Basic approach to diabetic ketoacidosis and hyperosmolar hyperglycemic state

1. By Dr. Nauman Zafar PGR Medicine
Diabetic Ketoacidosis (DKA) and
Hyperosmolar Hyperglycemic State
(HHS)

2. INTRODUCTION
 Diabetic ketoacidosis (DKA) and hyperosmolar
hyperglycemic state (HHS) are two of the most
serious acute complications of diabetes
 They are part of the spectrum of hyperglycemia
and each represents an extreme in the spectrum

3. HHS
 Previously known as Hyperglycaemic Hyperosmolar
Nonketotic Coma (HONK)
 Little or no ketoacid accumulation
 Serum glucose concentration frequently exceeds
1000 mg/dL
 Plasma osmolality may reach 380 mosmol/kg
 Neurologic abnormalities are frequently present
(including coma in 25 to 50 percent)
 Test negative for ketones in serum and urine,
although mild ketonemia may be present

4. DKA
 Triad of hyperglycemia, anion gap metabolic
acidosis, and ketonemia
 Serum glucose concentration is usually greater
than 500 mg/dl
 Glucose may be only mildly elevated due to
treatment with insulin prior to arrival in the
emergency department

5. DKA
HHSMild Moderate Severe
Plasma
glucose
(mg/dL)
>250 >250 >250 >600
Arterial pH 7.25-7.30 7.00-7.24 <7.00 >7.30
Serum
bicarbonate
(mEq/L)
15-18 10 to <15 <10 >18
Urine ketones Positive Positive Positive Small
Serum
ketones
Positive Positive Positive Small
Effective
serum
osmolality
(mOsm/kg)
Variable Variable Variable >320
Anion gap >10 >12 >12 Variable
Alteration in
sensoria or
Alert Alert/drowsy Stupor/coma Stupor/coma

6. KETONE BODIES
 Acetoacetate
 Beta hyroxybutyrate

8. PRECIPITATING FACTORS
 Infections (often pneumonia or urinary tract infection)
 Discontinuation of or inadequate insulin therapy
 Compromised water intake leading to dehydration
 New onset type 1 diabetes
 Poor compliance with the insulin regimen
 Acute major illnesses such as myocardial infarction,
cerebrovascular accident, or pancreatitis
 Drugs that affect carbohydrate metabolism, including
glucocorticoids, higher dose thiazide diuretics,
sympathomimetic agents, and second-generation
antipsychotic agents
 Cocaine use
 Psychological problems associated with eating disorders
and purposeful insulin omission, particularly in young
patients with type 1 diabetes

9. CLINICAL PRESENTATION
 Polyuria, polydipsia, and weight loss
 Neurological symptoms including lethargy, focal
signs, and obtundation, which can progress to
coma in later stages
 Hyperventilation, nausea, vomiting, and
abdominal pain ( mainly in DKA)

10. PLASMA OSMOLALITY
Plasma osmolality = 2[Na] + [Glucose]/18 + [ BUN
]/2.8
Normal Range = (285 – 295)
BUN [mg/dL] = Urea [mg/dL] / 2.14
Effective P. osmolality = 2[Na] + [Glucose]/18

11. INVESTIGATIONS
 Serum glucose
 Serum electrolytes (with calculation of the anion
gap), BUN, and serum creatinine
 Complete blood count with differential
 Urinalysis, and urine ketones by dipstick
 Plasma osmolality
 Serum ketones (if urine ketones are present)
 Arterial blood gas (if urine ketones or anion gap
are present)
 Electrocardiogram

12. MANAGEMENT
 Intravenous Fluids
 Insulin ( IV or IM )
 Potassium replacement
 Others
• Airway protection
• Bicarbonate replacement
• Antibiotics

13. DKA HHS
Total water (L) 6 9
Water (mL/kg) 100 100 to 200
Na+ (mEq/kg) 7 to 10 5 to 13
Cl- (mEq/kg) 3 to 5 5 to 15
K+ (mEq/kg) 3 to 5 4 to 6
Lose of Water and Electrolytes

14. IV Fluids
 Based on corrected serum sodium
[ Na = MeasuredSodium + 0.016 * (Glucose -
100)]
 If high/normal, use 0.45% NaCl
 If low/normal, use 0.9% NaCl
 Continue IV fluids at 250–1000 mL/hr, depending
on volume status, cardiovascular history, and
cardiovascular status (pulse, BP)

15. cont…..
 Fluid repletion is usually initiated with isotonic
saline
I. Replace the fluid deficit
II. Correct the extracellular volume depletion
more rapidly than one-half isotonic saline
III. Lower the plasma osmolality (since it is still
hypoosmotic to the patient
IV. Reduce the serum glucose concentration

16. cont…..
 10 to 15 mL/kg lean body weight per hour (about
1000 mL/hour in an average-sized person) during
the first few hours
 Administer 1 L during the first hour.
(Upto 3 L if patient in shock)
 Administer 1 L during the second hour.
 Administer 1 L during the following 2 hours
 Administer 1 L every 4 hours, depending on the
degree of dehydration and central venous
pressure readings

17. cont…..
 As the blood glucose concentration falls below
200-250 mg/dL (250 - 300 in HHS) dextrose
should be added to intravenous fluids to avoid
insulin induced hypoglycemia

18. Insulin
 Intrvenous Insulin regular is treatment of choice
 Intramuscular or Subcutaneous route may be
used when intravenous infusion not possible

19. cont…..
 Regular insulin bolus, 0.1 U/kg
 Then IV infusion, 0.1 U/kg/hr
 Check serum glucose hourly (should fall by
50–80 mg/dL/hr)
 If serum glucose rising or falling too slowly,
increase insulin infusion rate by 50–100%
 If serum glucose falling too rapidly, back off on
insulin infusion

20. K Replacement
 Obtain baseline serum potassium
 Obtain 12-lead ECG
 If initial [K] > 5.4 mEq/L do not give [K]
 If [K+] < 5.5 mEq/L and adequate urine output
I. [K+] = 4.5–5.4: add 20 mEq/L IV fluids
II. [K+] = 3.5–4.4: add 30 mEq/L IV fluids
III. [K+] < 3.5: add 40 mEq/L IV fluids
 Also treat if ECG changes of hypokalemia
present

21. cont…..
 Thereafter measure every 2-4 hourly
 Continue K repletion until serum [K] is stable at
4–5 mEq/L
 Hold K replacement if [K] > 5mEq/L

22. Bicarbonate Therapy
 Obtain ABG
 pH > 7.0 Bicarbonate therapy usually not
necessary
 pH < 7.0 50 mEq (1 amp) NaHCO3 over 1 hr
 pH < 6.9 100 mEq (2 amps) NaHCO3 over 2 hr
 Repeat ABG after bicarbonate administration

23. RESOLUTION
DKA
I. The ketoacidosis has resolved, as evidenced by
normalization of the serum anion gap (less than
12 meq/L
II. Serum glucose below 200 mg/dL
III. Serum bicarbonate ≥18 meq/L
IV. Venous pH >7.30

24. cont…..
 HHS
I. Serum glucose below 250 to 300
II. Patients are mentally alert and the plasma
effective osmolality is below 315 mosmol/kg

25. cont…..
 Subcutneous insulin is started and intravenous
insulin infusion should be continued for an
overlap of one to two hours
 Patient should be able to eat orally

26. Thank You