DKA vs HHS

• Common
• Mostly type I DM
• Younger (<65)
• Accounts for 4-9% of diabetic admissions
• Precipitated by infection
• Short prodromal sx
• Ketoacidosis
• Mortality 2-5 %

Differentials- Ketoacidosis

• Alcoholism: no hyperglycemia
• Starvation: bicarb >18mEq/l

Poor Compliance

General Malaise

High blood glucose

Confusion

Prodromal sx

MANAGEMENT

Poor insulin action

relative

absolute

peripheral

tissues

adipose

tissue

amino

acids

free

fatty

acids

Infection

• Pneumonia
• UTI
• Virus

Insulin

Unknown (5%)

Infarction

• MI
• CVA

HHS

PRECIPITANTS

Inadequate Insulin

• Deliberate/Psychological
• Equipment failure

New Presentation

• Regular 0.15U/kg IV bolus
• 0.1 U/kg/hr IV insulin
• If does not fall by 50mg/dL in first hour, double dose

Medications

• Steroids
• Thiazides

72 year gentleman brought in for 3 week history of anorexia, weakness, disorientation and drowsiness. His wife also reports increased thirst and frequency of urination. On exam, cachexic, profoundly dehydrated, hypotensive, and with a blood sugar of 650.

What to do now??

Fluids & Electrolytes

DKA

diabetic ketoacidosis

glycogenolysis

&

gluconeogenesis

ketone body

production

• Similar as DKA management
• NS infusion based on serum Na+
• Monitor K+
• Caution in elderly, those with renal and cardiac failure
• Caution with falling Na+
• Change to D5 after glucose = 300mg/dL

TO DO:

Arterial pH <7.3

Venous Bicarbonate <18mmol/L

Serum ketones +

Urine Ketones +

Anion gap >10

• ABCs!
• Correct hypovolemia
• Correct hyperglycemia
• Replace electrolyte losses
• Find the cause!

Plasma glucose >250mg/dl

Absolute Lack of Insulin

Increased GH, catecholamines, glucagon, and cortisol

Lipolysis > FFA

KETONEMIA

Increased GNG and Glycogenolysis

HYPERGLYCEMIA &

OSMOTIC

DIURESIS

IV FLUIDS

KETOACIDOSIS

Bicarb buffering > Low alkali reserve > High AG

Hypovolemic shock

• 0.9% NS 0.5 - 1 L/hr until SBP > 100 (avg fluid loss = 3 - 6L)
• If cardiogenic shock-monitor hemodynamics

Mild hypotension

• Evaluate corrected serum Na
• High/normal
• 0.45% NS 250-500 mL/hr (goal = replace half of water deficit over 12-24h)
• Low
• 0.9% NS 250-500 mL/hr

Characteristics:

• Plasma glucose level > 600
• Effective serum osmolality >320 mOsm/kg
• Profound dehydration: 8 - 10L lost
• Serum pH >7.30
• Bicarbonate >15 mEq/L
• Mild ketonuria/ketonaemia
• Some alteration in consciousness

Corrected serum Na+ = for each 100 mg/dl glucose >100 mg/dl, add 1.6 mEq to Na value

If K+ >3.3, give 20-30mEq per L of IV

If K+ >5, hold K and check q2h

Electrolyte Disturbance

• Osmotic Diuresis
• Severe Acidosis
• Hyperglycemia

When serum glucose = 250mg/dl, change to D5 with 0.45% NS at 150-250mL/hr with adequate insulin

TO DO

INSULIN

• Uncommon
• Mostly type 2 DM
• Elderly (>65)
• <1% of diabetic admissions
• Also precipitated by illness
• Longer prodromal sx
• Mortality 5-20%

• ABCs!
• Correct hypovolemia
• Correct hyperglycemia
• Replace electrolyte losses
• Find the cause!

• IV = IM
• Regular 0.15 U/kg bolus
• 0.1 U/kg/hr insulin infusion
• IF serum glucose does NOT fall by 50-70mg/dl in first hour...
• Double infusion

Total Body Potassium Loss

Total Body Sodium Loss

Dehydration

IF K+<3.3, hold insulin + give 40mEq K/hr until >3.3

NEW DIABETIC

Polydipsia and Polyuria

General Malaise

Nausea and Vomiting

Abdominal Pain

Anorexia and Weight Loss

Confusion

Resolution!

PRESENTATION

Hyperglycemic Crises

• venous pH > 7.3
• Bicarb > 18
• AG < 12
• Glucose < 200

H&P:

• Dry or in shock
• Kussmaul breathing
• Confusion/coma
• Abdominal pain
• Prodromal sx

KNOWN DIABETIC

osmotic diuresis

& dehydration

hyperketonemia & acidosis

References

DKA vs HHS

Umpierrez, G.E., Murphy, M.B., and Kitabchi, A.E. (2002). Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome. Diabetes Spectrum 15(1):28-36.