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DKA vs HHS

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by

Mona Guo

on 6 October 2013

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Transcript of DKA vs HHS

Hyperglycemic Crises
Common
Mostly type I DM
Younger (<65)
Accounts for 4-9% of diabetic admissions
Precipitated by infection
Short prodromal sx
Ketoacidosis
Mortality 2-5 %
Plasma glucose >250mg/dl
Serum ketones +
Urine Ketones +
Anion gap >10
Arterial pH <7.3
Venous Bicarbonate <18mmol/L
Differentials- Ketoacidosis
Alcoholism: no hyperglycemia
Starvation: bicarb >18mEq/l
PRECIPITANTS
Infection
Pneumonia
UTI
Virus
Infarction
MI
CVA
Unknown (5%)
Inadequate Insulin
Deliberate/Psychological
Equipment failure
New Presentation
Medications
Steroids
Thiazides
Increased GNG and Glycogenolysis
KETOACIDOSIS
Lipolysis > FFA
Increased GH, catecholamines, glucagon, and cortisol
Bicarb buffering > Low alkali reserve > High AG
Absolute Lack of Insulin
HYPERGLYCEMIA &
OSMOTIC
DIURESIS
KETONEMIA
Electrolyte Disturbance
Osmotic Diuresis
Severe Acidosis
Hyperglycemia
Total Body Potassium Loss
Total Body Sodium Loss
Dehydration
PRESENTATION
NEW DIABETIC
Polydipsia and Polyuria
General Malaise
Nausea and Vomiting
Abdominal Pain
Anorexia and Weight Loss
Confusion
KNOWN DIABETIC
Poor Compliance
General Malaise
High blood glucose
Confusion
Prodromal sx
H&P:
Dry or in shock
Kussmaul breathing
Confusion/coma
Abdominal pain
Prodromal sx
MANAGEMENT
IV FLUIDS
Hypovolemic shock
0.9% NS 0.5 - 1 L/hr until SBP > 100 (avg fluid loss = 3 - 6L)
If cardiogenic shock-monitor hemodynamics
TO DO
ABCs!
Correct hypovolemia
Correct hyperglycemia
Replace electrolyte losses
Find the cause!
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
INSULIN
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
Resolution!
venous pH > 7.3
Bicarb > 18
AG < 12
Glucose < 200
Uncommon
Mostly type 2 DM
Elderly (>65)
<1% of diabetic admissions
Also precipitated by illness
Longer prodromal sx
Mortality 5-20%
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??
ABCs!
Correct hypovolemia
Correct hyperglycemia
Replace electrolyte losses
Find the cause!
Fluids & Electrolytes

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
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
Insulin
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
Poor insulin action
relative
absolute
HHS
DKA
adipose
tissue

peripheral
tissues

glycogenolysis
&
gluconeogenesis
ketone body
production
osmotic diuresis
& dehydration
hyperketonemia & acidosis
amino
acids
free
fatty
acids
diabetic ketoacidosis
Corrected serum Na+ = for each 100 mg/dl glucose >100 mg/dl, add 1.6 mEq to Na value
IF K+<3.3, hold insulin + give 40mEq K/hr until >3.3
If K+ >3.3, give 20-30mEq per L of IV
If K+ >5, hold K and check q2h
When serum glucose = 250mg/dl, change to D5 with 0.45% NS at 150-250mL/hr with adequate insulin
TO DO:
References
Umpierrez, G.E., Murphy, M.B., and Kitabchi, A.E. (2002). Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome. Diabetes Spectrum 15(1):28-36.
DKA vs HHS
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