This document discusses hyperglycemic crises in diabetes, specifically Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar State (HHS). It defines the diagnostic criteria for each condition, including elevated blood glucose levels, metabolic acidosis, ketone levels, and effective serum osmolarity. Precipitating factors are also outlined. The document then describes the degree of DKA and HHS based on additional lab values and symptoms. Guidelines for treatment and criteria for resolution are provided.

1. Hyperglycemic Crisis
Diabetes Ketoacidosis (DKA)
Hyperglycemic Hyperosmolar State (HHS)
Ext.Sorawit Boonyathee

2. แนวทางการวินิจฉัย DKA
1) Hyperglycemia > 250 mg/dL
2) Metabolic Acidosis (High Anion gap > 12 mEq/L)
HCO3 < 15 mEq/L or
Arterial pH < 7.3
3) Ketonemia (moderately positive) or Ketonuria

3. แนวทางการวินิจฉัย HHS
1) Hyperglycemia > 600 mg/dL
2) Effective Serum Osmolarity > 320 mOsm/kg

4. Precipitating Factor : DKA
Acute Illness Drugs
Infection (30 – 40 %) Interferon - alpha
Omission of Insulin (15 – 20 %) Clozapine
New-Onset Diabetes (20 – 25 %) Cocaine
Lithium
Cerebrovascular accident
Olanzapine
Myocardial Infarction Orlistat
Acute pancreatitis Protease inhibitor
Other medical illness Terbutaline

5. Precipitating Factor : HHS
Acute Illness Drugs Endocrine
• Infection • Calcium channel blockers • Acromegaly
• Cerebrovascular accident • Chlopromazine
• Myocardial infarction • Cimetidime • Thyrotoxicosis
• Acute pancreatitis • Immunosuppressive agents • Cushing’s
• Pulmonary embolus • Phenytoin syndrome
• Peritoneal dialysis • Propanolol
• Renal failure • Steroids
• Intestinal obstruction • Thiazides diuretics
• Subdural hematoma • Total parenteral nutrition
• Previously undiagnosed
diabetes

6. Degree of DKA
Diagnosis
Mild Moderate Severe HHS
Criteria
Plasma
> 250 mg/dL > 600 mg/dL
glucose
Arterial pH 7.25 – 7.30 7.00 – 7.25 < 7.00 > 7.30
Serum HCO3
15 – 18 10 – 15 < 10 > 15
(mEq/L)

7. Degree of DKA (Cont.)
Diagnosis Criteria Mild Moderate Severe HHS
Urine Ketone Positive Small
Serum Ketone Positive Small
Effective Serum > 320
Variable
Osmolarity mOsm/kg

8. Degree of DKA (Cont.)
Diagnosis
Mild Moderate Severe HHS
Criteria
Anion Gap > 10 > 12 > 12 < 12
Alert / Stupor / Stupor /
Mental Status Alert
Drowsy Coma Coma

9. แนวทางการรักษา

10. Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the
American Diabetic Association. Diabetes Care. 2009;32:1335-1343.

11. Criteria for Resolution : DKA
plasma glucose < 11.1 mmol/L (200 mg/dL)
(at this point, insulin can be decreased by 50%)
serum bicarbonate > 18 mmol/L (18 mEq/L)
venous pH > 7.3
anion gap < 10
Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the
American Diabetes Association. Diabetes Care. 2006;29:2739-2748.

12. Criteria for Resolution : HHS
plasma glucose < 12.2 to 16.7 mmol/L
(< 250 - 300 mg/dL)
plasma effective osmolality < 315 mmol/kg
(< 315 mOsm/kg)
Improvement in hemodynamic and mental status
Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the
American Diabetes Association. Diabetes Care. 2006;29:2739-2748.