DKA and HHS

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) T est 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 HHS Mild 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 mental obtundation Alert Alert/drowsy Stupor/coma Stupor/coma

6. KETONE BODIES Acetoacetate Beta hyroxybutyrate

7. 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

8. 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)

9. 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

10. 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

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

12. 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

13. 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)

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

15. 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

16. 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

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

18. 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

19. 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 [K+] = 4.5–5.4: add 20 mEq /L IV fluids [K+] = 3.5–4.4: add 30 mEq /L IV fluids [K+] < 3.5: add 40 mEq /L IV fluids Also treat if ECG changes of hypokalemia present

20. c ont ….. 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

21. 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

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

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

24. 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

25. Thank You