A state of absolute or relative insulin deficiency aggravated by ensuing hyperglycemia, dehydration, and acidosis-producing derangements in intermediary metabolism, including production of serum acetone. Can occur in both Type I Diabetes and Type II Diabetes
An acute metabolic complication of diabetes mellitus characterized by impaired mental status and elevated plasma osmolality in a patient with hyperglycemia. Occurs predominately in Type II Diabetics
Causes of DKA/HHS
Infection (pneumonia, UTI) Alcohol, drugs Stroke Myocardial Infarction Pancreatitis Trauma Medications (steroids, thiazide diuretics) Non-compliance with insulin
Symptoms of DKA/HHS
Polyuria Polydypsia Blurred vision Nausea/Vomiting Abdominal Pain Fatigue Confusion Obtundation
Hypotension, tachycardia Kussmaul breathing (deep, labored breaths) Fruity odor to breath (due to acetone) Dry mucus membranes Confusion Abdominal tenderness
Chemistry
CBC
Leukocytosis (possible infection) To evaluate for pancreatitis BUT, DKA by itself can also increase them! Evaluate for possible MI
Amylase/Lipase
BUN/creatinine (dehydration) potassium sodium Pseudohyponatremia: to correct, add 1.6 mEq of sodium to every 100mg/dL of glucose above normal
EKG
Serum acetones
Positive in DKA; Possibly small in HNS Ketones (for DKA); leukocyte esterase, WBC (for UTI)
Urinalysis
Treatment of DKA
HYDRATION!!!
Normal Saline 500-1000 cc/hr for 4 hours, then 250 500 cc/hr for 4 hours, then 125-250 cc/hr Once glucose is < 200, should change fluids to D5 NS until insulin drip is stopped Insulin drip: Bolus: 0.15 units/kg, then infuse at 0.1 mg/kg/hr Ideally should decrease glucose 50-100 mg/dL per hour In DKA: Change to subcutaneous regimen once anion gap has closed and patient is ready to eat. Need to give long-acting insulin dose several hours prior to stopping insulin drip.
Every 1 hour initially, then every 2 hours, and so on. Potassium repletion
Insulin
Accuchecks
Serial Electrolytes
Should add potassium to IV fluids once potassium < 5
Treatment of HHS
Hydration!!!
Should be started only once aggressive hydration has taken place. Switch to subcutaneous regimen once glucose < 200 and patient eating. Potassium replacement.
Serial Electrolytes
Hypophosphatemia
Occurs after aggressive hydration/treatment Monitor phosphorus and replete as needed to keep > 1 Rare, but life threatening Usually in pediatric, adolescent patients Symptoms: Headache, altered mental status Treat with mannitol, hyperventilation
Cerebral edema
Case # 1
A 72-year old female with a history of diabetes mellitus, hypertension, GERD and obstructive sleep apnea, presents to the emergency room with nausea/vomiting and lethargy. Patient states that she skipped a few doses of her lantus, but has otherwise been good about her insulin. She admits to blurred vision, and some mild abdominal discomfort.
Case # 1 (cont.)
Physical Exam:
38.1, 110/78, 110, 22, 99% on RA Gen: Obese female, alert and oriented x 3; in NAD HEENT: very dry mucus membranes CV: RRR Resp: LCTA bilaterally Abd: soft, mildly tender diffusely, no rebound/guarding Ext: no LE edema
Case # 1 (cont.)
Labs:
Sodium: 130 Potassium: 5.9 Chloride: 102 Bicarbonate: 18 BUN: 38 Cr: 1.9 Glucose: 602
Case # 1
What does this patient have? How should you acutely treat this patient? What other tests would you send? What do you do when the patients glucose falls below 200?
Question #2
A 32-year old woman is admitted to the hospital in a semi-comatose, volume-depleted state, exhibiting marked air hunger. She has had type 1 diabetes mellitus for 12 years and ran out of insulin 3 days ago. Labs:
Glucose: 1075 mg/dL Serum bicarbonate: 4.5 mEq/L Potassium: 3.8 ABG: pH 6.90, PCO2: 23 mm Hg
Question # 2(cont.)
After 4 hours of treatment that includes standard doses of insulin (10 units/h) fluids, intravenous potassium chloride (10 mEq/L) plus 150 meq/L of sodium bicarbonate, the patients pH increases to 7.10. However, she suddenly develops respiratory failure followed by cardiac arrest.
Question # 2 (cont.)