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    Diabetic Ketoacidosis and Hyperglycaemic Hyperosmolar State

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    muhammadridhwan
    This document summarizes the key differences between diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS). DKA is characterized by high blood glucose levels, ketone production and a low pH due to a lack of insulin. It often occurs in type 1 diabetics. HHS features extremely high blood glucose without significant ketones or acidosis and usually affects elderly type 2 diabetics. Both require intensive fluid and electrolyte replacement as well as insulin therapy to stabilize the patient's condition.

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    Diabetic Ketoacidosis and Hyperglycaemic Hyperosmolar State

    Uploaded by

    muhammadridhwan
    125 views4 pages
    This document summarizes the key differences between diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS). DKA is characterized by high blood glucose levels, ketone production and a low pH due to a lack of insulin. It often occurs in type 1 diabetics. HHS features extremely high blood glucose without significant ketones or acidosis and usually affects elderly type 2 diabetics. Both require intensive fluid and electrolyte replacement as well as insulin therapy to stabilize the patient's condition.

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    My study group note on DKA and HHS

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    This document summarizes the key differences between diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS). DKA is characterized by high blood glucose levels, ketone production and a low pH due to a lack of insulin. It often occurs in type 1 diabetics. HHS features extremely high blood glucose without significant ketones or acidosis and usually affects elderly type 2 diabetics. Both require intensive fluid and electrolyte replacement as well as insulin therapy to stabilize the patient's condition.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    125 views4 pages

    Diabetic Ketoacidosis and Hyperglycaemic Hyperosmolar State

    Uploaded by

    muhammadridhwan
    This document summarizes the key differences between diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS). DKA is characterized by high blood glucose levels, ketone production and a low pH due to a lack of insulin. It often occurs in type 1 diabetics. HHS features extremely high blood glucose without significant ketones or acidosis and usually affects elderly type 2 diabetics. Both require intensive fluid and electrolyte replacement as well as insulin therapy to stabilize the patient's condition.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    Diabetic

    Ketoacidosis and Hyperglycaemic Hyperosmolar State


    Diabetic ketoacidosis Hypergylcaemia
    Hyperosmolar State
    Definitions State of absolute or relative Relative insulin def resulting
    insulin deficiency in marked hyperglycaemia
    but without ketone
    formation
    Clinical features Onset is over a Occurs in T2DM
    period of days Could be initial
    (acute) presentation of
    Polyuria, polydipsia, diabetic state
    nocturia Patients are often
    Weight loss elderly
    Hyperventilation May present with
    Acetone breath obtundation to coma
    Vomiting Severe dehydration
    Abdominal pain invariable
    Dehydration May have associated
    Hypotension lactic acidosis
    Drowsiness Precipitating factors
    coma similar to DKA
    High mortality
    Precipitating factors Stopping insulin or reducing the dose
    New onset of T1DM
    Stress, with increasing insulin resistance &
    requirement (trauma, infection, surgery, MI and
    stroke)
    Investigation Diagnosis Diagnosis
    RBS 14 mmol/L Blood glucose 33
    ABG : pH <7.3 ; HCO3 mmol/L
    <15mmol/L ABG:pH >7.3;HCO3
    Ketonaemia >18mmol/L
    (>3mmol/L) or Absence of
    ketonuria (2+) ketonuria or
    ketonaemia
    FBC
    RP (Na, K, urea,
    creatinine)
    Ix to delineate cause
    (CXR, infective
    screen, ECG, urine
    microscopy,
    amylase)
    Management Fluid therapy
    6-8L in DKA and 9L in HHS
    regime for moderately dehydrated patients
    Normal saline of 0.9% (154mmol/L NaCl)
    o 1L in 1 hr
    o 1L in 2 hr
    o 1L in 4hr
    o 1L in 6hr
    o 1L in 8hr
    Monitor the response by clinical state and lab
    result. Monitor CVP especially in older pt or when
    massive replacement is require
    If pt is in shock, fluid is either NS or colloids
    administered at suitable rate
    If serum Na is >145 mmol/L, use 0.45% NaCl
    If glucose <15mmol/L, ise
    Fluid containing glucose (dextrose saline) or
    5.10% dextrose water or
    alternating dextrose saline and 5% dextrose
    depending on N level *use 10% dextrose if
    persisting acidosis)

    Insulin therapy
    Continuous IV insulin infusion
    Soluble insulin diluted in 0.9% saline at
    concentration of 1 U/ml
    Give bolus 10U soluble insulin then followed by
    6U/hr by infusion pump or paediatric drip set
    Monitor glucose hourly->aims for drop of glucose
    10%
    Slow response suggest inadequate fluid therapy
    If adequate fluid therapy, the double the infusion
    rate
    When glucose <15mmol/L, change to dextrose
    solution and halve the infusion rate, Aim glucose
    around 8-12 mmol/L in DKA an 14-16mmol/L in
    HHS ( until plasma osmolality <315mmol/L and pt
    mentally alert)
    Cont infusion until metabolic acidosis resolve

    Electrolytes replacement
    Potassium
    Dont give without knowing the level
    Start immediately if ECG shows no hyperK, ample
    urine output, when plasma K<5mmol/L
    Add 1g KCL every 0.5L of fluid
    Monitor BUSE 4-6 hr and ECG monitoring
    Maintain K 4-5 mmol/L

    Bicarbonate and correction of acidosis
    Mixed with NS and give 1-2 ml NaHCO3 per Kg BW over 30
    minutes and recheck ABG

    Phosphate
    Replace if presence of anaemia, cardiac and respiratory
    dysfunction

    Correct the precipitating factors
    Broad spectrum antibiotic if necessary

    Beware of DKA complication
    Hypoglycaemia
    Cerebral oedema
    Arterial and venous thrombosis (SC heparin 5000U
    BD)
    Hypokalaemia
    Gastric dilatation

    *for HHS
    fluid regime should be less rapid
    when glucose is <15mmol/L, halve the insulin
    infusion rate and use 5% dextrose in pt with
    persistent hyperosmolality and hypernatraemia
    with frequent Na monitoring.
    Consider heparinising patient for 2-3 days to
    prevent venous and arterial thromboses.
    When stress and HHS resolve, may discharged pt
    with OAD.
    Recovery Long term insulin therapy in most cases except DKA
    induced by severe stress
    In HHS, pt might be able to discharged with OHA
    Change infusion from to SC insulin
    Cont infusion until acidosis resolve and negative
    ketonuria
    Ask pt to eat, give SC insulin while maintaining
    (overlap) the infusion for 1hr after the first SC
    insulin dose
    Start with immediate acting insulin ON, and short
    acting insulin three times before meal
    Monitor blood glucose prebed and premeal and
    adjust insulin accordingly





    DKA HHS
    Mild Moderate Severe
    pH 7.25-7.30 7.00 to <7.25 <7.0 >7.30
    bIcarbonate 18-15 15-10 <10 >18
    Urine ketone +ve +ve +ve Small
    Serum ketone +ve +ve +ve small
    Effective serum variable variable Variable >320mOsm/kg
    osmolality
    Anion gap >10 >12 >12 Variable
    Mental status alert Alert/drowsy Stupor/coma Stupor/coma

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