DKA and Hyperosmolar Hyperglycemic State HHS

1
DKA and Hyperosmolar Hyperglycemic State (HHS)

• Stephen Clement, M.D.

2
DKAPathogenesis

• Relative or absolute insulin deficiency
• Increased counterregulatory hormones (cortisol,
  glucagon, catecholamines)
• /\ hepatic glucose production
• /\ Lypolysis
• /\ ketone production by the liver (beta
  hydroxybutyrate and acetoacetate)
• Anion Gap acidosis

3
HHSPathogenesis

• Relative insulin deficiency
• Minimal insulin present to prevent ketosis

4
Both DKA and HHS

• Fluid and electrolyte loss due to glycosuria
• ? New onset diabetes
• May have precipitating factor (infection, MI,
  CVA, pancreatitis, alcohol abuse, trauma, drugs)
• If no precipitating factor found, suspect
  inadequate or missed insulin shots

5
S/S for DKA

• 4-5 day h/o polyuria, polydipsia, weight loss,
  fatigue
• Temp. may be normal or hypothermic
• Confusion, Coma
• P.E Hypotension, Tachycardia
• Kussmaul Respirations
• N / V, often heme positive
• Benign abdominal exam

6
S/S for HHS

• Elderly
• Coma
• Dehydration is severe
• Precipitating cause likely
• High mortality rate

7
Lab Values
8
Differential Dx

• Alcoholic Ketoacidosis
• BG lt 250 mg/dl
• Starvation ketosis
• HCO3 is gt 18
• Other forms of AG acidosis
• Lactic, salicylate, methanol, ethylene glycol,
  CRF

9
Treatment

• Fluid Replacement
• Insulin
• K, electrolyte replacement
• Find precipitating Cause

10
Diagnosis/Initial Tx

• Suspect DKA? ? Stat Chem Panel, amylase, serum
  ketones and fingerstick BG
• ABG if suspect DKA
• P.E. ECG, CXR, urine
• Start IV Fluids, normal saline
• IV insulin bolus once DKA confirmed and K is not
  low

11
IV Fluids

• Typical Deficit is 4-7 liters
• Start with .9 saline at 15-20 cc/kg/hour for
  first hour (1-1.5 L/hour)
• If corrected serum Na is normal or elevated,
  change to 0.45 saline
• If corrected serum Na is low, continue with NS
• Corrected Na add 1.6 mEq to Na value for every
  100 mg/dl glucose above 100 mg/dl
• Aim to correct fluid deficit within 24 hours
• Watch for fluid overload in cardiac patients

12
Insulin

• If serum K is lt 3.3, replace K first
• Bolus 0.15 units/kg IV
• Start insulin drip at 0.1 units/kg/hour
• Insulin drips are made in pharmacy
• Allow 20 cc insulin drip fluid to run out first
• If BG does not fall by 50 points in first hour,
  double insulin drip rate
• Change IVF to 5 dextrose once serum BG lt 250
  mg/dl and convert to insulin drip protocol.

13
Potassium

• Iatrogenic deaths? hypokalemia
• Typical deficit 350 mEq
• Start KCL replacement once serum K level falls
  below 5.5 mEq/l, and patient urinting
• Replace with 2/3 KCl and 1/3 K PO4, 30 mEq per
  liter IVF
• If Serum K lt 3.3, give IVF w/ 40 mEq/l KCL first
  before giving I.V. insulin
• Keep serum K 4-5 mEq/l range

14
Bicarbonate Therapy

• Use is controversial
• Only indicated if pH lt 7.0
• Never give w/o ICU help

15
Following Labs

• Keep a flow sheet (see article)
• Labs q 2 hours
• Resolution of DKA
• Glucose lt 200
• HCO3 gt 18
• Venous pH gt 7.3
• Anion Gap closed
• Once DKA resolved, continue on insulin drip until
  eating

16
Conversion to SC Insulin

• Calculate Basal Insulin
• 0.4 units/kg of basal insulin
• Calculate meal insulin
• 0.1 units/kg for each meal
• Continue insulin drip until BG lt 70, then d/c
  drip (insulin drip will shut itself off)
• Watch for hyperglycemia escape

17
Long-Term Care

• Diabetes Education
• Family Support/ Psych eval. if suspect omitted
  insulin shots
• Endocrine Consult to help with long-term f/u
• Tx underlying cause

18
Possible Complications of DKA/HHS

• Embolic Stroke
• Cerebral Edema
• MI
• Pulmonary Edema
• Hypoxia
• Pancreatitis (from lipemia)
• Acute abdomen

19
DKA Prevention

• Emphasize need to take insulin even when not
  eating
• Sick Day Rules
• Check urine ketones if BG gt 250
• Take extra fast-acting insulin if BG gt 250,
  especially if ketones are positive
• Drink clear liquids with salt (i.e., broth)
• Call M.D. or go to E.R. of BGs do not correct or
  if unable to keep down fluids

20
Best Reference

• Kitabchi et al. Diabetes Care 24131-153, 2001

21
Unknown Case

• 76 y/o male with type 2 DM
• Taking unknown oral diabetes medication
• Presents to E.R. with near coma
• No h/o of elicit drugs or EtOH
• BP 120/80, P 120, regular, Afebrile,
• BG 180 mg/dl
• pH 6.9, AG 25, HCO3 5, BUN 40, Creatinine 2.0
• Ketones trace positive

22
Unknown Case

• Cause of Acidosis?
• Treatment?