EMed

COVID-19 - in diabetics

Background

COVID-19 infection in people with or without previously recognised diabetes increases the risk of the emergency states of hyperglycaemia with ketones, Diabetic KetoAcidosis (DKA) and Hyperosmolar Hyperglycaemic State (HHS).

Changes

Changes in Diabetes with COVID-19
Where Δ seen Key difference with COVID-19 Actions
Early admission People with COVID-19 infection appear to have a greater risk of hyperglycaemia with ketones including:
  • People with type 2 diabetes (risk even greater if on a SGLT-2 inhibitor)
  • People with newly diagnosed diabetes
COVID-19 disease precipitates atypical presentations of diabetes emergencies (eg, mixed DKA and hyperosmolar states)
  • Check blood glucose in all admissions
  • Check ketones in:
    • everybody with diabetes being admitted
    • everybody with an admission glucose > 12 mmol/l
  • Stop SGLT-2 inhibitors and metformin in all people admitted to hospital
  • Consider using 10-20% dextrose where ketosis persists despite treatment in line with CUH DKA Guideline
Severe illness on admission Fluid requirements may differ in those with DKA/HHS and evidence of “lung leak” or myocarditis
  • After restoring the circulating volume the rate of fluid replacement regimen may need to be adjusted where evidence of “lung leak” or myocarditis
  • Contact the diabetes specialist team early
  • Early involvement of the critical care team
All patient areas Infusion pumps may not be available to manage hyperglycaemia using intravenous insulin as these are required elsewhere (e.g. for sedation in ICU) Use alternative s/c regimens to manage:
  • Hyperglycaemia
  • Mild DKA
Contact the diabetes specialist team for support
ICU Significant insulin resistance seen in people with type 2 diabetes in ICU settings
  • IV insulin protocols may need amending (people seen requiring up to 20 units/hr)
  • Patients often nursed prone so feeding may be accidentally interrupted – paradoxical risk of hypoglycaemia

CUH ED approach

Print version of the above algorithm.

Content by Dr Íomhar O' Sullivan 29/01/2020. Last review Dr ÍOS 10/06/21.