Diabetic ketoacidosis (DKA) vs Hyperosmolar hyperglycemic state (HHS) Differ clinically according to the presence of ketoacidosis and the

degree of hyperglycemia. - DKA (more common in type 1 DM, mortality 5-10%) o Hyperglycemia (usually 500-800) o Ketonemia o Anion gap metabolic acidosis (usually >20)  Bicab is mildly to severely reduced. - HHS (more common in type 2 DM, mortality 10-20%) o Very high serum glucose (frequently >1000) o No ketones in serum or urine (can have mild ketonemia)  Small amount of insulin prevents ketogenesis. o pH usually >7.30  Bicarb usually >20 o High plasma osmolality (may reach 380 mosmol/kg) o Neurological abnormalities often present **Significant overlap occurs, perhaps in as many as 1/3 of patients** DKA usually develops rapidly, over a 24 hour period HHS is more insidious, developing over several days with polydipsia, polyuria, and weight loss. Neurologic deterioration occurs with effective plasma osmolarity above 320 to 330 mosmol/kg. (Normal = 285-295) o Effective Posm = (2xNa) + (Glucose/18) Signs of volume depletion are common in both DKA and HHS: o Decreased skin turgor o Dry axilla and oral mucosa o Low JVP o Hypotension Neurological impairment is common in HHS. Fruity flavored breath (acetone) and deep respirations (Kussmaul) in DKA. Three ketone bodies are produced in DKA: o Two ketoacids  beta-hydroxybutyric acid  acetoacetic acid o One neutral ketone  acetone At presentation, Patients with DKA and HHS have a potassium deficit that averages 3 to 5 mg/kg. o Measured concentration is usually normal (or even elevated) however, probably due to insulin deficiency. -

o Insulin therapy can cause hypokalemia, and thus careful monitoring and administration of K is essential. Treatment Monitor glucose levels every 1 hour until stable. Monitor BMP, osmolality, and venous pH every 2-4 hours. o ABGs are not necessary as pH can be accurately estimated from VBG for this purpose. o Serum bicarb is usually sufficient for monitoring degree of acidosis. Average fluid loss is 3-6 liters in DKA and 8-10 liters in HHS. o Initiate fluid replacement with normal saline.  10-15mL/kg infusion rate. o Give regular insulin IV, continuous, at least 0.14U/kg/hr.  *Do not give if K is <3.3 o When serum glucose falls to 200 (for DKA) or 250-300 (for HHS), switch fluid to D5/NS or D10/NS. Goals: o Close anion gap o Restore mental status o Restore patient ability/desire to eat