liatis S, Makrilakis K, Tentolouris N, Tsapogas P (ed), Diabetes in Clinical Practice, Questions and Answers from Case Studies, West Sussex, England: John Wiley & Sons Ltd, 2006: 103-7.
Nikolaos Katsilambros, MD, PhD, FACP
SCOPE Founding Fellow
Professor of Internal Medicine
Athens University Medical School
Evgenideion Hospital and Research Laboratory ‘Christeas Hall’
Athens, Greece
Christina Kanaka-Gantenbein, MD, PhD
Associate Professor of Pediatric Endocrinology and Diabetology
First Department of Pediatrics, University of Athens
Agia Sofia Children’s Hospital
Athens, Greece
Stavros Liatis, MD
Consultant in Internal Medicine and Diabetology
Laiko General Hospital
Konstantinos Makrilakis, MD, MPH, PhD
Assistant Professor of Internal Medicine and Diabetology
Athens University Medical School
Laiko General Hospital
Athens, Greece
Nikolaos Tentolouris, MD, PhD
Assistant Professor of Internal Medicine and Diabetology
University of Athens
Laiko General Hospital
Athens, Greece
A John Wiley & Sons, Ltd., Publication This edition first published 2011 © 2011 by John Wiley & Sons, Ltd.
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Diabetic Emergencies: Diagnosis and Clinical Management provides emergency room staff, diabetes specialists and endocrinologists with highly practical, clear-cut clinical guidance on both the presentation of serious diabetic emergencies like ketoacidosis, hyperosmolar coma and severe hyper- and hypoglycemia, and the best methods of both managing the emergencies and administering appropriate follow-up care.
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