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עברית
Mar 11, 2024
Contributor: Ricky Dhaliwal, MD
Educational Pearls:
What are DKA and HHS?
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DKA (Diabetic Ketoacidosis) and HHS (Hyperosmolar Hyperglycemic State) are both acute hyperglycemic states.
DKA
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More common in type 1 diabetes.
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Triggered by decreased circulating insulin.
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The body needs energy but cannot use glucose because it can’t get it into the cells.
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This leads to increased metabolism of free fatty acids and the increased production of ketones.
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The buildup of ketones causes acidosis.
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The kidneys attempt to compensate for the acidosis by increasing diuresis.
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These patients present as dry and altered, with sweet-smelling breath and Kussmaul (fast and deep) respirations.
HSS
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More common in type 2 diabetes.
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In this condition there is still enough circulating insulin to avoid the breakdown of fats for energy but not enough insulin to prevent hyperglycemia.
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Serum glucose levels are very high – around 600 to 1200 mg/dl.
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Also presents similarly to DKA with the patient being dry and altered.
Important labs to monitor
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Serum glucose
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Potassium
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Phosphorus
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Magnesium
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Anion gap (Na – Cl – HCO3)
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Renal function (Creatinine and BUN)
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ABG/VBG for pH
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Urinalysis and urine ketones by dipstick
Treatment
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Identify the cause, i.e. Has the patient stopped taking their insulin?
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Aggressive hydration with isotonic fluids.
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Normal Saline (NS) vs Lactated Ringers (LR)?
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LR might resolve the DKA/HHS faster with less risk of hypernatremia.
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Should you bolus with insulin?
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No, just start a drip.
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0.1-0.14 units per kg of insulin.
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Make sure you have your potassium back before starting insulin as the insulin can shift the potassium into the cells and lead to dangerous hypokalemia.
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Should you treat hyponatremia?
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Make sure to correct for hyperglycemia before treating. This artificially depresses the sodium.
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Should you give bicarb?
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Replace if the pH < 6.9. Otherwise, it won’t do anything to help.
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Don’t intubate, if the patient is breathing fast it is because they are compensating for their acidosis.
References
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Andrade-Castellanos, C. A., Colunga-Lozano, L. E., Delgado-Figueroa, N., & Gonzalez-Padilla, D. A. (2016). Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. The Cochrane database of systematic reviews, 2016(1), CD011281. https://doi.org/10.1002/14651858.CD011281.pub2
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Chaithongdi, N., Subauste, J. S., Koch, C. A., & Geraci, S. A. (2011). Diagnosis and management of hyperglycemic emergencies. Hormones (Athens, Greece), 10(4), 250–260. https://doi.org/10.14310/horm.2002.1316
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Dhatariya, K. K., Glaser, N. S., Codner, E., & Umpierrez, G. E. (2020). Diabetic ketoacidosis. Nature reviews. Disease primers, 6(1), 40. https://doi.org/10.1038/s41572-020-0165-1
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Duhon, B., Attridge, R. L., Franco-Martinez, A. C., Maxwell, P. R., & Hughes, D. W. (2013). Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. The Annals of pharmacotherapy, 47(7-8), 970–975. https://doi.org/10.1345/aph.1S014
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Modi, A., Agrawal, A., & Morgan, F. (2017). Euglycemic Diabetic Ketoacidosis: A Review. Current diabetes reviews, 13(3), 315–321. https://doi.org/10.2174/1573399812666160421121307
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Self, W. H., Evans, C. S., Jenkins, C. A., Brown, R. M., Casey, J. D., Collins, S. P., Coston, T. D., Felbinger, M., Flemmons, L. N., Hellervik, S. M., Lindsell, C. J., Liu, D., McCoin, N. S., Niswender, K. D., Slovis, C. M., Stollings, J. L., Wang, L., Rice, T. W., Semler, M. W., & Pragmatic Critical Care Research Group (2020). Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials. JAMA network open, 3(11), e2024596. https://doi.org/10.1001/jamanetworkopen.2020.24596
